Every finding on record at Timber Springs Rehab and Retirement

Based on record review and interview, the facility failed to refer a resident with a newly diagnosed mental disorder to the appropriate state-designated authority for Level II PASARR evaluation and determination for 1 ( #5) of 2 residents reviewed for PASARR. Findings:A review of Resident #5's medical record revealed an admission date of 04/27/2015 with a diagnosis of Generalized Anxiety Disorder on 11/05/2020. Further review revealed Resident #5 was not referred to the appropriate state-designated authority for a Level II PASARR evaluation.During an interview on 03/25/2026 at 2:00 p.m., S3 Social Services acknowledged a Level II PASARR evaluation was not completed for Resident #5 after new diagnosis of generalized anxiety disorder.During an interview on 03/25/2026 at 2:30 p.m., S3 Corporate Nurse confirmed a Level II PASARR was not completed after a new diagnosis of generalized anxiety disorder for Resident #5 and should have been.

Based on record review and interview the facility failed to revise the care plan to reflect changes of a resident's falls for 1 (#50) of 3 residents reviewed for accidents. Findings:Review of Resident #50's medical record revealed a readmission date of 06/03/2025 with the following diagnoses which included but not limited to: Bilateral primary osteoarthritis of knee, muscle weakness, muscle wasting and atrophy multiple sites, abnormalities of gait and mobility, dementia, and unsteadiness on feet.Review of Resident #50's Annual MDS assessment dated [DATE] revealed a BIMS score of 06 indicating severely impaired cognition.Review of the facility's Incident Log revealed Resident #50 had falls on 02/18/2026 and 02/21/2026.Review of the medical record revealed Resident #50 was care planned for risk of falls with the most current intervention date of 01/07/2026. Further review failed to reveal the care plan was revised to reflect the falls on 02/18/2026 and 02/21/2026.During an interview on 03/25/2026 at 1:13 p.m. S1 DON reported the Resident #50's care plan should be updated with each fall. After reviewing Resident #50's record, S1 DON acknowledged there was no documentation Resident #50's care plan was updated to reflect the falls on 02/18/2026 and 02/21/2026 and should have been.

Based on record review and interview the facility failed to ensure a comprehensive person-centered care plan was developed for 1 (#50) of 26 sampled residents. The facility failed to ensure an activities care plan had been developed with interventions for Resident #50. Findings: Review of Resident #50's medical record revealed an initial admitted [DATE] with diagnoses that included, in part, anxiety disorder, essential (primary) hypertension, and depression. Review of Resident #50's 12/02/2024 Quarterly MDS (Minimum Data Set) revealed Resident #50 had a BIMS (Brief Interview Mental Status) score of 15, which indicated Resident #50 was cognitively intact. Review of Resident #50's 09/09/2024 Admission MDS, Section F-Preferences for Customary Routine and Activities revealed, in part: -It was very important to listen to music Resident #50 likes. -It was somewhat important for Resident #50 to have books, newspapers, and magazines to read. -It was somewhat important for Resident #50 to go outside and get fresh air when the weather is good. Review of Resident #50's care plan failed to reveal and activities care plan with interventions had been developed. During an interview on 01/15/2024 at 11:42 a.m. S3 MDS Coordinator reviewed Resident #50's care plan and comfirmed Resident #50 did not have a care plan for activities and should have.

