Every finding on record at The Oaks

Based on record reviews and staff, home health agency representatives, Resident and family member interviews, the facility failed to ensure Resident #1 received the required medical supplies, coordination of home health services, and adequate caregiver instruction for 1 of 3 residents reviewed for transfer/discharge (Resident #1). Findings included:Resident #1 was admitted to the facility on [DATE] with diagnoses of diabetes mellitus, gastroparesis (a long-term medical condition where the stomach empties food into the small intestine much too slowly), encounter for attention to the gastrostomy (a medical procedure that creates an opening from the outside of the abdomen directly into the stomach. It allows for the placement of a feeding tube/G-tube to deliver nutrition, and medications when a person cannot swallow or eat safely) and cellulitis (a common, potentially serious bacterial skin infection that affects the deep layers of the skin and underlying tissues) of the abdominal wall. The admission Minimum Data Set (MDS) completed on 7/9/26 revealed intact cognition, use of a walker and wheelchair for mobility, and 26-50% of calories given via G-tube. Active diagnoses included gastroesophageal reflux disease, diabetes, malnutrition. Resident #1 anticipated returning to the community at discharge. The comprehensive care plan dated 7/8/26 stated Once I have completed my current treatment plan as ordered, I anticipate a planned discharge to home with spouse (Date Initiated: 07/08/2026). Provide me and/or my representative with contact information for any possible community resources as needed prior to discharge. Review all discharge instructions with me and/or my representative including treatments, medications, outpatient services, appointments, etc. A review of the Social Services admission note dated 7/2/26 entered by the Social Worker (SW), indicated Resident #1 was admitted to the facility on [DATE] from the hospital with diagnoses including type I diabetes with hyperglycemia; polyneuropathy; gastroparesis; severe protein-calorie malnutrition; encounter for attention to gastrostomy and is a Do Not Resuscitate. Resident #1 was cognitively intact, and on a regular diet, with regular texture, thin liquids, and had a G-tube for additional nutrition but refused tube feeding formula most days. It was documented Resident #1 required assistance with activities of daily living care and incontinence care at times and could ambulate with supervision with the use of a rolling walker as tolerated. Resident#1's goal is to discharge home with spouse. A physician's order was written on 7/16/26 for home health services (nurse and nurse aid), a rolling walker, tube feeding, gastroenteric tubing, syringes, and a pump to administer liquid nutrition. A review of the Discharge summary dated [DATE] and prepared by the Social Worker indicated that the facility had contacted Home Health Agency #4 to provide physical therapy, nursing services, nurse aide bathing assistance, instructions, and demonstrations related to gastric tube feeding care. The discharge summary also listed tube feeding formula 1.2 strength cartons (237 milliliters) 4 per day, a wheeled walker, the phone number for the durable medical equipment (DME) provider and the phone number for Resident #1's emergency contact. A list of discharge medications was attached to the discharge summary. Nurse #1 and Resident #1 signed the discharge summary.An interview with Nurse #1 on 8/4/26 at 2:41 pm revealed she had gone over the discharge summary with Resident #1 which included a list of her medications, a follow up appointment with her primary doctor, home health (how to flush her gastrostomy tube with water before and after receiving her feedings, and durable medical equipment (DME) delivery. Nurse #1 indicated that she told the resident it was the same process she had been doing at home prior to going into the hospital, and that Resident #1 had 20 years of practice from previous at home administration of feeding formula via her G-tube. Nurse #1 recalled she told Resident #1 that she would have home health to come in and help her set up the infusion pump to administer her tube feeding. A phone interview was conducted on 8/4/26 at 11:45 am with Resident #1 and her family member. She explained that the Social Worker had told her around 7/9/26 that she would be going home in about a week. Resident #1 stated she believed there would be plenty of time for the facility to order her supplies and arrange home health services. Resident #1 indicated that when she was informed she was going home on 7/16/26, she described multiple staff members grabbing her belongings and hurrying her out of the room. Resident #1 reported that she told the nurse to wait because she had not been given any instructions on how to use the new feeding pump and had not been told how she would receive her supplies once she was home. Resident #1 did not receive any of the durable medical equipment (DME) supplies required (rolling walker, tube feeding formula, gastroenteric tubing, syringes or an infusion pump) prior to leaving the facility. Resident #1 stated was told she would have a home health nurse come to her home and help with set-up of her infusion pump and this had not occurred. A follow up phone interview with Resident #1 and her family member, on 8/5/26, at 12:33 pm revealed the family member was not present during the teaching of the flushes and tube feeding prior to discharge and the family member stated that Resident #1 had medications that made her sleepy and sometimes she would need him to do the flushes or the feeding. Resident #1 indicated that she had not been using the G-tube very often prior to admission to the facility. The G-tube had fallen out and had been out over a month. The family member revealed that Resident #1 had an old pump at home, packed in a box in the laundry room, but it was not the same as the one Resident #1 was using at the facility. The family member also indicated that the tube feeding formula she had at home was thrown out because it had expired. A review of the facility E-mails to outside home health agencies in the month of July 2026, could only confirm that E-mails had been sent out to home health agency #2. There was not any documentation to show where home health agencies #1, #3 and #4 had been contacted. The Email sent out that specifically names Resident #1 was to home health agency #2 on 7/21/26 at 1:10pm, with her information attached, asking for acceptance for home health services, with a follow-up on 7/22/26 at 2:47pm to see if there was any update. There was no E-mail indicating any further correspondence or acceptance. The E-mails requested acceptance of Resident #1's insurance for home health services and did not have any specific details regarding what services or DME Resident #1 needed. During an interview with the Social Worker on 8/4/26 at 12:17pm she explained that she was responsible for completing the discharge paperwork including the orders, discharge date , any equipment needed, home health nurses, nurse aides, therapy, DME including walkers, wheelchairs, bedside commodes, etc., alerting the ombudsman, and making copies for the Resident. The Social Worker indicated that she was responsible for calling the residents 24 to 48 hours after discharge to make sure they are safe and that they have received the services, supplies, equipment and medication they were supposed to have. The Social Worker admitted that she had not followed up with Resident #1 after discharge and she had not received any confirmation from Home Health Agency #4 that Resident #1 was accepted for services, adding she had failed to arrange for the discharge services and DME for this resident. On 8/4/26 at 12:45 pm during a follow up interview, the Social Worker stated that Home Health Agency #4 was the first agency she contacted but she had also contacted three other home health agencies as well but had not received confirmation from any of the companies. The Social Worker stated that she thought she contacted Home Health Agency #4 prior to resident's discharge but was unable to produce proof that this was done. The Social Worker stated that she sent out E-mails prior to discharge but could not produce proof she had done so.An interview with the admission Coordinator with Home Health Agency #2 on 8/4/26 at 12:59 pm revealed no contracts or service arrangements had been established for Resident #1, but they had received an E-mail 7/21/26 with her information for home health services but were unable to accept the client at that time because there was an insurance issue. The Social Worker indicated that when the Resident information is sent to the home health agency, they are responsible for completing the paperwork for admission acceptance or notifying if they can accept the insurance. There was no other documentation regarding placement of Resident #1 indicating difficulty with insurance acceptance.An interview with the Branch Manager with Home Health Agency #4 on 8/4/26 at 12:39 pm revealed they had not received an E-mail for referral for Resident #1. An interview with the Branch Manager for Home Health Agency #1 on 8/4/25 at12:55 pm revealed they had not received an E-mail for referral for Resident #1. An interview with the referral coordinator with Home Health Agency #3 on 8/4/26 at 1:03 pm revealed they had not received an E-mail for referral. A phone interview on 8/5/26 at 10:28 am with the Director of Nursing (DON) revealed Resident #1 had refused her liquid nutrition frequently due to chronic abdominal pain and nausea. The DON explained that Resident #1 did eat a regular diet and consumed thin liquids requiring less of a need for liquid nutrition. The DON stated she did expect the Social Worker to do her part in getting all of the residents discharged properly, making sure they received all of the services (home health, physical and occupational therapy, etc.) and supplies (liquid nutrition, dressing supplies for wounds, wheelchairs, walkers, etc.) needed within 24 hours of being discharged . The DON indicated she was not aware until 8/5/26 that Resident #1 did not receive her home health services, supplies and DME. She did indicate that there was a breakdown in the system with Resident #1 in that the Social Worker was responsible for obtaining home health services for Resident #1 and ordering the DME to be delivered to her home, if it could not be delivered to the facility before she discharged home. An interview with the Administrator on 8/4/26 at 6:30 pm revealed it was his expectation for the discharge procedure to be properly carried out including discussion of the discharging residents in the morning meetings, discharge summary and orders to be given to the nurse to go over with the Resident being discharged , any home health and equipment information needed to make sure the resident was safely discharged . The Administrator explained that the Social Worker was expected to follow up in 24 hours with the resident discharged home to make sure they are safe and have what they need, and that they have been contacted by the home health agency. The Administrator did not recall Resident #1 being discussed in the morning meeting but assured if Resident#1 was on the list she would have been discussed.

Based on record review, observations and staff interviews, the facility dietary staff failed to demonstrate competency with monitoring the chemical sanitization level for the low temperature dish machine by not performing testing at least once per shift which could affect 111 of the 111 residents. The findings included: The program brochure for the low temperature dish machine was reviewed. It stated the minimum chemical sanitizer rinse requirements were 50 parts per million (ppm) of chlorine. An observation of the dish machine with Dietary Manager (DM) was conducted on 8/11/25 at 9:46 AM and the DM confirmed the chlorine level of the low temperature dish machine measured 0 ppm. During an interview with the Dietary Manager on 8/11/25 at 9:48 AM, the Dietary Manager stated that dietary staff were supposed to test the chemical sanitization level daily. However, the dish machine temperature log only included temperatures of the rinse/wash cycles, and not the chemical sanitization level. During a follow up interview with the DM on 8/11/25 at 12:41 PM, she revealed that the vendor had fixed the dish machine an hour earlier. The DM stated the vendor reported the nozzle to the chemical sanitization was not working properly. The DM indicated that she was able to wash and sanitize all dishes prior to lunch meal service on 8/11/25. An observation and interview were conducted with Dietary Aide #1 on 8/12/25 at 9:45 AM. The low temperature dish machine measured 272 ppm, which was in the optimal range. Dietary Aide #1 stated she had never measured the chemical sanitization level of the dish machine before, only the 3-part sanitization sink for the pots/pans. Dietary Aide #2 was interviewed on 8/13/25 at 11:56 AM. She revealed that she did not always record the temperatures of the dish machine but had never measured the chemical sanitization level. During a follow-up interview with the Dietary Manager on 8/14/25 at 8:00 AM, she revealed that she had never used a low temperature dish machine before and was not aware of the minimum chemical sanitization level. An interview was conducted with the Administrator on 8/14/25 at 12:08 PM. He revealed that the dish machine chemical sanitization level should be checked every morning and documented appropriately. If any issues were found where the level was below 50 ppm, then the vendor should have been contacted immediately.