Based on record reviews, observations and interviews, the facility failed to ensure correct use and maintenance of bed rails for 7 (#1, #4, #24, #25, #42, #48, #49) of 7 (#1, #4, #24, #25, #42, #48, #49) residents reviewed for the use of bed rails. The facility failed to ensure: 1. Residents #1, #4, #24, #25, #42, #48, and #49 were assessed for the risk of entrapment prior to the use of bed rails, less restrictive approaches were attempted prior to the use of bed rails, ongoing assessments for the risk of entrapment were conducted after bed rail installation, and residents were care planned with specific interventions for the use of bed rails, and; 2. Bed rails were securely attached to the bed for resident # 4, and #25. Findings: Review of the facility's Bed Rails policy (undated) revealed in part: Policy Explanation and Compliance Guidelines: 1. The facility will use appropriate alternatives prior to installing a side or bed rail. 2. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including, but not limited to the following elements: a. Assess the resident for risk of entrapment from bed rails prior to installation f. Regularly inspect bed rails to ensure they have not become stiff or loosened over time. 3. If after a facility has attempted alternatives to bed rails and determined that these alternatives do not meet the resident's needs, the facility will assess the resident for the risks of entrapment and possible benefits of bed rails. In determining whether to use bed rails to meet the needs of a resident, the following components of the resident assessment should be considered including, but no limited to: medical diagnosis, conditions, symptoms, and/or behavioral symptoms, size and weight, sleep habits, medications, acute medical or surgical interventions, underlying medical conditions, existence of delirium, ability to toilet self safely, cognition, communication, mobility (in and out of bed), risk of falling 4. In addition, the resident assessment must include an evaluation of the alternatives to the use of a bed rail that were attempted and how these alternatives failed to meet the resident's assessed needs. Possible alternatives include, but are not limited to foam bolsters, low bed, concave mattress. 6. The facility will conduct routine preventive maintenance of beds and bed rails according to manufacturer's recommendations and specifications to ensure they meet current safety standards and are not in need of repair. 7. The facility will conduct ongoing assessments to evaluate risks and assure the bed rail is used to meet the resident's needs. 8. The facility will document in the resident's care plan specific interventions and services for the use of the bed rail. 1. Resident #1 Review of Resident #1's record revealed an initial admitted [DATE] with diagnoses that included, in part: metabolic encephalopathy, unsteadiness on feet, other idiopathic peripheral autonomic schizophreniform disorder, unspecified bipolar disorder, generalized anxiety disorder, other seizures, generalized muscle weakness, unspecified altered mental status, cognitive communication deficit, and depression unspecified. Review of Resident #1's current physician orders revealed an order dated 11/22/2024 - may use AR (assist rail) x 1 to aid in bed mobility & define boundaries. Review of Resident #1's Quarterly MDS (Minimum Data Set) assessment with ARD (Assessment Reference Date) of 12/01/2024 revealed Resident #1 had a BIMS (Brief Interview for Mental Status) score of 15, indicating Resident #1 was cognitively intact. Further review of 12/01/2024 MDS revealed Resident #1 had an impairment to one side of upper and lower extremities in regard to ROM (Range of Motion). Review of Resident #1's State Optional MDS assessment with ARD of 11/06/2024 revealed Resident #1 required extensive assistance with bed mobility and transfers. Review of Resident #1's Comprehensive Care Plan revealed no specific interventions or services for the use of the bed rails per facility policy. Review of Resident #1's record failed to reveal any assessments for risk for entrapment. Review of Resident #1's Physical Restraint/Device Consent form indicated consent obtained from Resident #1's mother and brother on 10/26/2024, and revealed the section titled Less restrictive approaches tried and proven ineffective was left blank. Observation on 01/13/2025 at 11:18 a.m. revealed Resident #1 was positioned with the left side of his bed against wall (while lying on back in bed) and 1/4 bedrail up to Resident #1's right side of upper bed. Observation on 01/14/2025 at 1:07 p.m. revealed Resident #1 was asleep in bed with HOB (Head of Bed) up and 1/4 bed rail up x 1 to resident's right side of upper bed. Resident #4 Review of Resident #4's record revealed an admitted [DATE] with diagnoses that included, in part: unspecified abnormalities of gait and mobility, cognitive communication deficit, other symbolic