Based on observation and staff interviews, the facility failed to 1) to maintain the minimum chemical sanitization level of the low temperature dish machine according to the manufacturer's recommendations 2) clean the convection ovens, the fryer, the toaster, steamer, stove and plate warmer for 3 of 3 observations 3) allow cooking pans and dishes to completely dry prior to assemblage and stacking for two of two observations, 4) remove cracked and dirty plates prior to meal service for 1 of 1 observation and clean 2 of 3 meal carts. These practices had the potential to affect food served to residents. 1. The manufacturer program brochure for the low temperature dish machine was reviewed and specified the minimum chemical sanitizer rinse requirements were 50 parts per million (ppm) of chlorine. An observation and interview with the Dietary Manager (DM) were conducted on 8/11/25 at 9:46 AM. During dish service, the chlorine level of the low temperature dish machine measured 0 ppm. The DM stated that she needed to contact the Maintenance Director. During an interview with the Maintenance Director on 8/11/25 at 9:47 AM, he revealed that the chemical sanitization was serviced by the vendor. During a follow up interview with the DM on 8/11/25 at 9:48 AM, she revealed that the vendor last came to service the low temperature dish machine about 3 weeks ago. She stated they were supposed to test the chemical sanitization level daily. However, the dish machine temperature log only included temperatures of the rinse/wash cycles, and not the chemical sanitization level. During a follow up interview with the DM on 8/11/25 at 9:57 AM, she revealed that all breakfast dishes would be rewashed and sanitized in the 3-part sink that measured within the desirable range chemical sanitization level. The DM stated she planned to purchase paper goods to serve at lunch, so the sanitized dishes could air dry prior to dinner service. During a second follow up interview with the DM on 8/11/25 at 12:41 PM, she revealed that the vendor had fixed the dish machine an hour earlier. The DM stated the vendor reported the nozzle to the chemical sanitization was not working properly. The DM indicated that she was able to wash and sanitize all dishes prior to lunch meal service on 8/11/25.During an additional follow up interview with the DM on 8/14/25 at 8:00 AM, she revealed that she had never used a low temperature dish machine before and was not aware of the minimum chemical sanitization level. An interview was conducted with the Administrator on 8/14/25 at 12:08 PM. He revealed that the dish machine chemical sanitization level should be checked every morning and documented appropriately. If any issues were found where the level was below 50 ppm, then the vendor should have been contacted immediately. 2. An observation of the kitchen and interview with [NAME] #1 was conducted on 8/11/25 at 9:51 AM. The doors of the two convection ovens were coated with a light brown substance, and a darker brown substance was seen on the inside of both ovens. The bottom of the fryer was covered with a dark brown liquid and food crumbs. The food crumbs were also seen along all inside walls of the fryer. [NAME] #1 stated that the kitchen equipment should be cleaned weekly; however, he could not say when the ovens were cleaned last. He stated the fryer was used within the last two days, and it was cleaned sometime last week. [NAME] #1 indicated the fryer would not be used today.An observation of the kitchen and interview with [NAME] #2 was conducted on 8/12/25 at 9:38 AM. The doors of the two convection ovens were coated with a light brown substance, and a darker brown substance was seen on the inside of both ovens. The bottom of the fryer was covered with a dark brown liquid and food crumbs. The food crumbs were also seen along all inside walls of the fryer. A white residue covered the outer surfaces of the steamer and the stove. [NAME] #2 stated the kitchen equipment was cleaned every 3 weeks and was due to be cleaned tomorrow (8/13/25). An interview was conducted with the Dietary Manager on 8/12/25 at 9:39 AM. She stated the kitchen equipment should be cleaned daily, but only she and [NAME] #2 were the staff willing to do so. The DM stated the last time the kitchen equipment was cleaned was two weeks ago. An observation of the kitchen and interview with Dietary Aide #1 was conducted on 8/13/25 at 7:07 AM. The plate warmer was noted to have white residue covering the entire top of the equipment, and a stiff, yellow piece of food and other brown pieces of food were seen near one of the plate openings. Dietary Aide #1 stated the evening staff on 8/12/25 were supposed to clean it. During a follow up appointment with the Dietary Manager on 8/14/25 at 8:02 AM, she revealed that she expected dietary staff to clean the kitchen equipment daily and after use. The Dietary Manager indicated that dietary staff had been very resistant to any instructions they were given. She stated she had been working on building a better team in the kitchen since she was hired at the facility five weeks ago. The Administrator was interviewed on 8/14/25 at 12:14 PM. He revealed that the cooks should follow the Dietary Manager's expectations of kitchen equipment cleaned daily and deep cleaned weekly. The Administrator stated that the Dietary Manager was new to the facility, and it would take time to improve the kitchen.3. An observation of the kitchen and interview with the Dietary Manager were conducted on 8/11/25 at 9:55 AM. Observed on the cooks' clean rack were two large silver pans approximately 4 inches deep, and two smaller silver pans approximately 4 inches deep, were seen with wet nesting. The Dietary Manager apologized and went to rewash them. She stated the cooks were responsible for cleaning the pans they used.During a follow up interview with [NAME] #1 on 8/11/25 at 9:56 AM, he stated he normally let the pans air dry on the rack in the dish room prior to storage. However, he must not have let the pans air dry fully prior to placing them ready for use. An observation of the kitchen and interview with [NAME] #1 was conducted on 8/11/25 at 10:01 AM. Sixteen cereal bowls and eighteen small plates had wet nesting next to the tray line. [NAME] #1 confirmed the dishes were wet and brought them back to the dish machine area. During a follow up interview with the Dietary Manager on 8/14/25 at 8:05 AM, she revealed that dietary staff should air dry all pots, pans, and dishes prior to storage for use. She stated she did not have enough time during dishwashing to air dry because the nursing staff did not bring the dirty dishes to the kitchen in a timely manner. The Dietary Manager indicated that the staff from the kitchen had to stop what they were doing daily to retrieve the meal trays and meal carts from each hall after service. An observation of the kitchen and interview with the Dietary Manager was conducted on 8/12/25 at 9:41 AM. Six silver pans approximately 4 inches deep, and three smaller silver pans approximately 4 inches deep, were seen with wet nesting on the clean rack in the cooks' area. The Dietary Manager stated she had educated the cooks numerous times about letting the pans air dry, but they have not complied. She further stated that she would rewash the pans that were wet.The Administrator was interviewed on 8/14/25 at 12:07 PM. He revealed that all dishes and pots/pans should not have wet nesting and be air dried prior to use. The Administrator indicated that the Dietary Manager was new to the facility, and it would take time for her to improve the dietary department.4. An observation of the kitchen and interview with Dietary Aide #1 on 8/13/25 at 7:04 AM. Thirteen plate holders had food residue on them, and twenty-seven dinner plates had cracks. She stated that the Dietary Manager told her to throw them away, but if she did that then they would not have any plates for meal service. During a follow up interview with the Dietary Manager on 8/13/25 at 7:08 AM, she revealed that she had new dinner plates available in storage and went to go wash them. During a follow up interview with the Dietary Manager on 8/13/25 at 7:15 AM, she revealed that she educated all dietary staff about cracked dishes and proper cleaning of the dishes. An observation of the 100 hall and interview with the Dietary Manager was conducted on 8/13/25 at 8:29 AM. The meal cart had white residue marks all over the inside and outside. The Dietary Manager stated that she told Dietary Aide #3 to clean all meal carts yesterday. An observation of the 200 hall and interview with Dietary Aide #3 was conducted on 8/13/25 at 8:31 AM. The meal cart had marks of white residue that covered the inside and outside. Dietary Aide #3 stated he was supposed to clean all meal carts yesterday but forgot. During a follow-up interview with the Dietary Manager on 8/14/25 at 8:08 AM, she revealed that she expected that the meal carts would be cleaned daily and deep cleaned on the weekends. The Administrator was interviewed on 8/14/25 at 12:12 PM. He revealed that if plates were chipped, they should not be used during meal service and should have been replaced. The Administrator indicated that all dishware should be clean before use, including meal carts.

Based on observation and staff interviews, the facility failed to ensure debris was removed from behind the dumpsters for 3 of 3 dumpsters observed. This practice had the potential to attract pests and rodents. An observation of the dumpster area was conducted on 8/11/25 at 10:04 AM. Behind all 3 dumpsters, used debris items such as straws, cup lids, empty chip bags, and empty milk cartons were observed. An interview was conducted with the Maintenance Director on 8/11/25 at 10:07 AM. He stated that he normally picked up debris items in the parking lot, but the dietary department was responsible for the dumpster area. He stated he would grab a shovel and pick up the debris behind the dumpsters. During an interview with the Dietary Manager on 8/12/25 at 9:52 AM, she revealed that the Maintenance Director was responsible for cleaning the dumpster area. The Maintenance Director told her that when the garbage truck emptied the dumpsters, debris would often get left behind the dumpsters. During a follow up interview with the Maintenance Director on 8/14/25 at 9:42 AM, he revealed that he was unsure of who was assigned to clean behind the dumpsters, but it was most likely him. However, he requested clarification by the Administrator. The Administrator was interviewed on 8/14/25 at 12:05 PM. He revealed that the dietary department was responsible for cleaning the dumpster area. However, maintenance and housekeeping currently cared for the dumpster area. The Administrator stated that the debris should not be left behind the dumpsters even after the dumpsters were emptied. Managing the dumpster area should be a daily cleaning task.

Based on record review and staff interviews, the facility failed to submit accurate payroll data on the Payroll Based Journal (PBJ) report to the Centers for Medicare and Medicaid Services (CMS) related to Registered Nurse (RN) hours. This was for 1 of 3 Federal Fiscal Year quarters reviewed for sufficient nurse staffing (Quarter 2: January 1-March 31, 2025).Findings included:The PBJ report for the Federal Fiscal Year Quarter 2 2025 (January 1 through March 31, 2024) revealed there were no Registered Nurse (RN) hours for 2/22/25, 2/23/25, 3/10/25, and 3/16/25. The nursing staff time detail reports for 2/22/25, 2/23/25, 3/10/25, and 3/16/25 revealed there was not a RN onsite for at least 8 hours a day. The daily staff schedules for 2/22/25, 2/23/25, 3/10/25, and 3/16/25 revealed there was a RN onsite for at least 8 hours a day. During an interview on 8/14/25 at 2:27 PM with the Scheduling Coordinator, she provided documentation of an agency RN on 2/22/25, 2/23/25, 3/10/25, and 3/16/25. The Scheduling Coordinator explained that sometimes the agency nurses don't clock in when they arrive at the facility for work. She further stated that when they fail to clock in, that information doesn't get transcribed into the PBJ report. During an interview on 8/14/25 at 4:25 PM with the Administrator, he stated he was unaware that some agency nurses were not clocking in at the facility and it resulted in inaccurate data being submitted to the PBJ. He stated that all staff, regardless of agency status, should be documenting their time in the facility timecard system.

Based on record reviews, and staff and resident interviews, the facility failed to honor residents' preference for eating in the dining room for 9 days due to a COVID-19 outbreak when one employee tested positive on 8/2/25 for 3 of 5 residents reviewed for choices (Residents #20, #63, and #110).Review of the facility's policy COVID-19 Response Program last revised August 2025 revealed that the term outbreak was not defined and there was not any instruction for dining activity during an outbreak. The policy did state for the facility to notify the health department of any suspected or confirmed cases. During an observation of the dining room on 8/11/25 at 12:20 PM, there were not any residents eating lunch in the dining room. An interview with the Administrator on 8/11/25 at 12:45 PM revealed the facility was currently in outbreak status and the dining room had been closed since 8/2/25 when one employee tested positive. He stated he was instructed by someone from the county health department to temporarily cease all group interactions, including dining. a. Resident # 20 was readmitted to the facility on [DATE]. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #20 was cognitively intact, had adequate vision/hearing, had clear speech, and understood/understands. She was independent with eating. During an interview with Resident #20 on 8/11/25 at 1:45 PM, she revealed that she often ate lunch and dinner in the dining room. She stated it upset her that the facility closed the dining room all last week (8/2/25 - 8/11/25) due to a COVID-19 outbreak. b. Resident #63 was admitted to the facility on [DATE]. Review of the comprehensive MDS assessment dated [DATE] revealed that Resident #63 was cognitively intact, had adequate vision/hearing, had clear speech, and understood/understands. She was independent with eating. Resident #63 was interviewed on 8/11/25 at 1:47 PM. She revealed that she enjoyed eating lunch and dinner in the dining room every day. She stated that she was unhappy because the facility closed the dining room since 8/2/25 due to a COVID-19 outbreak. c. Resident #110 was readmitted to the facility on [DATE]. Review of the comprehensive MDS assessment dated [DATE] revealed that Resident #110 was moderately cognitively intact, had adequate vision/hearing, had clear speech, and understood/understands. She was independent with eating. An interview was conducted with Resident #110 on 8/11/25 at 1:53 PM. She revealed that she was upset the dining room was closed since 8/2/25 due to a COVID-19 outbreak. She ate lunch and dinner in the dining room daily. The Director of Nursing (DON) was interviewed on 8/14/25 at 9:50 AM. She revealed that according to the facility's policy titled, COVID-19 Response Program last revised August 2025, one positive COVID-19 case was considered an outbreak and would remain in outbreak status until 14 days without a positive test result. The DON stated that the health department told her to suspend all group dining, and one positive result was considered an outbreak. She indicated that there were not any residents that complained to her about being upset with the dining room being closed for the last 9 days. Review of an email sent by the Communicable Disease Nurse to the Staff Development Coordinator on 8/4/25 revealed that guidance was provided about source control. However, there was not a suggestion to temporarily cease dining activities for residents with one positive case of COVID-19 in the building. During an interview with the Communicable Disease Nurse for the county on 8/15/25 at 9:09 AM, she revealed that she never spoke to anyone from the facility about the outbreak that started on 8/2/25. She indicated that she only received a voicemail from the facility notifying her that one employee tested positive for COVID-19 on 8/2/25. She explained if only one employee tested positive for COVID-19, then that would cause the facility to be under surveillance and should have conducted contact tracing and testing. The Communicable Disease Nurse for the county stated she would never give the facility advice to temporarily cease group dining, since an outbreak was considered 2 or more cases within a 14-day period. An interview was conducted with the Public Health Nursing Supervisor over Communicable Disease on 8/14/25 at 11:37 AM. She revealed that 2 or more cases of COVID-19 would be considered an outbreak. If there was only one positive case, the facility would be under observation, and the public health department would not suggest that group activities be ceased temporarily. The Administrator was interviewed on 8/14/25 at 11:56 AM. He stated that someone (unknown name) from the health department told him to temporarily cease all group dining for 14 days. The Administrator indicated that he did what he was asked to do. He stated that he was taking precautionary measures, and he expressed understanding that one positive case of COVID-19 was not considered an outbreak.

Based on observations, record review, and resident council member and staff interviews, the facility failed to conduct resident council meetings in a private area for 6 of the 6 resident council meetings reviewed in the last 6 months (2/19/25, 3/19/25, 4/16/25, 5/21/25, 6/18/25, and 7/23/25).The findings included:Review of the resident council minutes reviewed from 02/19/25 through 07/23/25 revealed resident council meetings had been held in the dining area.A resident council meeting was held on 08/12/25 at 3:00 PM with resident council members (Resident #2, Resident #20, Resident #22, Resident #30, Resident #33, Resident #61, Resident #63, Resident #99, Resident #110, Resident #113, and Resident #124.) The resident council members revealed they had their meetings in the lounge area next to the dining room. It was further revealed staff and visitors often disrupted the meeting due to not having any walls or doors. The resident council members stated they were unable to meet privately, and it was often frustrating.An observation of the lounge area next to the dining room on 08/12/25 at 4:15 PM revealed the room to be one open area with no privacy. It addition, the entrance hallway from the front door of the facility is adjacent to the lounge with no divider or wall separating them. Staff and visitors in the hallway can hear conversations in the lounge and there is no privacy between the lounge, dining room and hallway. An interview conducted with the activity's director on 08/12/25 at 10:30 AM revealed resident council meetings were held in the dining area. It was further revealed she did not have an activity room or private area to hold meetings. The activity director indicated she tried to keep meetings private, but sometimes visitors and staff were not aware of the meeting and would disrupt. An interview conducted with the Administrator on 08/14/25 at 3:05 PM revealed he was not aware that resident council meetings needed to be held in a private area and was not aware residents had complained. The Administrator indicated he did not have a meeting place that was private for resident council meetings but would work on getting one.

Based on record review and staff interviews, the facility failed to complete a baseline care plan that addressed the resident's immediate needs within 48 hours of admission for 2 of 30 sampled residents (Residents #51 and #106).The findings included: 1. Resident #51 was admitted to the facility on [DATE] with diagnoses that included diabetes, heart failure, and end stage chronic kidney disease. The nursing admission data collection assessment initiated and completed on 5/19/25 and revealed Resident #51 was on dialysis and also received antidepressant and diuretic medications. Review of Resident #51's electronic medical record on 8/13/25 revealed no evidence a baseline care plan that addressed her immediate needs was completed within 48 hours of her admission to the facility on 5/19/25. During an interview with the Minimum Data Set (MDS) Coordinator on 08/13/2025 at 3:10 PM, he stated the baseline care plans included the resident's standing orders, new medication orders, and their admitting diagnoses. He explained they were usually completed within 72 hours at the interdisciplinary care conference. The MDS Coordinator also stated that if a resident was admitted on a Thursday, the baseline care plan would be completed on the following Monday. During an interview with the Director of Nursing (DON) on 8/14/2025 at 9:44 AM, she stated the baseline care plan should be started immediately after admission and would include goals and interventions regarding the care of the resident. The DON reported that the baseline care plan should be completed within 72 hours of admission to the facility. During an interview with the Corporate Nurse Consultant on 8/14/25 at 3:37 PM she stated that the baseline care plans should be completed within 48 hours of a resident's admission. She stated the baseline care plan should contain pertinent information that addressed a resident's immediate care needs for staff until the comprehensive care plans were developed. 2. Resident #106 was admitted to the facility on [DATE] with diagnoses that included multiple sclerosis, polyneuropathy, depression, and pressure ulcers of left and right buttocks. The nursing admission data collection assessment initiated and completed on 7/11/25 and revealed Resident #106 received antidepressant medications, would begin physical therapy as tolerated, and required daily dressing changes for wound care. Review of Resident #106's electronic medical record on 8/13/25 revealed no evidence a baseline care plan that addressed her immediate needs was completed within 48 hours of her admission to the facility on 7/11/25. During an interview with the Minimum Data Set (MDS) Coordinator on 08/13/2025 at 3:10 PM, he stated the baseline care plans included the resident's standing orders, new medication orders, and their admitting diagnoses. He explained they were usually completed within 72 hours at the interdisciplinary care conference. The MDS Coordinator also stated that if a resident was admitted on a Thursday, the baseline care plan would be completed on the following Monday. During an interview with the Director of Nursing (DON) on 8/14/2025 at 9:44 AM, she stated the baseline care plan should be started immediately after admission and would include goals and interventions regarding the care of the resident. The DON reported that the baseline care plan should be completed within 72 hours of admission to the facility. During an interview with the Corporate Nurse Consultant on 8/14/25 at 3:37 PM she stated that the baseline care plans should be completed within 48 hours of a resident's admission. She stated the baseline care plan should contain pertinent information that addressed a resident's immediate care needs for staff until the comprehensive care plans were developed.

Based on record review, observations, and resident and staff interviews, the facility failed to apply compression wraps to Resident #87's legs as ordered. The deficient practice occurred in 1 of 1 resident reviewed for providing services to meet professional standards (Resident #87).Findings included:Resident #87 was admitted to the facility on [DATE] and had cumulative diagnoses including congestive heart failure, morbid obesity and lymphedema.Review of records revealed a physician's order dated 5/28/25 for compression wraps to bilateral (both right and left) legs every morning and to be removed every evening for lymphedema.A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #87 was cognitively intact.A revised care plan dated 7/21/25 revealed focus areas for congestive heart failure, lymphedema, and activities of daily living deficit. Review of Resident #87's Treatment Administration Record (TAR) for 8/13/25 revealed documentation by nursing staff that compression wraps were placed at 8:00 AM by Nurse #1. On 8/13/25 at 10:00 AM an interview with Resident #87 was conducted in conjunction with an observation. Resident #87 stated that she did not have compression wraps on her legs. Resident #87 stated she was very worried about the staff not putting the compression wraps on her legs and explained she did not want her lymphedema to get worse. Resident #87 stated historically that staff had put the wraps on in the morning and then took them off at night. Resident #87 then uncovered both of her legs which revealed no compression wraps in place to either of her legs. On 8/13/25 at 2:30 PM an interview and record review were conducted with Resident #87's primary nurse, Nurse #1. Nurse #1 reported she did not have anything to do with Resident #1's compression wraps. Nurse #1 stated she did not know how often the compression wraps should be applied or when they should be removed. Nurse #1 reviewed the TAR for 8/13/25, which had Nurse #1's initials documenting application of the compression wraps, and Nurse #1 confirmed that her initials were noted on the TAR as documenting that the compression wraps were applied on the resident by her at 08:00 AM. Nurse #1 stated she did not know how her initials got there. Nurse #1 then acknowledged that she did not place the wraps on at 08:00 AM but said that the wraps were already on, and that was what she charted on at 08:00 AM. Nurse #1 stated she did not how or when Resident #87's leg wraps were removed or who may have removed them.On 8/13/25 at 3:05PM, an interview with the Director of Nursing (DON) was conducted. The DON stated if a task was ordered by the physician, it should be carried out by nursing staff.

Based on record review, observations, and resident, staff and physician interviews, the facility failed to provide ordered physical therapy for a resident with history of stroke and spastic contractures in 1 of 1 resident reviewed for rehabilitation services (Resident #5).Findings included:Resident #5 was admitted to the facility on [DATE] with diagnoses of cerebral vascular accident with right sided hemiparesis and hemiplegia with spasticity (weakness and paralysis with muscle spasms), type II diabetes, neuropathy, atrial fibrillation and depression.A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 was cognitively intact. A revised care plan dated 6/24/25 showed focus areas for stroke, with hemiplegia/hemiparesis, contractures, falls, diabetes, atrial fibrillation, depression, activities of daily living deficits, psychotropic medication monitoring, braces for contractures and physical therapy.Review of records revealed a facility physical therapy functional maintenance program sheet dated December 2024. The functional maintenance program specified that Resident #5 was to be up in his wheelchair for three to four hours daily, was to perform wheelchair mobility exercises and to maintain proper sitting posture while in his wheelchair. The functional maintenance program sheet contained no stipulations or benchmarks to assess for decline in function or who to notify if needs arose. A Neurology physician office note dated 7/25/25 revealed Resident #5 had spastic quadriparesis following multiple strokes and during the same visit, received botox injections to various muscle groups in his left arm and his right arm due to spasticity which had adversely affected his function. The physician noted Resident #5's strokes in 2024 which rendered his left side weaker than his right side. The physical assessment noted restriction of left shoulder flexion, restriction of left elbow extension and supination as well as restriction of finger extension of the left and right hands due to spasticity. The physician then noted the in-office botox injection procedure and Resident #5's need for continued physical therapy. Review of records also revealed that on 7/25/25, the Neurology physician ordered a physical therapy referral and that Resident #5 was to wear his left elbow and left wrist brace for 4 hours every day and for four hours every night. Further review of records revealed no documentation pertaining to initiation of physical therapy services following the order on 7/25/25. In an interview with Resident #5 on 8/11/25 at 10:30 AM, Resident #5 was observed sitting up in bed. He was awake, alert, groomed and watching TV. He said that he got up to his wheelchair as often as he could. Resident #5 reported that he was very concerned that the doctor had ordered physical therapy for him a few weeks ago but I haven't had any therapy yet.On 8/13/25 at 09:30 AM, Resident #5 was observed in his room, awake, sitting up in bed, watching TV conversing with visitors at his bedside. In an interview with the Rehabilitation Manager on 8/13/25 at 10:30 AM, the Rehabilitation Manager informed that the 7/25/25 order for the Physical Therapy (PT) referral had not been completed yet. The Rehabilitation Manager stated that Resident #5 was on a wait list because there was only one physical therapist working in the building. The Rehabilitation Manager stated that when they received an order for PT, rehab services first conducted a rehab screening. Then if the screening gave indication that a referral was needed, then the referral was completed. The Rehabilitation Manager stated that only once the screening and referral deemed a resident was appropriate for PT services, would a resident be accepted for PT. The Rehabilitation Manager stated that there was no set timeframe for when an order was received and when services began and this varied based on a resident's needs. The Rehabilitation Manager further stated that specific findings that moved a resident from screening to referral, to formal physical therapy also varied based on resident's needs. The Rehabilitation Manager stated that the timeframe from 7/25/25 to 8/12/25 was longer than usual but that they were very behind schedule because there was only one therapist working on PT screenings. The Rehabilitation Manager stated that Resident #5 was last seen by PT in December 2024 and was discharged at that time with a functional maintenance program. The Rehab Manager further stated that nursing staff was to notify the physician and rehabilitation services of any need for additional therapy. On 8/13/25 at 11:00 AM, an interview with the Physical Therapist was conducted. The Physical Therapist stated that she was not contracted but was a facility staff member. The Physical Therapist confirmed that Resident #5 had received an order for a physical therapy referral on 7/25/25 and Resident #5 was on a wait list for the referral. The Physical Therapist stated that when they received an order for physical therapy, a screening was done first, then a referral, then the decision was made whether or not a resident was appropriate to picked up for formal physical therapy services. The Physical Therapist stated that because she was the only physical therapist in the building, she had not yet been able to screen Resident #5, but that there were only two other residents ahead of him as of today. The Physical Therapist stated that Resident #5 had been on the physical therapy schedule before but was discharged in December 2024. When he was discharged from therapy he was placed on a functional maintenance program in order to prevent functional decline. The Physical Therapist stated that the functional maintenance programs varied based on specific needs of residents and there was no standard criteria for how or when a resident was moved through the process of screening, to referral and then to being formally accepted for physical therapy services. The Physical Therapist further stated that because Resident #5 was on a functional maintenance program, he would be a lower priority for screening in the event of long wait lists, but that she was doing her best to get to all the residents on the wait list. In a follow up interview with Resident #5 on 8/13/25 at 2:00 PM, Resident #5 was observed in his room. Resident #5 stated that he had a doctor's appointment a few weeks ago, he had been feeling worse, his arms were very stiff before that appointment. The doctor gave him some injections and that helped a lot, and his arms did not feel that stiff now. Resident #5 stated that he felt better right now because of the injections he received but that the doctor told him that he needed therapy so his arms didn't get worse again. He wanted to get his therapy so his arm would stay limber. Resident #5 said he wore his arm braces on his left elbow and left wrist every day for 4 hours like his doctor told him to. Resident #5 stated his family helped him put his braces on some of the time and that staff helped him at other times.Attempts to contact the ordering Neurology physician were unsuccessful. Attempts to interview Resident #5's assigned nurse (Nurses #1) were not successful. Attempts to interview the Director of Nursing were unsuccessful.In an interview with the Administrator on 8/14/25 10:45 AM, the Administrator stated that he did not know the expectations or expected timeframes of when a physical therapy order was placed and when the order should be implemented, but that sometimes the timeframes were different based on resident needs. The Administrator stated that the therapist does a screening, but he did not know anything else because that was out of his scope of practice. In an interview with the Medical Director on 8/14/25 at 2:30 PM, the Medical Director stated that the timeframe of when Resident #5's physical therapy referral order was placed, and the current date was too long. The Medical Director said that she would have expected that order to be carried out within one week and we dropped the ball and there was a breakdown in communication, and I will be following up on that today.

Based on observations, and resident and staff interviews, the facility failed to provide a privacy curtain for 2 of 16 rooms on the 200-hall reviewed for privacy (Resident #27 and Resident #40). The findings included:a. Resident #27 was admitted to the facility on [DATE].The annual Minimum Data Set (MDS) dated [DATE] revealed Resident #27 was cognitively intact.An observation and interview conducted with Resident #27 on 08/11/25 at 10:00 AM revealed Resident #27 did not have a privacy curtain and shared a room with another resident. Resident #27's room was closest to the door and provided no privacy if the Resident's door was open. Resident #27 further revealed he had not had a privacy curtain in a while and could not recall why he did not have one.An observation conducted on 08/12/25 at 11:35 AM revealed Resident #27 did not have a privacy curtain hanging.b. Resident #40 was admitted to the facility on [DATE].The admission MDS dated [DATE] revealed Resident #40 was cognitively intact.An observation and interview conducted with Resident #40 on 08/11/25 at 10:15 AM revealed Resident #40 did not have a privacy curtain and shared a room with another resident. Resident #40's room was closest to the door and provided no privacy if the Resident's door was open. Resident #40 further revealed he had not had a privacy curtain since admission and had asked nursing staff, but they had yet to bring one. Resident #40 stated he would like a privacy curtain due to his roommate and staff constantly entering.An observation conducted on 08/12/25 at 11:10 AM revealed Resident #40 did not have a privacy curtain hanging.An observation and interview conducted with the Director of Housekeeping on 08/12/25 at 11:20 AM revealed she was not aware Resident #27 and Resident #40 did not have a privacy curtain. It was further revealed housekeeping should be checking for curtains daily and making sure they are clean and hanging.An interview conducted with the Administrator on 08/14/25 at 3:05 PM revealed he was not aware Resident #27 and Resident #40 did not have a privacy curtain. It was further revealed it was housekeeping's responsibility to make sure each resident had a privacy curtain. The Administrator stated he expected rooms to be checked daily for privacy curtains and the cleanliness of the privacy curtains.