dysfunctions, abnormal posture, generalized muscle weakness, lack of coordination, repeated falls, unspecified psychosis not due to a substance or known physiological condition, and Alzheimer's disease. Review of Resident #4's current physician orders revealed an order dated 01/21/2024 - may use 1/2 SR x 2 (Side Rails times 2) to aid in bed mobility and define bed boundaries. Review of Resident #4's MDS assessments with ARD of 12/09/2024 (State Optional and Quarterly) revealed the resident had a BIMS score of 5, indicating a severe cognitive impairment. Further review revealed the resident required limited assistance with one person physical assist for bed mobility and transfers. Review of Resident #4's Comprehensive Care Plan revealed no specific interventions or services for the use of the bed rails per facility policy. Review of Resident #4's record failed to reveal any assessments for risk for entrapment. Review of Resident #4's Physical Restraint/Device Consent form signed by the resident's responsible party 10/23/2024 revealed the section titled Less restrictive approaches tried and proven ineffective was left blank. Resident #24 Review of Resident # 24's record revealed an admitted [DATE] with diagnoses that included, in part: muscle weakness, metabolic encephalopathy, and sequelae of cerebral infarction. Review of Resident # 24's current Physician Orders revealed an order dated 11/22/2024 - may use 1/2 side rail to aid in bed mobility and define bed boundaries. Review of Resident #24's Quarterly MDS revealed a BIMS was not done due to Resident #24 is rarely/never understood. Further review revealed Resident #24 required extensive assistance with one person physical assistance. Review of Resident #24's comprehensive care plan revealed no specific focus/interventions or services for the use of bed rails per facility policy. Review of Resident #24's record failed to reveal any assessments for risk for entrapment. Review of Resident # 24's Physical Restraint/Device Consent for 1/2 side rails times 2 signed by Resident #24's family member on 11/23/2024 revealed the section titled less restrictive approaches tried and proven effective was blank. Observation on 1/13/2025 at 1:31 P.M. revealed Resident #24 sitting in day area in a wheel chair. Observation of Resident #24's room on 1/13/2025 at 1:31 p.m. revealed Resident #24 had 1/2 side rails in raised position on each side of the bed. During an interview on 1/13/2025 at 10:00 p.m S15 CNA confirmed side rails were used when Resident # 24 was in bed. Resident #25 Review of Resident #25's record revealed an admitted [DATE] and diagnoses that included, in part: anxiety disorder, unspecified psychosis not due to a substance or known physiological condition, generalized muscle weakness, unspecified abnormalities of gait and mobility, and Alzheimer's disease. Review of Resident #25's current physician orders revealed an order dated 11/21/2024 - May use 1/2 SR x 2 to aid in bed mobility and define bed boundaries. Review of Resident #25's MDS assessments with ARD of 10/21/2024 (admission) revealed the resident had a BIMS score of 4, indicating a severe cognitive impairment. Further review revealed the resident required extensive assistance with 2 plus persons physical assist for bed mobility and transfers. Review of Resident #25's Comprehensive Care Plan revealed no specific interventions or services for the use of the bed rails per facility policy. Review of Resident #24's record failed to reveal any assessments for risk for entrapment. Review of Resident #25's Physical Restraint/Device Consent form signed by the resident's responsible party 10/23/2024 revealed the section titled Less restrictive approaches tried and proven ineffective was left blank. Resident #42 Review of Resident #42's record revealed an initial admitted [DATE] with diagnoses that included, in part: vascular dementia unspecified severity with agitation, postural orthostatic tachycardia syndrome [POTS], unspecified anxiety disorder, unspecified depression, essential (primary) hypertension, and generalized muscle weakness. Review of Resident #42's current physician orders revealed an order dated 11/21/2024 - may use 1/2 SR X1 to aid in bed mobility and define bed boundaries. Review of Resident #42's MDS assessments with ARD of 11/06/2024 (State Optional and Quarterly) revealed Resident #42's BIMS was not conducted as Resident #42 rarely /never understood. Further review revealed Resident #42 required extensive assistance with bed mobility and transfers. Review of Resident #42's Comprehensive Care Plan revealed no specific interventions or services for the use of the bed rails per facility policy. Review of Resident #42's record failed to reveal any assessments for risk for entrapment. Review of Resident #42's Physical Restraint/Device Consent form indicated consent obtained from Resident #42's son on 10/26/2024, and revealed the section titled Less restrictive approaches tried and proven ineffective was left blank. Observation on 01/13/2025 at 11:18 a.m. revealed Resident #42 was in bed with HOB slightly elevated and bed against wall on Resident #42's left side, and upper 1/4 bed rail up on Resident #42's right side. Resident #48 Review of Resident #48's record revealed an initial admitted [DATE] with diagnoses that included, in part: malignant neoplasm of retroperitoneum, lumbago with sciatica unspecified side, other osteoporosis without current pathological fracture, other idiopathic peripheral autonomic neuropathy, and unspecified depression. Review of Resident #48's physician orders revealed an order dated 01/14/2025 - may use 1/2 SR X2 to aid in bed mobility and define bed parameters. Review of Resident #48's MDS assessments with ARD of 10/30/2024 (State Optional and Significant Change) revealed Resident #48 had a BIMS score of 09, which indicated a moderate cognitive impairment. Further review of MDS revealed Resident #48 had an impairment to one side of upper and lower extremities in regard to ROM and required extensive assistance with bed mobility and transfers. Review of Resident #48's Comprehensive Care Plan revealed no specific interventions or services for the use of the bed rails per facility policy. Review of Resident #48's record failed to reveal any assessments for risk for entrapment. Review of Resident #48's Physical Restraint/Device Consent form indicated consent obtained from Resident #48's daughter on 11/05/2024, and revealed the section titled Less restrictive approaches tried and proven ineffective was left blank. Observation on 01/13/2025 at 11:21 a.m. revealed Resident #48 lying on back in bed with HOB elevated and 1/4 bed rails up on each side of upper bed. Observation on 01/14/2024 at 1:14 p.m. revealed Resident #48 lying in bed on back with 1/4 bed rails up on each side of upper bed. Resident #49 Review of Resident # 49's record revealed an admitted [DATE] and diagnoses that included, in part: unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of Resident #49's current Physician Orders revealed an order dated 12/31/2024 - may have 1/2 side rails to aid in bed mobility and define bed parameters every shift. Review of Resident #49's Quarterly MDS dated [DATE] revealed a BIMS of 6 which indicated a severe cognitive impairment. Further review revealed the resident required limited assistance with one person physical assist for bed mobility. Review of Resident #49's Comprehensive Care Plan revealed no specific interventions or services for the use of the bed rails per facility policy. Review of Resident #49's record failed to reveal any assessments for risk for entrapment. Review of Resident # 49's Physical Restraint/Device Consent for 1/2 side rails x 2 signed by the resident's family member on 10/24/2024 revealed the section titled less restrictive approaches tried and proven effective was blank. Observation on 1/13/2025 at 3:20 p.m. revealed Resident #49 sitting in day area in a wheel chair. Observation on 1/13/2025 at 3:20 p.m. revealed Resident #49 had 1/2 side rails in raised position on each side of the bed. During an interview on 01/15/2025 at 1:48 p.m., S2 DON (Director of Nursing) reported there were no documented initial or ongoing resident assessments for the risk of entrapment or less restrictive approaches attempted prior to the use of bed rails for Residents #1, #4, #24, #25, #42, #48, and #49 and there should be. S2 DON further confirmed the residents were not care planned with specific interventions for the use of bed rails and should have been. 2. Resident #4 Observation on 01/13/25 at 9:50 a.m. Resident #4 in room seated in her wheelchair. Resident #4's bed was positioned with the left side up against the wall, and 1/2 metal bed rail to right side of bed in raised position-fits bed, but not firmly attached-moves freely back and forth parallel to bed. Observation on 01/14/2025 at 2:18 p.m. revealed Resident #4 lying in bed with eyes closed, 1/2 metal bed rail to right side of bed in lowered position, but still loose. Observation on 01/14/2025 at 9:30 a.m. revealed Resident #4 up in wheelchair. The 1/2 metal bed rail to right side of bed was in the lowered position, but still loose. During an interview on 01/14/2025 at 9:50 a.m. S10 CNA reported she was familiar with Resident #4. S10 CNA reported Resident #4 used the bed rail on her bed for positioning and mobility when she was in bed, and they were lowered when she got out of bed. S10 CNA observed the right rail on Resident #4's bed and confirmed it was loose and needed to be tightened. S10 CNA tried to turn the knob that adjusts the rail and said it was as tight as it would go. Resident #25 Observation on 01/13/2025 at 10:00 a.m. Resident #25 lying in bed. Further observation revealed bilateral 1/2 metal bed rails affixed to the upper half of Resident #25's bed in the raised position. The rails were not firmly attached