Based on record review, observations, and resident and staff interviews, the facility failed to ensure accurate medical records regarding the documentation of the application of compression wraps to Resident #87's legs. The deficient practice occurred in 1 of 1 resident reviewed for resident records (Resident #87).Findings included:Review of records for Resident # 87 revealed a physician's order dated 5/28/25 for compression wraps to bilateral (both right and left) legs every morning and to be removed every evening for lymphedema.Review of Resident #87's Treatment Administration Record (TAR) for 8/13/25 revealed documentation by nursing staff that compression wraps were placed at 8:00 AM.On 8/13/25 at 10:00 AM an interview with Resident #87 was conducted in conjunction with an observation. Resident #87 stated that she did not have compression wraps on her legs. Resident #87 uncovered both of her legs which revealed no compression wraps in place to either of her legs. On 8/13/25 at 2:30 PM an interview and record review, with Resident #87's primary nurse, Nurse #1, was conducted. Nurse #1 informed that she did not have anything to do with the Resident's compression wraps. Nurse #1 stated she did not know how often the compression wraps should be applied or when they should be removed. Nurse #1 reviewed the TAR for 8/13/25, which had Nurse #1's initials documenting application of the compression wraps. Nurse #1 confirmed that her initials were noted on the TAR as documenting that the compression wraps were applied on the resident by her at 08:00 AM. Nurse #1 stated she did not know how her initials got there. Nurse #1 then acknowledged that she did not place the wraps on at 8:00 AM but said the wraps were already on, and that was what she charted on at 8:00 AM. Nurse #1 stated she did not how or when Resident #87's leg wraps were removed or who may have removed them.On 8/13/25 at 3:05PM, an interview with the Director of Nursing (DON) was conducted. The DON stated nurses should always document what they do accurately. The DON further explained the expectation was for the nurses to chart what they did and that if a task was charted as having been completed, the expectation was that particular staff member actually completed the task.In an interview with the Administrator on 8/14/25 at 11:55 AM, the Administrator stated his expectation regarding nursing documentation on a TAR was that the initials documented for an order or task at a given time would be the initials of the nurse or staff member completing the task. The Administrator further explained if the nurse or staff member's initials were present, it would indicate the nurse or staff member was the person who completed that task.

Based on record review, and staff and resident interviews the facility failed to provide resolution of Resident Council Meeting grievances for 3 of 3 monthly Resident Council Meetings. The Resident Council had repeated concerns regarding water cups were not filled timely and snacks were not available (2/19/24, 3/18/24, 4/15/24). Findings included: On 2/19/24 the Resident Council Meeting Minutes noted a nursing concern that residents water cups were not filled timely, and snacks were not available. The Resident Council Follow-Up form attached to the 2/29/24 Resident Council Meeting Minutes did not demonstrate the facility's response to grievances voiced during the resident council. On 3/18/24 the Resident Council Meeting Minutes noted a nursing concern that residents water cups were not filled timely, and snacks were not available. The Resident Council Follow-Up form attached to the 3/18/24 Resident Council Meeting Minutes did not demonstrate the facility's response to grievances voiced during the resident council. On 4/15/24 the Resident Council Meeting Minutes noted a nursing concern that residents water cups were not filled timely, and snacks were not available. The Resident Council Follow-Up form attached to the 2/29/24 Resident Council Meeting Minutes did not demonstrate the facility's response to grievances voiced during the resident council. a.Resident # 65 was admitted to the facility on [DATE]. Resident #65's quarterly Minimum Data Set assessment dated [DATE] indicated she was cognitively intact and had no behaviors. On 7/22/24 at 2:00pm during the Resident council Meeting Resident #65 stated that snacks were not always available to residents and that water cups were not filled timely. She further revealed that these grievances had been an issue, and the facility has not addressed their concerns. b. Resident #15 was admitted to the facility on [DATE]. Resident #15's quarterly Minimum Data Set assessment dated [DATE] indicated she was cognitively intact and had no behaviors. On 7/22/24 at 2:00pm during the Resident council Meeting Resident #15 stated that the residents in the meeting had made the facility aware that their water cups were not filled timely, and snacks were not always available to residents, and that the facility staff had not followed up with the committee on the status of their complaints. A review of the grievance logs for 2/1/24-4/30/24 revealed no group resident council grievances. An interview was conducted with the Activities Director on 7/23/24 at 10:58 am. She revealed that during the months of February, March, and April 2024 the process was for her to take minutes and note any grievances voiced during the meeting on the minutes and then to either report them to the facility social worker or the designated department head to address their departmental concerns. She further revealed that the follow-up was completed on the follow-up form by the department head and then she would review that information at the next meeting. An interview was conducted with the Director of Nursing on 7/24/24 at 11:56 am. She indicated that she should have addressed the concerns voiced during 2/16/24, 3/18/24, and 4/15/24 Resident Council Meetings and noted a synopsis of all efforts used to address their grievances. An interview was conducted with the Administrator on 7/23/24 at 2:06 pm and he indicated that grievances voiced during resident council meetings should be addressed and residents should have received follow up to their stated grievances.

Based on observations, record review, resident and staff interviews, the facility failed to assist a resident in obtaining dentures. This occurred for 1 of 3 residents reviewed for dental services. The findings included: Resident # 2 was admitted [DATE] with diagnosis that included hemiplegia. A review of the annual comprehensive Minimum Data Set (MDS) dated [DATE] revealed Resident #2 was cognitively impaired and had no rejection of care. The MDS indicated Resident #2 had obvious or likely cavity or broken natural teeth, no difficulty swallowing or chewing and had weight loss. A review of the care plan revised 1/10/24 included a focused area that was initiated 5/19/22, that read, Resident #2 is at risk for weight fluctuations secondary to hemodialysis. A review of Resident #2's orders revealed a mechanically altered diet. A review of the dental provider #1's documentation for Resident #2 revealed: 1) 4/3/23 Patient had dentures would like new dentures. 2) 10/23/23 Patient requests upper denture. Waiting for approval for lower partial. An interview was conducted with Resident #2 on 7/21/24 at 10:53 am. Resident #2 revealed he had dentures at one time due to missing teeth but could not recall when the last time he had dentures. Resident #2 indicated he had requested new dentures from the facility dentist but had not received any dentures to date. Resident #2 indicated he was able to eat with current diet but when he had dentures, he was able to eat a regular consistency diet and enjoyed eating his food more. A telephone interview was conducted with the dental provider #1 on 7/23/24 at 11:48 am. She revealed Resident #2 was treated last at the facility on 10/23/23 and upper dentures had been approved by Medicaid and the provider was waiting on Medicaid approval for the lower partial. She further revealed the facility terminated their contract before the new dentures could be made. A telephone interview was conducted with dental provider #2 on 7/23/24 at 5:10 pm and she indicated that she worked with the facility to assist in the transition process. She further revealed the dental provider had met with the social worker on 1/30/24 as part of the transition process. The dental provider counseled the social worker on the process of transitioning over residents to their services and provided the new consent forms so the social worker could contact residents or resident representatives to offer services and have consents signed for those who were interested. Dental provider #2 indicated the facility did not provide any referral information to the provider for Resident #2 and was not a current patient of record. An observation was conducted of Resident #2 on 7/23/24 at 3:00 pm eating a chicken snack provided by his responsible party. Resident #2 was able to eat the chicken without difficulty. An interview was conducted with the responsible party on 7/23/24 at 3:04 pm. She indicated that she was not sure why Resident #2 had not received dentures yet and should have had them by now. She further revealed that she had not been contacted by the facility or any dental providers regarding the status of the requested dentures. An interview was conducted with the social worker on 7/24/24 at 8:58 am. She confirmed that she received the new consent forms from dental provider #2 in January of 2024 but did not reach out to Resident #2 or his responsible party to offer dental services because she got busy. An interview was conducted with the Administrator on 7/24/24 at 12:06 pm. He indicated dental services should be provided to residents in a timely manner and the facility social worker should have offered Resident #2's responsible party the opportunity to transition Resident #2 to the new dental provider for services.

Based on record review, and staff and resident interviews, the facility failed to invite the resident to participate in the care planning process for 1 of 23 residents whose care plans were reviewed (Resident # 78). Findings Included: Resident #78 was originally admitted on [DATE]. The most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #78 was cognitively intact. During an interview on 7/21/24 at 10:45 am, Resident #78 stated he had not been invited to attend a care plan meeting for a long time and that he wanted to be asked to attend his care plan meetings. An interview was conducted with the facility Social Worker on 7/23/24 at 12:22 pm. She indicated Resident #78 had not attended a care plan meeting since August 2022 and was not able to confirm if he had been invited to attend any of his care plan meetings after August 2022. She further revealed the [NAME] Office Manager was responsible for sending out care plan invitations. An interview was conducted on 7/23/24 at 2:16 pm with the [NAME] Office Manager. She revealed that she had not invited Resident #78 to his care plan meetings because Resident #78 always seemed to want to run things by his friend. She further revealed that she should have provided Resident #78 with an invitation to attend his care plan meetings and sent out an invitation to his friend as well. An interview was conducted on 7/24/24 at 12:12 pm with the facility Administrator. He indicated that residents should be invited to attend their care plan meetings.

Based on observations, record review, staff interviews, and Nurse Practitioner interview, the facility failed to provide incontinent care in a safe manner which caused a fall (Resident #29). This was for 1 of 3 residents reviewed for accidents. The findings included: Resident #29 was admitted to the facility on [DATE] with diagnoses of Vascular Dementia and Hemiparesis (paralysis of one side of the body) affecting right side of body. Record review revealed Resident #29's care plan last reviewed 2/23/24, showed she required two person staff assistance to re-position and turn in bed. Review of the quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #29 was severely cognitively impaired. She had range of motion (ROM) limitations and impairment to the one side of her body-upper and lower extremity. She required substantial/maximum assistance personal hygiene and bed mobility. Review of incident report dated 2/28/24 revealed Resident #29 rolled off the bed to the floor during morning care while turned on her left side. The bed was in a high position at the time. The report stated the Nurse Practitioner (NP) and Nurse #8 were called to the room. Resident #29 was assessed and found to have a bump forming on her left forehead. Resident was lifted back to bed using mechanical lift. Orders given by NP to send resident out for evaluation and treatment. emergency room notes dated 2/28/24 revealed Resident #29 had developed a hematoma (bruise) on the left side of her forehead described to be approximately an inch in diameter. A computerized tomography (CT) scan of the head and spine was negative for fracture or intracranial hemorrhage. She also received x-rays for her pelvis and upper/lower extremities which were also negative for fracture. No other treatments were provided, and Resident #29 returned to the facility the same day. During an interview with Nurse Aide (NA) #5 on 7/22/24 at 11:38 am, she stated she was on the adjacent hall when she heard NA #4 call out for help. She stated she arrived at Resident #29's room and saw her on the floor. She stated NA #4 told her she was performing incontinent care and had rolled the resident onto her side. She stated she was trying to pull the under pad back toward the center of the bed when Resident #29 rolled off the other side. NA#5 stated the bed was in high position when she walked into the room. NA #5 stated the NP and Nurse #8 were down the hall when the incident occurred. She stated both came and assessed the resident. NA #5 stated she and NA #4 assisted Resident #29 back to bed using the mechanical lift. NA #5 also stated she had not worked with Resident #29 much but she did state she was available to assist NA #4 and did not know why she didn't ask for help. NA#4 was not employed by the facility at the time of survey. Multiple attempts to reach her were unsuccessful. Nurse #8 was not employed by the facility at the time of survey. Multiple attempts to reach her were unsuccessful. During an interview with the Nurse Practitioner (NP) on 7/24/24 at 11:00 am, she stated she was present in the facility when the resident fell . She stated she responded to the room along with Nurse #8 and assessed the resident from head to toe. The bed was in high position when she arrived to the room. She stated Resident #29 had a hematoma that was starting to form on her left forehead. The NP stated the resident's vitals were fine and she had no other complaints. She stated she decided to send her out for evaluation anyway because of the hematoma/head injury. During an interview with the Nurse Consultant, the Administrator, and the Director of Nursing (DON) on 7/24/24 at 2:38 pm, the Administrator stated that he had been made aware of the incident as soon as it occurred and began a plan of correction on 2/29/24. The current DON was not employed at the facility during the incident, but she stated she did continue the monthly audits through May. The Nurse Consultant stated the individual care guide for each resident is available for all staff members for review and all staff members, including agency staff, are expected to follow the care guides when providing care to the residents for their safety. The administrator stated fall prevention is still a part of their monthly quality improvement meetings. The facility provided the following Corrective Action Plan with a completion date of 3/7/24: On 2/28/24, Resident #29 was receiving care by only one aide who attempted to turn Resident #29 in her bed by herself resulting in a fall. The bed was in a high position at the time. The report stated the Nurse Practitioner and Nurse #8 were called to the room. Resident #29 was assessed and found to have a bump forming on her left forehead. Resident was lifted back to bed using mechanical lift. The Nurse Practitioner gave orders to send resident out to the hospital for further evaluation. On 2/29/24, the DON completed an audit of all current residents who required two staff members to assist with bed mobility. On 2/29/24 the DON in-serviced all nursing staff, including agency, on the falls prevention policy and included using the care guides for bed mobility. The DON or designee will ensure that any staff who does not complete the in-service training by 3/4/24 will not be allowed to work. The facility made the decision to discuss the deficiency, the plan of correction including monitoring, and when to begin discussing it in their weekly QA meetings on 3/7/24. Beginning 3/8/24, the DON or designee will monitor staff weekly for 2 weeks, every other week x 2 months, and then monthly using the bed mobility monitoring tool to ensure staff members were following the care guides when providing incontinent care to residents and using two staff members for bed mobility as care planned. Reports will be presented to the weekly QA committee beginning 3/11/24 by the Administrator or DON to ensure corrective action initiated as appropriate. Compliance will be monitored and ongoing auditing program reviewed at the weekly QA meetings. Allegation of Compliance Date: 3/7/24 Interviews with nursing staff, including agency staff, revealed the facility had provided education and training on how to care for residents requiring two-person assistance for bed mobility and using the mechanical lift for transfers. The training also included where to locate information on residents who required two-person assistance for bed mobility and those who required the mechanical lift for transfers. Staff rosters were provided by the facility and showed most of the training occurred on 2/29/24 with additional staff completing the training on 3/1/24. Any staff member who did not completed the training by 3/1/24 would not be allowed to work. All new agency staff and new hires completed the training during orientation. The survey team did multiple observations during the week of residents who required two staff members for bed mobility. Staff members were observed providing incontinent care and bed baths using two staff members as needed based on the resident's care guide. Staff interviewed all verbalized they had been observed performing incontinent care and bed baths by the DON or designee and were able to verbalize where to locate the care guide for each individual resident. Review of the monitoring tool showed audits were performed weekly x 2 weeks, every other week x 1 month and then monthly for an additional 2 months. No further falls related to care have occurred. The Corrective Action plan was validated on 7/24/24 and concluded the facility had implemented an acceptable corrective action plan on 3/7/24.

Based on observations, record review, and staff interviews, the facility failed to secure the urostomy (an opening in the urinary system) tubing per the physician order on 1 of 4 residents observed for urinary catheters (Resident #48). Findings included: Resident #48 was admitted to the facility on [DATE]. Resident 48's diagnoses included urinary bladder cancer with urine retention. His admission Minimum Data Set (MDS) assessment, dated 6/12/24, revealed the resident was moderately cognitively impaired. He required extensive assistance with activities of daily living, including incontinent care, had a urostomy and was always incontinent of bowel. Review of Resident 48's plan of care, dated 7/22/24, revealed a urostomy, related to urinary bladder cancer, with interventions including anchoring (through use of the leg band) the catheter (tubing) to prevent excess tension. Review of the physician's s order for Resident #48, dated 6/6/24, revealed an order for urostomy catheter care every shift and as needed. Ensure the leg band is in place. On 7/23/24 at 8:05 AM, during the observation of incontinent care for Resident #48, provided by Nurse Aide #3, the urostomy tubing was observed to be unsecured to the resident's leg. There was no anchoring device present on the resident's legs. On 7/23/24 at 8:20 AM, during an interview, Resident #48 indicated he was not sure about securing the urostomy catheter tubing and could not recall the anchoring device on his legs. On 7/23/24 at 8:55 AM, during an interview, Nurse Aide #3 indicated that she did not know that Resident #48 had his urostomy catheter tubing unsecured at the beginning of her shift. She continued it was the responsibility of the nurses to apply the anchors to secure the urinary catheter tubing to the resident's leg. She did not observe the anchoring device on resident's legs. On 7/23/24 at 10:05 AM, during an interview, Nurse #8 indicated she was not aware Resident #48 did not have his urostomy tubing secured to the leg, nor did he have the stabilization device (leg band) on his leg. Nurse #8 confirmed that it was the nurses' responsibility to secure the urinary catheter tubing to the resident's leg. Nurse #8 did not check the urinary catheter tubing status at the beginning of her shift today. The nurse aides did not report absences of tubing anchor for Resident #48. On 7/23/24 at 1:15 PM, during an interview, the Director of Nursing (DON) expected the nursing staff to have secured the urinary catheters tubing to prevent injury to the resident and to maintain the urine flow.

Based on record reviews and staff interviews, the facility failed to provide Registered Nurse (RN) coverage at least 8 consecutive hours a day for 7 out of 72 days reviewed for staffing. The failure to have RN coverage for the facility had a high likelihood of impacting every resident in the facility. The facility also failed to prevent the Director of Nursing (DON) from serving as a charge nurse with a facility census of greater than 60 residents for two days, 8/20/23 and 7/30/23. The findings included: Review of the Posted Nurse Staffing as compared to the Staff Schedule/Assignment Sheets, and RN timecard reports revealed there was no RN coverage for eight consecutive hours for 9/10/23, 9/3/23, 8/12/23, 8/6/23, 8/5/23, 7/23/23, 7/2/23. Further review of the Posted Nurse Staffing as compared to the Staff Schedule/Assignment Sheets and RN timecard reports for the same period revealed the DON served as the charge nurse on 8/20/23 with a facility census of 103 and on 7/30/23 with a facility census of 104. An interview was conducted on 9/13/23 at 3:09 PM with the DON. She stated she did not have an RN on 9/10/23, 9/3/23, 8/12/23, 8/6/23, 8/5/23, 7/23/23, 7/2/23. She further stated the agency did not have an RN available at that time. She stated she has had a hard time finding an RN to hire. The DON also stated that the facility currently has only 3 Registered Nurses on staff. She stated she was not aware that she could not be listed as the only RN on duty for the day if the facility census was greater than 60. An interview was conducted on 9/13/13 and 9/15/23 at 1:35 PM with the facility Nurse Consultant who stated she was unaware of the RN staffing issues at the facility. She did state that she is aware of the regulation that stated the facility had to provide RN coverage for at least 8 consecutive hours a day and that the DON can't serve as a charge nurse with a facility census greater than 60.

Based on record review and staff, Medical Director, Nurse Practitioner, and Pharmacist interviews, the facility failed to prevent a significant medication error by failing to administer a prescribed medication for Parkinson's disease at the dose ordered by a physician for 11 of 11 doses administered for 1 of 1 resident (Resident #354) reviewed for medication errors. Findings Included: Resident #354 was admitted to the facility on [DATE]. His cumulative diagnosis included Parkinson's disease (a disease of the central nervous system that affects movements, often including tremors). Physician order dated 8/29/23 read Azilect (a medication used to treat the symptoms of Parkinson's disease) oral tablet 0.5 milligrams (mg) give one tablet by mouth in the morning for Parkinson's disease. The start date was 8/30/23 at 9:00 A.M. Review of the admission Minimum Data Set (MDS) dated [DATE] showed Resident #354 was cognitively intact. Review of the Medication Administration Record (MAR) for 8/30/23 through 9/12/23 revealed Azilect was documented as follows. - 8/30/23 at 9:00 A.M. not administered by Nurse #3; medication was unavailable - 8/31/23 at 9:00 A.M. administered by Nurse #3 - 9/1/23 at 9:00 A.M. not administered by Nurse #3; resident had nausea/vomiting - 9/2/23 at 9:00 A.M. administered by Nurse #6 - 9/3/23 at 9:00 A.M. administered by Nurse #7 - 9/4/23 at 9:00 A.M. administered by Nurse #3 - 9/5/23 at 9:00 A.M. administered by Nurse #8 - 9/6/23 at 9:00 A.M. administered by Nurse #3 - 9/7/23 at 9:00 A.M. not administered by Nurse #3; resident out of the facility. - 9/8/23 at 9:00 A.M. administered by Nurse #3 - 9/9/23 at 9:00 A.M. administered by Nurse #9 - 9/10/23 at 9:00 A.M. administered by Nurse #10 - 9/11/23 at 9:00 A.M. administered by Nurse #3 - 9/12/23 at 9:00 A.M. administered by Nurse #3 An interview was attempted with Resident #354 on 9/15/23 at 7:40 A.M, 9/15/23 at 10:40 A.M., and 9/15/23 at 11:35 A.M. The interview was unsuccessful. On 9/12/23 at 9:06 A.M., Nurse #3 was observed as she prepared and administered medication to Resident #354. The administered medications included one tablet of Azilect 1 mg. An interview was conducted on 9/12/23 at 9:43 A.M. with Nurse #3. During the interview the packaged bubble sheet for Resident #354's Azilect was reviewed with Nurse #3. The packaged bubble sheet for Azilect showed 1 tablet of Azilect 1 mg sealed in each bubble slot. The label read in part Take 1 tablet by mouth every morning. The label on the Azilect package was compared with the physician orders. Nurse #3 confirmed the physician order read administer Azilect 0.5mg each morning and on 9/12/23 during Resident #354's 9:00 A.M. medication pass, she had administered Azilect 1mg to Resident #354. Nurse #3 stated she had only verified Resident #354's name and the name of the medication on the pharmacy package. During the interview, Nurse #3 stated the nurse who administered medication to residents were responsible for verifying the medication dispensed from the bubble sheet matched the resident's name, the medication name, and the dosage ordered by the physician. During the interview, Nurse #3 stated she had not verified the dose of Azilect removed from the bubble sheet matched the physician order because she had previously administered Resident #354 his medications from the same packaging and she thought the medication was the right dose. During the interview, Nurse #3 stated Resident #354 had not voiced any concerns to her of not feeling well on 9/12/23 and to the best of her knowledge Resident #354 had no complaints of not feeling well since his admission. During a follow-up interview conducted on 9/15/23 at 11:44 A.M. with Nurse #3, she stated she notified the Nurse Practitioner (NP)of the error on Resident #354's Azilect's label from the pharmacy on 9/12/23 at about 10:30 A.M. Nurse #3 explained the NP told her to not use the medication in the bubble package until it had been corrected and the NP advised her to contact the pharmacy to have a new bubble package of Azilect sent with the dose of 0.5mg. An interview was attempted with Nurse #6 who was assigned to Resident #354 on 9/2/23 during the 9:00 A.M. medication administration pass was unsuccessful. An interview was attempted with Nurse #7 who was assigned to Resident #354 on 9/3/23 during the 9:00 A.M. medication administration pass was unsuccessful. An interview was conducted with Nurse #8, who was assigned to Resident #354 on 9/5/23 during the 9:00 A.M. medication administration pass. During the interview, Nurse #8 stated she works throughout the facility, and she does not specifically recall Resident #354's medication administration pass on 9/5/23 at 9:00 A.M. During the interview, Nurse #8 stated when she administered medication, she checked the name and dosage of medication on the packaged bubble sheet and compared the information with the physician order. Nurse #8 explained if she had identified the dose did not match, she would have cut the Azilect in half and administered only half the tablet to equal the correct dose. Nurse # 8 was unable to recall if the Azilect tablet had been cut in half. An interview was attempted with Nurse #9 who was assigned to Resident #354 on 9/9/23 during the 9:00 A.M. medication administration pass was unsuccessful. An interview was conducted on 9/15/23 at 11:50 A.M. with Nurse #10 who was assigned to Resident #354 on 9/10/23 during the 9.00 A.M. medication administration pass. During the interview, Nurse #11 stated she does not recall Resident #354 or administering him his medications on 9/10/23. Nurse #11 explained when the pharmacy sent bubble packages with the resident's medications, each bubble contained the correct dosage of medication for each medication administration. Nurse #11 stated she would have pushed the tablet out of one sealed bubble and administered the medication to the resident. During the interview, Nurse #11 stated she had never cut medication in half when she removed the medication from the bubble and explained if half a pill was needed the pharmacy would have sent a half a pill in each bubble. Nurse #11 stated she does not recall Resident #354 having any concerns of not feeling well when she was assigned to his care on 9/10/23. An interview was conducted on 9/14/23 at 11:03 A.M. with the Pharmacist. During the interview, the Pharmacist stated they received an order for Resident #354's Azilect 0.5mg on 8/29/23. The order was filled incorrectly by the pharmacy when the numeric code used to identify the medication by manufacturer and strength was incorrect, and a packaged bubble sheet of Azilect 1mg was sent to the facility on [DATE]. The Pharmacist explained Azilect was not a medication the facility had on hand in a backup pharmacy at the facility and the order had to be filled and delivered by the pharmacy staff. The Pharmacists reviewed Resident #354's record and stated there were no phone calls logged from the staff at the facility on the dosing of Resident #354's Azilect being inaccurate until 9/12/23. She explained at this time the pharmacy sent a new bubble sheet for Resident #354 which contained Azilect 0.5mg. The Pharmacist explained Resident #354 would not have been affected by the higher dose of Azilect because Resident #354's record showed he did not have a diagnosis of liver damage. An interview was completed on 9/14/23 at 4:22 P.M. with the Nurse Practitioner (NP). During the interview, the NP stated on 9/12/23 she was in the building working when Nurse #3 showed her Resident #354's medication bubble sheet for Azilect and explained the dosage did not match the physician order. The NP stated she reviewed the physician order for Resident #354's Azilect and saw the order read Azilect 0.5mg every morning and the bubble sheet read Azilect 1mg every morning. The NP advised Nurse #3 to call the pharmacy and make them aware of the discrepancy. The NP further stated when she worked on 9/12/23, no concerns were brought to her about Resident #354 not feeling well. The NP further stated there would have been no negative outcome for Resident #354 had he taken 1mg of Azilect instead of 0.5mg of Azilect. An interview was conducted on 9/13/23 at 4:14 P.M. with the Director of Nursing (DON). During the interview the DON stated during each medication administration pass, the nurse who administered medications was responsible for verifying the dosage of dispensed medication with the physician order prior to administering the medication to residents. The DON further explained when the physician order did not match Resident #354's dispensed dose of Azilect on the medication cart, the assigned nurse was responsible for verifying the dose of Resident #354's Azilect with the pharmacist and/or the physician prior to administering Resident #354 his medication. The DON was unsure why this had not occurred for Resident #354's Azilect. An interview was completed on 9/13/23 at 12:55 P.M. with the Medical Director. During the interview, the Medical Director stated when staff did not have the correct dose of medication to administer to a resident, the staff were responsible for contacting either herself or the Nurse Practitioner and making them aware so additional orders could be given as needed. The Medical Director stated Azilect was used to control tremors in patients with Parkinson's disease and she explained Resident #354 would not have been harmed when he received a 1 mg dose instead of a 0.5mg dose of Azilect.