and moved freely back and forth. During an interview on 01/13/2025 at 10:00 a.m., Resident #25 reported she used the rails to assist with positioning when staff turn her. Observation on 01/14/2025 at 10:50 a.m. revealed S8 CNA performing incontinence and catheter care for Resident #25 assisted by S9 CNA. Resident #25 was observed to be use bilateral bed rails to assist with positioning during the incontinence care. Both bed rails were observed to be loose and freely moveable back and forth and side to side. During an interview on 01/14/2025 at 10:51 a.m. S9 CNA confirmed the right bed rail attached to the upper half of Resident #25's bed moved freely back and forth and side to side, and needed to be tightened. During an interview on 01/14/2025 at 10:52 a.m. S8 CNA confirmed the left bed rail attached to the upper half of Resident #25's bed moved freely back and forth and side to side, and needed to be tightened. Observation on 01/15/2025 at 9:00 a.m., revealed bilateral 1/2 metal bed rails affixed to Resident #25's bed in the raised position. Both bed rails were observed to be loose and freely moveable back and forth and side to side. During an interview on 01/15/2025 at 3:20 p.m., S7 Maintenance viewed Resident #4 and #25's bed rails with the surveyor and confirmed they were loose and needed to be tightened. 37867 40015

Based on observations, interviews, and record review, the facility failed to ensure a resident's environment remained free of accident hazards. The facility failed to ensure a resident's TV (television) was positioned in a secure manner for 1 (#12) of 4 (#4, #12, #23, #25) residents reviewed for accidents. Findings: Review of Resident #12's record revealed an admitted [DATE] and diagnoses including: Unspecified abnormalities of gait and mobility, muscle weakness, unspecified glaucoma, repeated falls and lack of coordination. Review of Resident #12's Quarterly MDS (Minimum Data Set) dated 12/24/2024 revealed the resident had severe impaired vision. An observation on 01/13/2025 at 1:56 p.m. revealed Resident #12's TV was positioned in a manner of which not all 4 legs were positioned on the nightstand. An observation on 01/15/2025 at 10:55 a.m. with S6 CNA (Certified Nursing Assistant) revealed Resident #12's TV was positioned on the nightstand with one of the 4 legs hanging off of the nightstand and another leg only halfway on the nightstand. During an interview on 01/15/2025 at 10:55 a.m. S6 CNA examined how Resident #12's TV was positioned on the nightstand and acknowledged the TV was not positioned in a secure manner and was unstable. S6CNA confirmed Resident #12 was visually impaired and could easily bump into the TV knocking it over. During an observation on 01/15/2025 at 1:40 p.m. Resident #12's TV remained positioned in an unstable manner, with one leg off and another leg halfway off of the nightstand. During an interview on 01/15/2025 at 1:40 p.m. S2 DON (Director of Nursing) and S7Maintenance Supervisor acknowledged the TV was unstable on the nightstand.

Based on record review and interviews the facility failed to ensure MDS (Minimum Data Set) assessments were completed and transmitted within the specified time frames for 3 (#1, #5, #12) of 26 sampled residents. The facility failed to ensure: 1. An annual assessment had been completed for Resident #1. 2. A discharge assessment had been completed for Resident #5. 3. An entry assessment had been transmitted for Resident #12. Findings: 1. Review of Resident #1's medical record revealed an admitted [DATE] with diagnoses that included, in part, cerebral infarction unspecified, metabolic encephalopathy, acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure, schizophreniform disorder, bipolar disorder, generalized anxiety disorder, and depression. Review of Resident #1's medical record revealed the following Accepted MDS assessments, in part: 12/19/2023 Admission/Medicare-5 day MDS 12/12/2023 Entry MDS Further review failed to reveal an annual MDS assessment had been completed and submitted within the specified timeframe. During an interview on 01/15/2025 at 9:01 a.m. S3 MDS Coordinator reviewed Resident #1's MDS assessments and reported the 12/11/2024 MDS assessment was completed and transmitted as a quarterly MDS and should have been completed and transmitted as an annual MDS assessment. 2. Review of Resident #5's medical record revealed an initial admitted [DATE], and admission (reentry) date of 08/23/2024 and a discharge date of [DATE] with diagnoses that included, in part, cerebrovascular disease, major depressive disorder, and anxiety disorder. Review of Resident #5's progress notes revealed a note dated 09/02/2024 at 11:10 a.m.: Resident discharged home. All meds and personal belongings sent with resident. Condition stable. Review of Resident #5's medical record revealed the following Accepted MDS assessments, in part: 8/23/2024 Entry MDS 8/30/2024 Admission MDS Further review failed to reveal a discharge MDS assessment had been completed and transmitted. During an interview on 01/15/2025 at 8:59 a.m. S3 MDS Coordinator reviewed the MDS assessments and reported a discharge MDS had not been completed for Resident #5's 09/02/2024 discharge and should have been. 3. Review of Resident #12's medical record revealed an initial admitted [DATE]. Review of Resident #12's medical record revealed an Entry MDS assessment dated [DATE] was Export Ready. During an interview on 01/15/2025 at 8:51 a.m. S3 MDS Coordinator reported she did not transmit Resident #12's Entry MDS assessment dated [DATE] and should have. 40015 FACILITY