Based on observations, record review and staff interview, the facility's Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedures and monitor the interventions that the committee put into place following the recertification, complaint, and infection control surveys completed on 7/23/21 and 9/24/21. This was for 2 deficiencies that were cited in the areas of Label/Store Drugs and Biologicals (761) which was cited on 7/23/21 and recited on the current recertification and complaint survey of 9/15/23; and Residents are Free of Significant Medication Errors (760) which was cited on 9/24/21 and recited on the current recertification and complaint survey of 9/15/23. The continued failure of the facility during three federal surveys showed a pattern of the facility's inability to sustain an effective Quality Assessment and Assurance Program (QAA). The findings included: This citation is cross-referenced to: F760: Based on record review and staff, Medical Director, Nurse Practitioner, and Pharmacist interviews, the facility failed to prevent a significant medication error by failing to administer a prescribed medication for Parkinson's disease at the dose ordered by a physician for 11 of 11 doses administered for 1 of 1 resident (Resident #354) reviewed for medication errors. During the complaint investigation survey on 9/24/21, the facility failed to initiate the administration of two intravenous antibiotics after receipt of a physician's order for 1 of 1 resident reviewed who required treatment with an intravenous antibiotic medication. F761: Based on observations and staff interview, the facility failed to properly discard three expired vaccines, Prevnar 20 (Pneumococcal 20-valent Conjugate Vaccine) that were available for use in 1 of 3 medication rooms (100 hall nurse's station). During the recertification, complaint investigation, and infection control survey on 7/23/21, the facility failed to discard expired medications stored in 3 of 3 medication carts (200 Hall Med Cart, 500 Hall Med Cart, and 400 Hall Med Cart) and in 1 of 2 medication rooms (200/300 Hall Med Room) observed. During an interview on 9/15/23 at 2:30 PM, the Administrator revealed the QAA committee meets monthly and whenever needed. He stated negative trends were brought to the QAA committee's attention via staff, residents, families, and/or other members. The Administrator stated that during each monthly QAA meeting, a non-QAA staff from one of the departments is invited to attend monthly meetings to teach them the QAPI process including the education, audit and monitoring process as quality control/plan of care.

Based on record review and staff interviews the facility Transportation Aide failed to secure the wheelchair to the floor of the facility van according to manufacturer's instructions before transporting one of one resident reviewed for van transportation, Resident #54. During transport the wheelchair with Resident #54 fell backwards with the resident landing on her back and hitting her head on the van floor. Resident #54 complained of right shoulder pain after the incident. The Transportation Aide failed to call 911 and the facility after the incident and moved the resident back to a sitting position in the wheelchair after the incident. Resident #54 complained of right shoulder pain after the incident. This was for one of one residents transported in the facility van Resident #54. The findings included: Review of the manufacturer's recommendations Q'Straint provided the following instructions to secure the wheelchair: 1. Place wheelchair facing forward in securement area; apply wheel locks or turn power off. 2. Attach tie-downs into floor anchorages and ensure they are locked in. 3. Attach the four tie-down hooks to solid frame members or weldments, near seat level. Ensure tie-downs are fixed at approximately 45 degrees, and are within angles shown. Do not attach hooks to wheels, plastic, or removable parts of wheelchair. 4. Ensure all tie-downs are locked and properly tensioned. If necessary, rock wheelchair back and forth or manually tension retractor knobs to take up additional webbing slack. Review of the facility policy and procedure for resident transportation, with a revision date of ,[DATE] included in part: on page 4 of 8, Transportation Policy: 1. Resident transportation should be completed by employees who have been trained to do so. Transportation aides must be current Nursing Assistants or Emergency Medication Technicians. The must also have valid CPR training . 5. In the event of an emergency, call 911. Provide basic first aid. Implement CPR if it is indicated such as no heartbeat or breathing. Do not move patient if injury is suspected or unless life is threatened . Resident #54 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), a significant change, dated [DATE] indicated Resident #54 had no impairment with long or short memory and she exhibited no behaviors. The MDS indicated she required extensive assistance of two staff for bed mobility, dressing and transfer. She was not ambulatory, and required extensive assistance of one staff member for personal hygiene. Review of Transportation Aide (TA) #1's safety training for use of the van dated [DATE] revealed a check list that included Secure Resident Safely for Lift Operation and Secure resident for transport with approved system safety device which includes using seat belts to secure the person and using approved safety straps, belts and hooks to secure the chair. Both of these were checked indicating she had been observed and was able to perform the tasks. Review of an incident report dated [DATE] at 6:43 PM indicated Resident #54 was observed during a facility van transport, while in-route, to have her legs up in the air when viewed by the TA #1 in her rear- view mirror. TA #1 stopped the van, found Resident #54 lying on her back in the wheelchair. The incident report indicated the whole wheelchair fell backwards. Resident #54 informed the van driver her wheelchair fell backwards while the bus was turning. Review of the nurse's note dated [DATE] at 7:34 PM indicated the nurse was informed of the incident after Resident #54 was in the dining room eating dinner. After the resident finished her meal, the nurse took her to her room for an assessment. The resident had no bumps or bruises on her head and no bruises or red areas noted on her body. Full range of motion of her extremities was checked with no #1 after Resident #54 was in the dining room eating dinner. After the resident finished her meal, the nurse took her to her room for an assessment. The resident had no bumps or bruises on her head and no bruises or red areas noted on her body. Full range of motion of her extremities was checked with no limitations. Resident #54 complained of pain of the right shoulder when her arm was raised. Nurse #1 documented the family and the on call Physician's Assistant were notified of the incident. An order was obtained to X-Ray the resident's right shoulder. Review of the nurses' note dated [DATE] revealed an X-Ray report indicated negative results for a fracture or dislocation of the right shoulder. The X-Ray indicated Resident #54 had chronic rotator cuff tear, moderate [MEDICAL CONDITION] and osteopenia. Review of a self-report by the facility dated [DATE] revealed a report of an allegation of neglect that occurred on [DATE] at 5:00 PM. The report indicated Resident #54 had tipped backward in the wheelchair during transport. Part of the investigation included a statement by the TA#1. TA #1's statement included she arrived at a doctor's office around 4:26 PM on [DATE], to pick the resident up for transport back to the facility. She secured all four bases of the wheelchair with safety straps. She placed the seatbelt strap around the resident's waist and through the right side of the resident's arm rest, securing both straps in place. As the driver made a left turn onto (Street Name) road, the resident informed her the wheelchair had fallen over. She looked into the rearview mirror and realized the resident's foot was upright. She proceeded to drive until she was able to find a safe and secure place to park. She kept in verbal contact with the resident to ensure she was conscious. She was about 2 blocks from the facility when she stopped the van. She asked the resident if she was alright and/or hurt. The resident informed her that she had hit the right side of her head against the van floor. The resident had no apparent injuries so she proceeded to secure the seatbelt strap to release and move the resident and secure the wheelchair upright. After the wheelchair was secured with all four straps in place, she lifted the resident and placed her into the wheelchair. Again, she checked to see if the resident had any open wounds or bruises. She then secured her with the seatbelt and proceeded back to the facility while talking to the resident. Upon arrival to the facility, she unloaded the resident and brought her into the building. She notified the administrator of the incident. Resident #54 had been discharged from the facility to an assisted living facility in a neighboring state. She was not available for interview. Interview on [DATE] at 8:46 AM with the Administrator revealed she had TA #1 do a return demonstration of how she tied down the wheelchair in the van. After the demonstration, it was determined TA#1had not placed the securing device correctly to lock it and had not pulled it tight to secure it. The van driver was the back up driver. It was determined in the facility investigation TA #1 did not follow protocol after the incident. The Administrator would expect the driver to call 911, not move the resident and not proceed to the facility. The van driver had her own personal cell phone when the incident occurred. The administrator explained the van had not been used by the facility since [DATE]. A sister facility had the van until yesterday ([DATE]). The keys to the van are in the administrator's office and secured by the administrator. Further interview revealed TA#1 had been terminated on [DATE]. The main TA#2 would be in-serviced by the corporate management staff before using the van again. The administrator did express the facility would be using the van after the training was completed. At present, there was not a date certain as to when the van would be used. No other incidents had occurred during transport with the facility van prior to [DATE]. Interview with the Director of Nursing (DON) on [DATE] at 11:10 AM revealed she received a call an incident had occurred with Resident #54 in the van. The resident tilted backwards during transport from a doctor's visit to the facility. Further interview revealed she did not remember who called her. The Administrator had completed an investigation of the event. A return demonstration was performed by TA#1 in the presence of the Administrator. The TA #1 was suspended pending the outcome of the investigation and all transports using the facility van was suspended on [DATE]. Interview with the Nurse #1 on [DATE] at 1:02 PM revealed the TA #1 had not informed her of the incident. Nurse #1 was the charge nurse for Resident #54. The Administrator had approached her and asked her to complete an incident report on the occurrence. She had not observed the resident before she was brought into the facility and was not sure when Resident #54 had returned to the facility. The resident returned to the facility approximately 5:00 PM and the nurse was informed about two hours later. She completed the incident report and assessed the resident after Resident #54 had finished eating supper. Nurse #1 clarified there were no injuries observed during her assessment. An attempt to call the van driver #1 on [DATE] at 3:00 PM was made with no answer at the phone number provided. Follow up interview with the Administrator on [DATE] at 4:40 PM revealed the facility van had been in use from [DATE] to [DATE]. Review of the re-training of TA's #2 and #3 indicated it was completed on [DATE] by a corporate staff member. The facility provided a plan of correction with a correction date of [DATE]. The plan of correction included: The facility immediately began investigating the incident involving resident #54 occurring on [DATE] in which resident was being transported back to the facility after a medical appointment. In route to the facility resident #54 informed the van transportation aide that her wheelchair had fallen over. The van transportation aide then looked into the rearview mirror and realized the patient's foot was upright. The van transportation aide then proceeded to drive until she was able to find a safe and secure place to park, while talking to the patient to make sure patient remained conscious. The van transportation aide was about two blocks from the facility when she stopped the van. The van transportation aide then asked resident if she was alright and or hurt. The patient per the van transportation aide had no apparent injuries so she proceeded to secure the seatbelt strap to release and move patient so she could secure the wheelchair upright. Once the wheelchair was upright and secured with all four straps in place, the van transportation aide lifted the patient placing her into the wheelchair. The van transportation aide then checked to make sure the patient did not have any open wounds and or bruises. The van transportation aide then secured patient with seatbelt and proceeded back to the facility while continuing to talk to patient. Upon arriving to the facility, the van transportation aide unloaded the resident and brought her into the facility dining room. The van transportation aide informed Administrator of the incident. The administrator then notified the nurse on the hall of the incident. At that time, when administrator was notifying the nurse, the resident was in the dining room. When the administrator finished notifying the nurse of the incident, the nurse went into the dining room to find the resident was eating her dinner independently and was talking with other residents. Nurse informed resident that she needed to complete an assessment due to the incident that happened in the van. Resident then told the nurse that she wanted to finish dinner and asked if the nurse could wait until she was done with dinner. Resident did not show any signs of distress, no apparent or obvious signs of injury were noted. Once the resident completed her dinner, the nurse then proceed to take resident back to the room and transferred her to the bed. The nurse completed a full body assessment. The nurse assessed residents head with a flash light and observed no bumps or discolorations. Full range of motion was done to her extremities. Nurse noted that resident moved all extremities well but did complain about her right shoulder hurting when she raised her arm up. Neurochecks were initiated and were all within normal limit. Vital signs were obtained and were Temperature 98.7, P-87, and R -20 B/P 125 /72. Resident #54 family member and Physicians were called and informed of the incident. An order was obtained for a right shoulder x ray. X -Ray to right shoulder was completed on [DATE]. There was no evidence of acute fracture or dislocation. The findings were compatible with chronic rotator cuff tear, moderate [MEDICAL CONDITION], and moderate osteopenia. On [DATE], the facility van was taken out of operation through [DATE]. A 24 hour report was completed on [DATE] and a 5 day report was completed on [DATE]. Outside transportation company was used to scheduled necessary transports for the facility. The involved employee #1 was suspended on [DATE] and subsequently terminated on [DATE]. The facility owned van was taken out of operation from [DATE] through [DATE]. On [DATE], 2 facility staff designated to aide in facility transportations were checked off by the corporate van trainer utilizing the skills checklist and Q' Straint manufacturer guidelines. The corporate van trainer has received training directly from Q' Straint/Surelock National Training Seminar products in [DATE]. The corporate van trainer utilizes the training he received, Q' Straint manufacturer guidelines, and a skills checklist to educate van transporters. A skills validation is also completed where the staff member must demonstrate the skills appropriately. This also included educating the new team members on the need to stop and call 911 for any accident that occurs during transports. Training was completed by the corporate van trainer on [DATE] prior to the transportation aide completing any van transports. The facility owned van was placed back in service from [DATE] through [DATE]. The facility has not utilized the facility owned van since [DATE] and the facility owned van keys were with the Administrator and no one has access to the keys. The facility owned van will be out of service until new facility staff are designated and trained by the corporate van trainer. On [DATE], corporate van trainer educated 2 facility staff designated to aide in facility transportations; Education included; Investigation of incident: Prior to transporting any patient on the company owned van, the employee conducting the transport must be trained by our corporate van trainer .This training will include the policy statement that: In the event of an emergency, STOP and call 911. Provide basic first aid. Implement CPR if it is indicated such as no heartbeat or breathing. Do not move patient if injury is suspected or unless life is threatened. This information has been integrated into the standard orientation training and in the required in-service refresher courses for all employees who operate the facility van and will be reviewed by the Quality Assurance process to verify that the change has been sustained. Any staff member designated to aide in facility transportation or any in-house staff involved with the facility transportation, who did not receive in-service training will not be allowed to work or participate in facility transportation using the facility owned van until training is completed. Validation of the credible allegation of compliance included review of the training information on safety and emergency procedures, interviews of the two TAs to verify their understanding of the safety training, verification the TA was CPR certified, review of the van audits completed by the corporate staff member and visualizing the van keys kept in the administrator's office.

Based on record review and staff interviews the facility Transportation Aide failed to secure the wheelchair to the floor of the facility van according to manufacturer's instructions before transporting one of one resident reviewed for van transportation, Resident #54. During transport the wheelchair with Resident #54 fell backwards with the resident landing on her back and hitting her head on the van floor. Resident #54 complained of right shoulder pain after the incident. The findings included: Review of the manufacturer's instructions Q'Straint provided the following: 1. Place wheelchair facing forward in securement area; apply wheel locks or turn power off. 2. Attach tie-downs into floor anchorages and ensure they are locked in. 3. Attach the four tie-down hooks to solid frame members or weldments, near seat level. Ensure tie-downs are fixed at approximately 45 degrees, and are within angles shown. Do not attach hooks to wheels, plastic, or removable parts of wheelchair. 4. Ensure all tie-downs are locked and properly tensioned. If necessary, rock wheelchair back and forth or manually tension retractor knobs to take up additional webbing slack. Review of the facility policy and procedure for resident transportation, with a revision date of [DATE] included in part: on page 4 of 8, Transportation Policy: 1. Resident transportation should be completed by employees who have been trained to do so. Transportation aides must be current Nursing Assistants . must also have valid CPR training . 5. In the event of an emergency, call 911. Provide basic first aid. Implement CPR if it is indicated such as no heartbeat or breathing. Do not move patient if injury is suspected or unless life is threatened . Resident #54 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), a significant change, dated [DATE] indicated Resident #54 had no impairment with long or short memory and she exhibited no behaviors. The MDS indicated she required extensive assistance of two staff for bed mobility, dressing and transfer. She was not ambulatory, and required extensive assistance of one staff member for personal hygiene. Review of the Transportation Aide (TA) #1's safety training for use of the van dated [DATE] revealed a check list that included Secure Resident Safely for Lift Operation and Secure resident for transport with approved system safety device which includes using seat belts to secure the person and using approved safety straps, belts and hooks to secure the chair. Both of these items were checked indicating she had been observed and was able to perform the tasks. Review of an incident report dated [DATE] at 6:43 PM indicated Resident #54 was observed during a facility van transport, while in-route, to have her legs up in the air when viewed by TA #1 in her rear view mirror. TA #1 stopped the van, found Resident #54 lying on her back in the wheelchair. The incident report indicated the whole wheelchair fell backwards. Resident #54 informed the van driver her wheelchair fell backwards while the bus (van) was turning. Review of the nurse's note dated [DATE] at 7:34 PM and signed by Nurse #1, indicated Nurse #1 was informed of the incident after Resident #54 was in the dining room eating dinner. After the resident finished her meal, the nurse took her to her room for an assessment. The resident had no bumps or bruises on her head and no bruises or red areas noted on her body. Full range of motion of her extremities was checked with no limitations. Resident #54 complained of pain of the right shoulder when her arm was raised. Review of the medical record revealed neurological assessments were initiated on [DATE] at 7:34 PM as part of the nurses' assessments. Resident #54 had no symptoms of a head injury per the assessments. Review of the nurses' note dated [DATE] revealed an X-Ray was ordered of the right shoulder with negative results for a fracture or dislocation. The X-Ray indicated Resident #54 had chronic rotator cuff tear, moderate osteoporosis and osteopenia. Review of the nurse practitioner's progress note dated [DATE] indicated the resident was seen due to a fall from the wheelchair while inside the van. Resident #54 was assessed and found to have limited range of motion of bilateral shoulders which was chronic. The X-Ray report and findings were reviewed with no fracture or dislocation noted. The progress note listed [DIAGNOSES REDACTED]. Review of self-report by the facility dated [DATE] revealed a report of an allegation of neglect that occurred on [DATE] at 5:00 PM. The report indicated Resident #54 had tipped backward in the wheelchair during transport. Part of the investigation included a statement by TA #1 indicated she arrived at a doctor's office around 4:26 PM on [DATE], to pick the resident up for transport back to the facility. She secured all four bases of the wheelchair with safety straps. She placed the seatbelt strap around the resident's waist and through the right side of the resident's arm rest, securing both straps in place. As the driver made a left turn onto (Street Name) road, the resident informed her the wheelchair had fallen over. She looked into the rearview mirror and realized the resident's foot was upright. She proceeded to drive until she was able to find a safe and secure place to park. She kept in verbal contact with the resident to ensure she was conscious. She was about 2 blocks from the facility when she stopped the van. She asked the resident if she was alright and/or hurt. The resident informed her that she had hit the right side of her head against the van floor. The resident had no apparent injuries so she proceeded to secure the seatbelt strap to release and move the resident and secure the wheelchair upright. After the wheelchair was secured with all four straps in place, she lifted the resident and placed her into the wheelchair. Again, she checked to see if the resident had any open wounds or bruises. She then secured her with the seatbelt and proceeded back to the facility while talking to the resident. Upon arrival to the facility, she unloaded the resident and brought her into the building. She notified the administrator of the incident. Resident #54 had been discharged from the facility to an assisted living facility in a neighboring state. She was not available for interview. Interview on [DATE] at 8:46 AM with the Administrator revealed she had the TA#1 do a return demonstration of how she tied down the wheelchair in the van. After the demonstration, it was determined the TA#1 had not placed the securing device correctly to lock it and had not pulled it tight to secure it. TA #1 was the back up driver. The administrator explained the van had not been used by the facility since [DATE]. A sister facility had the van until yesterday ([DATE]). The keys to the van were in the administrator's office and secured by the administrator. Further interview revealed TA#1 had been terminated on [DATE]. TA#2 will be in-serviced by the corporate management staff before using the van again. The administrator did express the facility would be using the van after the training was completed. At present, there was not a date as to when the van would be used. No other incidents had occurred during transport with the facility van prior to [DATE]. Interview with the Director of Nursing (DON) on [DATE] at 11:10 AM revealed she received a call an incident had occurred with Resident #54 in the van. The resident tilted backwards during transport from a doctor's visit to the facility. Further interview revealed she did not remember who called her. The administrator had completed an investigation of the event. A return demonstration was performed by the TA#1 in the presence of the Administrator. TA#1 was suspended pending the outcome of the investigation and all transports using the facility van were suspended on [DATE]. Interview on [DATE] at 8:46 AM with the Administrator revealed she had TA#1 do a return demonstration of how she tied down the wheelchair in the van. After the demonstration, it was determined TA #1 had not placed the securing device correctly to lock it and had not pulled it tight to secure it. TA#1 was the back up driver. It was determined in the facility investigation TA#1 did not follow protocol after the incident. The Administrator would expect the driver to call 911, not move the resident and not proceed to the facility. The van driver had her own personal cell phone when the incident occurred. Interview with the Nurse #1 on [DATE] at 1:02 PM revealed TA#1 had not informed her of the incident. Nurse #1 stated the Administrator had approached her and asked her to complete an incident report on the occurrence. The nurse explained she had not observed the resident before she was brought into the facility and was not sure when she had returned to the facility. Nurse #1 completed the incident report and assessed the resident after Resident #54 had finished eating supper. She clarified there were no injuries observed during her assessment. An attempt to call TA#1 on [DATE] at 3:00 PM was made with no answer at the phone number provided. Follow up interview with the Administrator on [DATE] at 4:40 PM revealed the facility van had been in use from [DATE] to [DATE]. Review of the re-training of TA#2 and #3 indicated it was completed on [DATE] by a corporate staff member. The facility provided a plan of correction with a correction date of [DATE]. The plan of correction included: The facility immediately began investigating the incident involving Resident #54 occurring on [DATE] in which resident was being transported back to the facility after a medical appointment. In route to the facility Resident #54 informed the van transportation aide that her wheelchair had fallen over. The van transportation aide then looked into the rearview mirror and realized the patient's foot was upright. The van transportation aide then proceeded to drive until she was able to find a safe and secure place to park, while talking to the patient to make sure patient remained conscious. The van transportation aide was about two blocks from the facility when she stopped the van. The van transportation aide then asked the resident if she was alright and or hurt. The patient per the van transportation aide had no apparent injuries so she proceeded to secure the seatbelt strap to release and move patient so she could secure the wheelchair upright. Once the wheelchair was upright and secured with all four straps in place, the van transportation aide lifted the patient placing her into the wheelchair. The van transportation aide then checked to make sure the patient did not have any open wounds and or bruises. The van transportation aide then secured patient with seatbelt and proceeded back to the facility while continuing to talk to patient. Upon arriving to the facility, the van transportation aide unloaded the resident and brought her into the facility dining room. The van transportation aide informed Administrator of the incident. The administrator then notified the nurse on the hall of the incident. At that time, when Administrator was notifying the nurse, the resident was in the dining room. When the administrator finished notifying the nurse of the incident, the nurse went into the dining room to find the resident was eating her dinner independently and was talking with other residents. Nurse informed resident that she needed to complete an assessment due to the incident that happened in the van. Resident then told the nurse that she wanted to finish dinner and asked if the nurse could wait until she was done with dinner. Resident did not show any signs of distress, no apparent or obvious signs of injury were noted. Once the resident completed her dinner, the nurse then proceed to take resident back to the room and transferred her to the bed. The nurse completed a full body assessment. The nurse assessed residents head with a flash light and observed no bumps or discolorations. Full range of motion was done to her extremities. Nurse noted that resident moved all extremities well but did complain about her right shoulder hurting when she raised her arm up. Neurochecks were initiated and were all within normal limit. Vital signs were obtained and were Temperature 98.7, P-87, and R -20 B/P 125 /72. Resident #54's family member and Physicians were called and informed of the incident. An order was obtained for a right shoulder x ray. X -Ray to right shoulder was completed on [DATE]. There was no evidence of acute fracture or dislocation. The findings were compatible with chronic rotator cuff tear, moderate osteoporosis, and moderate osteopenia. On [DATE], the facility van was taken out of operation through [DATE]. A 24 hour report was completed on [DATE] and a 5 day report was completed on [DATE]. Outside transportation company was used to schedule necessary transports for the facility from [DATE] to [DATE]. The involved employee #1 was suspended on [DATE] and subsequently terminated on [DATE]. On [DATE], the corporate van trainer investigated the incident and determined the root cause of this event was the transportation aide failed to secure the front floor retractors to the resident's wheelchair according to Q' Straint manufacturer guidelines. On [DATE], 2 facility staff designated to aide in facility transportations were checked off by the corporate van trainer utilizing the skills checklist and Q' Straint manufacturer guidelines. The corporate van trainer has received training directly from Q' Straint/Surelock National Training Seminar products in [DATE]. The corporate van trainer utilizes the training he received, Q' Straint manufacturer guidelines, and a skills checklist to educate van transporters. A skills validation is also completed where the staff member must demonstrate the skills appropriately. This also included educating the new team members on the need to stop and call 911 for any accident that occurs during transports. Training was completed by the corporate van trainer on [DATE] prior to the transportation aide completing any van transports. The facility owned van was placed back in service from [DATE] through [DATE]. On [DATE] facility owned van was then utilized by sister facility through [DATE]. The facility has not utilized the facility owned van since [DATE] and the facility owned van keys are with the Administrator and no one has access to the keys. The facility owned van will be out of service until new facility staff are designated and trained by the corporate van trainer. Resident #54 was not able to reenact the incident and was not able to recall how the straps were placed on her wheelchair. On [DATE] Employee reenacted the incident to the administrator and stated I loaded the patient into the van, securing all four bases of the patient's wheelchair with safety straps. I also placed the seatbelt strap around patient's waist and through the right side of patient's armrest, securing both straps in place. The root cause of the incident is employee #1 did not follow Q' Straint manufacturer guidelines and facility policy in securing the resident and wheelchair prior to completing the transport. On [DATE], the facility van was taken out of operation through [DATE]. On [DATE], the corporate van trainer completed the Vehicle Inspection: Safety Inspection check list for the one facility owned van. No concerns were identified. On [DATE] the administrator began interviewing all alert and oriented residents that were transported on the facility owned van to ensure they were secured by the shoulder and lap seatbelt and front and back floor retractors according to facility policy and Q' Straint manufacturer guidelines. This audit was conducted weekly for 4 weeks. No concerns were identified. A quality review will also be implemented when transports are started back on [DATE]. The review includes the administrator or maintenance director in their absence will observe facility van transports weekly for 2 weeks to ensure residents and the chair are secured to the vehicle by visualizing that all 4 floor retractors are hooked to the wheelchair, that the seat belt is attached across the residents lap and secured to floor restraints, shoulder strap is positioned across the shoulder and secured to the lap belt. The administrator will be responsible for ensuring safe transportation of residents. In addition to this, alert and oriented residents will be interviewed asking if their wheelchairs were secured and seat belts applied according to Q'Straint manufacturer instructions. If errors are identified the employee will be suspended pending an investigation of the allegations. Any staff member designated to aide in facility transportation or any in-house staff involved with the facility transportation, who did not receive in-service training will not be allowed to work or participate in facility transportation using the facility owned van until training is completed. Validation of the credible allegation of compliance included review of the training information on safety and emergency procedures, interviews of the two current TA's to verify their understanding of the safety training, verification the van driver was CPR certified, review of the van audits completed by the corporate staff member and visualizing the van keys kept in the administrator's office.