Based on record review, observation, and interviews, the facility failed to ensure a resident received proper treatment to maintain and/or improve hearing for 1 (#12) of 1 (#12) residents reviewed for communication and sensory problems. Findings: Review of Resident #12's record revealed an inital admitted [DATE] and diagnoses including: unspecified abnormalities of gait and mobility; unspecified glaucoma; and impacted cerumen (earwax), unspecified ear. Review of Resident #12's physician order dated 11/04/2024 revealed an order for a referral by the ENT (Ear, Nose, and Throat doctor) for an audiogram (a hearing test). Review of Resident #12's care plan failed to reveal a care plan for hearing impairment. Review of Resident #12's medical record failed to reveal an appointment was scheduled for an audiogram. During an interview on 01/13/2025 at 02:12 p.m. Resident #12 reported she had increased hearing loss. Resident #12 further reported she was supposed to see a doctor about her hearing loss, but did not believe an appointment was ever made. Resident #12 reported in Novembere of 2024 the ENT doctor told her she may have nerve damage in her ear. Resident #12 was waiting on an appointment because her hearing just keeps getting worse. An observation on 01/13/2025 at 2:12 p.m. revealed the surveyor had to speak loudly during the interview with Resident #12. During an interview on 01/15/2025 at 2:41 p.m. S2 DON (Director of Nursing) reported Resident #12 did not have a care plan for hearing impairment. During an interview on 01/15/2025 at 9:43 a.m. S13 LPN (Licensed Practical Nurse) reviewed Resident #12's medical record and reported Resident #12 had an appointment with an ENT doctor for ear wax removal on 10/14/2024 and further reported there was a referral for Resident #12 to have an audiogram. S13 LPN reported S14 Transportation CNA (Certified Nursing Assistant) was responsible for appointments. During an interview on 01/15/2025 at 12:20 p.m. S14 Transportation CNA reported she was responsible for follow-ups with referrals and transporting residents to their appointments. S14 Transportation CNA reported Resident #12 was transported to the local ENT doctor on 11/04/2024 and the ENT doctor referred Resident #12 to see an Audiologist. S14 Transportation CNA reported she failed to follow up with the referral and did not have a method to keep up with who had completed referrals.

Based on record review and interview the provider failed to ensure a resident received appropriate monitoring when receiving antidepressant medications for 1 (Resident #20) of 5 (Residents #3, #20, #24, #29, #301) residents reviewed for unnecessary medications, psychotrpic medications, and medication regimen review. Record review of Resident #20's diagnosis revealed the following, in part: Heart failure Constipation Depressive episodes Record review of Resident #20's physician orders for December 2023 revealed the following, in part: Duloxetine 30mg (milligrams) by mouth every morning with start date of 10/01/2023. Fluoxetine 40mg by mouth every morning with start date of 10/01/2023. Record review of Resident #20's comprehensive care plans revealed the following, in part: Descripton- Antidepressant medication use: At risk for side effects. I have diagnosis of depression. Interventions- monitor patterns of target behaviors, assess for adverse side effects and report, monitor of signs of extrapyramidal symptoms and document . Record review of Resident #20's MDS (minimum data set) dated 10/06/2023 revealed the following, in part: Section C showed a BIMS (brief interview of mental status) of 6 indicating the resident is moderately impaired. Section I showed the resident had a diagnosis of depression. Record review of Resident #20's medication administration record for November and December 2023 revealed the following, in part: Duloxetine 30mg by mouth and Fluoxetine 40mg by mouth were given every day from November 1st through December 4th. Monitoring for an antidepressant was not completed from November 1st through December 4th of 2023. During an interview on 12/06/2023 at 10:05 a.m., S2DON verified monitoring of antidepressant medications were not completed for Resident # 20 from November 1st through December 4th of 2023 and monitoring should have been completed.