Based on record review and staff interview, the facility's administration failed to operationalize manufacturer's recommendations for transporting a resident in the facility van resulting in a fall with Resident #54 hitting her head on the van floor. The facility administration failed to enforce a policy that would ensure the resident's wheelchair was secured according to manufacturer's instructions and follow emergency procedures when the wheelchair fell backwards with the resident. After the resident fell in the van, the facility staff moved the resident back into the wheelchair and drove her back to the facility without assessment from licensed staff for potential injury. This was evident in 1 (Resident #54) of 1 sampled resident who was transported using the facility's van. Findings included: 1. Cross refer: F323. Based on record review and staff interviews the facility Transportation Aide (TA) #1 failed to secure the wheelchair to the floor of the facility van according to manufacturer's instructions before transporting one of one resident reviewed for van transportation, Resident #54. During transport the wheelchair with Resident #54 fell backwards with the resident landing on her back and hitting her head on the van floor. Resident #54 complained of right shoulder pain after the incident. 2. Cross refer: F309. Based on record review and staff interviews the facility TA#1 failed to secure the wheelchair according to manufacturer's recommendation for Resident #54, to the floor of the facility van before transport. During transport the wheelchair with Resident #54 fell backwards with the resident landing on her back and hitting her head on the van floor. The TA#1 failed to call 911 and the facility after the incident and moved the resident back to a sitting position in the wheelchair after the incident. Resident #54 complained of right shoulder pain after the incident. This was for one of one residents transported in the facility van Resident #54. The facility provided a plan of correction with a correction date of [DATE]. The plan of correction included: The facility immediately began investigating the incident involving resident #54 occurring on [DATE] in which resident was being transported back to the facility after a medical appointment. In route to the facility resident #54 informed the van transportation aide that her wheelchair had fallen over. The van transportation aide then looked into the rearview mirror and realized the patient's foot was upright. The van transportation aide then proceeded to drive until she was able to find a safe and secure place to park, while talking to the patient to make sure patient remained conscious. The van transportation aide was about two blocks from the facility when she stopped the van. The van transportation aide then asked resident if she was alright and or hurt. The patient per the van transportation aide had no apparent injuries so she proceeded to secure the seatbelt strap to release and move patient so she could secure the wheelchair upright. Once the wheelchair was upright and secured with all four straps in place, the van transportation aide lifted the patient placing her into the wheelchair. The van transportation aide then checked to make sure the patient did not have any open wounds and or bruises. The van transportation aide then secured patient with seatbelt and proceeded back to the facility while continuing to talk to patient. Upon arriving to the facility, the van transportation aide unloaded the resident and brought her into the facility dining room. The van transportation aide informed Administrator of the incident. The administrator then notified the nurse on the hall of the incident. At that time, when administrator was notifying the nurse, the resident was in the dining room. When the administrator finished notifying the nurse of the incident, the nurse went into the dining room to find the resident was eating her dinner independently and was talking with other residents. Nurse informed resident that she needed to complete an assessment due to the incident that happened in the van. Resident then told the nurse that she wanted to finish dinner and asked if the nurse could wait until she was done with dinner. Resident did not show any signs of distress, no apparent or obvious signs of injury were noted. Once the resident completed her dinner, the nurse then proceed to take resident back to the room and transferred her to the bed. The nurse completed a full body assessment. The nurse assessed residents head with a flash light and observed no bumps or discolorations. Full range of motion was done to her extremities. Nurse noted that resident moved all extremities well but did complain about her right shoulder hurting when she raised her arm up. Neurochecks were initiated and were all within normal limit. Vital signs were obtained and were Temperature 98.7, P-87, and R -20 B/P 125 /72. Resident #54 family member and Physician were called and informed of the incident. An order was obtained for a right shoulder x ray. X -Ray to right shoulder was completed on [DATE]. Impression revealed no evidence of acute fracture or dislocation. The findings were compatible with chronic rotator cuff tear, moderate [MEDICAL CONDITION], and moderate [MEDICAL CONDITION]. On [DATE], the facility van was taken out of operation through [DATE]. A 24 hour report was completed on [DATE] and a 5 day report was completed on [DATE]. Outside transportation company was used to schedule necessary transports for the facility. The involved employee #1 was suspended on [DATE] and subsequently terminated on [DATE]. On [DATE], the corporate van trainer investigated the incident and determined the root cause of this event was the transportation aide failed to secure the front floor retractors to the resident's wheelchair according to Q' Straint manufacturer guidelines. The facility owned van was taken out of operation from [DATE] through [DATE]. On [DATE], 2 facility staff designated to aide in facility transportations were checked off by the corporate van trainer utilizing the skills checklist and Q' Straint manufacturer guidelines. The corporate van trainer has received training directly from Q' Straint/Surelock National Training Seminar products in [DATE]. The corporate van trainer utilizes the training he received, Q' Straint manufacturer guidelines, and a skills checklist to educate van transporters. A skills validation is also completed where the staff member must demonstrate the skills appropriately. This also included educating the new team members on the need to stop and call 911 for any accident that occurs during transports. Training was completed by the corporate van trainer on [DATE] prior to the transportation aide completing any van transports. The facility owned van was placed back in service from [DATE] through [DATE]. On [DATE] facility owned van was then utilized by sister facility through [DATE]. The facility has not utilized the facility owned van since [DATE] and the facility owned van keys are with the Administrator and no one has access to the keys. The facility owned van will be out of service until new facility staff are designated and trained by the corporate van trainer. Resident #54 was not able to reenact the incident and was not able to recall how the straps were placed on her wheelchair. On [DATE] Employee reenacted the incident to the administrator and stated I loaded the patient into the van, securing all four bases of the patient's wheelchair with safety straps. I also placed the seatbelt strap around patient's waist and through the right side of patient's armrest, securing both straps in place. The root cause of the incident is employee #1 did not follow Q' Straint manufacturer guidelines and facility policy in securing the resident and wheelchair prior to completing the transport. On [DATE], the corporate van trainer completed the Vehicle Inspection: Safety Inspection check list for the one facility owned van. No concerns were identified. On [DATE], the one facility owned van was removed from operation and outside transportation company was used to scheduled necessary transports for the facility from [DATE] to [DATE]. On [DATE], Corporate van trainer educated 2 facility staff designated to aide in facility transportations; they were educated on the following Resident Transportation Policy and Procedure. Transportation Policy: 1. Resident transportation should be completed by employees who have been trained to do so. Transportation aides must be current Nursing Assistants or Emergency Medication Technicians. They must also have valid CPR training. 2. PRIOR to operating a facility transportation vehicle, the TSP-101 DAILY VAN CHECKLIST will be completed. All residents will be properly secured with appropriate strapping of wheelchairs and/or seatbelt placement. Under no circumstances will the van be operated without adequate seatbelts for every resident being transported. If there is an issue identified on the daily checklist, it must be reviewed and corrected prior to the van being used if it is a patient safety issue. 3. The van will also be inspected by the maintenance director or designee on a weekly basis. Results of the inspection will be documented on form TSP-102 WEEKLY CHECKLIST. 4. All van drivers must hold a valid North Carolina drivers license, have had a drivers license DMV check, and have had documented training on van usage prior to transportation of residents. 5. In the event of an emergency, STOP and call 911. Provide basic first aid. Implement CPR if it in indicated such as no heartbeat or breathing. Do not move patient if injury is suspected or unless life is threatened. 6. All wheelchairs used for transportation of residents must be approved for transport use. If a personally-owned wheelchair (not a wheelchair provided or arranged by the facility) is to be used for transportation, it must be approved by Liberty Risk Management to determine if it is safe for transport use. 7. Power wheelchairs must be fitted with transportation appropriate straps for correct tie down procedures in order to be ready for use in the transportation van. If they do not have manufacturer installed safety strap attachment points or cannot be fitted with attachment devices from the manufacturer, they cannot be considered safe for transport. 8. All transportation Aids must have completed annual transportation safety training. 9. Training must include the safe procedures for loading and unloading of residents, the safe and proper use of the approved safety restraint system provided by the manufacturer of the transportation van and emergency measures to remove residents from the safety restraint system. 10. Immediately notify the Administrator when an incident occurs during a van transport regardless of how minor the incident is. This includes resident and non-resident incidents. Incidents include but are not limited to: fall from wheelchair, equipment malfunction, refusal of resident to utilize safety belts, and injury of any nature. The following amendment to the policy is to insure safety of residents during loading and application of the safety restraint system; Item #1: All wheelchairs used in transportation must have foot rests in place (attached to the chair) during loading, transport and unloading of residents. It has been determined that the resident's feet must be on the wheelchair foot rests to prevent feet and toes being caught or pinched in the lift bridge plate during lift operations, resulting in injury. Foot rests can help to keep feet in a position that will not allow toes to slide under the bridge plate. If the chair being used for transportation does not have foot rests attached at the time of transport, appropriate foot rests are to be located and attached to the chair properly or another chair with foot rests is to be used. It is recommended the transportation aids set aside a wheelchair for transportation use ahead of time to void the necessity of locating and fitting another wheelchair. Item #2: All wheelchairs used in transportation must be of the types that have removable arm rest. Access to the unrestricted back of the wheelchair seat is required to secure the lap safety belt in place over the resident's lap. Placing the lap belt through the underside of the arm rest does not allow the belt to restrain the resident at the hip. The safety lap belt must cross over the lap from hip to hip to keep the resident from slipping out of the seat. Item #3: Wheelchair Floor restraints are never to be attached to the cross (X) bars of the wheelchair. The cross bars are not part of the frame of the chair and will collapse if the chair is forced on its side as in a hard turn. All floor straps are to be attached to the frame at or above the point where welded joints connect the frame. This is typically found where the wheels or wheel casters are attached. Item #4 Geriatric Chairs can never be used for transport. Gerri Chairs have no way to lock the reclining feature of the chair and may fall into a reclining position during transport. IN the event of a chair reclining during transport the safety harness system will not protect the resident and may result in a serious or fatal event. Item #5 Power Wheelchairs must be approved for transportation before they can be used for transport of a resident. If they are not considered safe for transport, the facility must provide a facility approved chair for the resident transportation needs. Item #6 Unoccupied wheelchairs will no longer be transported on the facility van. This information has been integrated into the standard orientation training and in the required in-service refresher courses for all employees who operate the facility van and will be reviewed by the Quality Assurance process to verify that the change has been sustained. A quality review will also be implemented when transports are started back once we start using facility owned van. The review includes the administrator or maintenance director in their absence will observe facility van transports daily for 2 weeks to ensure residents and the chair are secured to the vehicle by visualizing that all 4 floor retractors are hooked to the wheelchair, that the seat belt is attached across the residents lap and secured to floor restraints, shoulder strap is positioned across the shoulder and secured to the lap belt. The administrator will be responsible for ensuring safe transportation of residents. In addition to this, alert and oriented residents will be interviewed asking if the transporter secured both front and back safety harnesses as well as the wheelchair to the van floor. If errors are identified the employee will be suspended pending an investigation of the allegations. The administrator and director of nursing attended the van training on [DATE] provided by the corporate van trainer to ensure proper knowledge of the safety harness system in order to verify that it is completed correctly. Any staff member designated to aide in facility transportation or any in-house staff involved with the facility transportation, who did not receive in-service training will not be allowed to work or participate in facility transportation using the facility owned van until training is completed. Validation of the credible allegation of compliance was conducted on [DATE]. TA's #2 and #3 were interviewed regarding the training provided and safety procedures to follow. Both drivers confirmed training had been provided and were able to explain procedures for securing the van and how to respond in an emergency situation. Review of the audits confirmed both had been observed to correctly secure a resident's wheelchair in the van. Sampled residents were selected for record review that had been transported in the facility van and no incidents had occurred. Facility record review revealed the TAs were nursing assistants with current CPR certification.