Based on record reviews and interviews, the facility failed to ensure documentation of resident rights regarding Advance Directives for 7 (#3, #8, #23, #24, #27, #45, #301) of 11 (#3, #8, #14, #20, #23, #24, #27, #40, #41, #45, #301) residents reviewed for Advanced directives by failing to: 1) Ensure each residents or resident's representative was provided with written information concerning advance directives and/or the option to formulate an advance directive. for Resident #3, #8, #23, #24, #27, and #301. 2) Ensure a copy of the resident's Advance Directives was in the medical record and accessible to all staff for Resident #45. Findings: 1) Review of Resident #3's medical record revealed Resident #3 was admitted to the facility on [DATE]. Further review of Resident #3's medical record failed to reveal resident or resident's representative was provided with written information concerning advance directives and/or the option to formulate an advance directive. Review of Resident #8's medical record revealed Resident #8 was admitted to the facility on [DATE]. Further review of Resident #8's medical record failed to reveal resident or resident's representative was provided with written information concerning advance directives and/or the option to formulate an advance directive. Review of Resident #23's medical record revealed Resident #23 was admitted to the facility on [DATE]. Further review of Resident #23's medical record failed to reveal resident or resident's representative was provided with written information concerning advance directives and/or the option to formulate an advance directive. Review of Resident #24's medical record revealed Resident #24 was admitted to the facility on [DATE]. Further review of Resident #24's medical record failed to reveal resident or resident's representative was provided with written information concerning advance directives and/or the option to formulate an advance directive. Review of Resident #27's medical record revealed Resident #27 was admitted to the facility on [DATE]. Further review of Resident #27's medical record failed to reveal resident or resident's representative was provided with written information concerning advance directives and/or the option to formulate an advance directive. Review of Resident #301's medical record revealed Resident #301 was admitted to the facility on [DATE]. Further review of Resident #301's medical record failed to reveal resident or resident's representative was provided with written information concerning advance directives and/or the option to formulate an advance directive. During an interview on 12/05/2023 at 12:23 p.m. S4 Social Services Director confirmed Resident #3, #8, #23, #24, #27, #45, and #301's medical record did not contain documentation that resident or resident's representative was provided with written information concerning advance directives and/or the option to formulate an advance directive. During an interview on 12/05/2023 at 2:50 p.m. S3 Business Office Manager/Human Resources/Minimum Data Set Nurse confirmed Resident 3, #8, #23, #24, #27, #45, and #301's medical record did not contain documentation that resident or resident's representative was provided with written information concerning advance directives and/or the option to formulate an advance directive. 2) Review of Resident #45's medical record revealed Resident #45 was admitted to the facility on [DATE]. Review of Resident #45's Advance Directives/Medical Treatment Decisions Acknowledgement of Receipt form signed by the resident's representative on 04/27/2023 revealed the box indicating Resident #45 had a Living Will was checked. Further review of Resident #45's medical record failed to reveal a copy of Resident #45's living will. During an interview on 12/05/2023 at 2:49 p.m. S3 Business Office Manager/Human Resources/Minimum Data Set Nurse in the presence of S1 Administrator confirmed Resident #45's Advance Directive form indicated he had a living will. S3 Business Office Manager/Human Resources/Minimum Data Set Nurse further confirmed the facility should have a copy of Resident #45's living will and did not. 34708 37867

Based on record review and interview the facility failed to ensure a baseline care plan was completed within 48 hours of admission for 1 (#301) of 15 (#3, #8, #10, #14, #20, #23, #24, #27, #29, #40, #41, #45, #49, #50, #301) residents reviewed for care plans Findings: Review of record revealed Resident #301 had an admitted [DATE]. Further review of Resident #301's clinical record failed to reveal a baseline care plan had been completed within 48 hours of admitted . During an interview on 12/05/2023 at 2:00 p.m. S3 Business Office Manager/Human Resources/Minimum Data Sets reported a baseline care plan for resident #301 had not been completed and should have been completed within 48 hours of admitted . 36664

Based on record review, observation, and interview the provider failed to ensure an oxygen concentrator filter was placed appropriately in the intake port of the concentrator for 1 (Resident #29) of 1 (Resident #29) residents reviewed for respiratory care. Record review of Resident # 29's physician orders for December 2023 revealed the following, in part: Oxygen at two liters per minute per nasal cannula at night time. (09/18/2023) Change the oxygen cannula, sterile water, and tubing every seven days and as needed. Wash filters from oxygen concentrators every seven days with soap and water. Rinse and squeeze dry. (09/18/2023) Record review of Resident # 29's comprehensive care plans revealed the following, in part: Description- I have history of shortness of breath. I get oxygen saturations checked each shift. Interventions- Administer oxygen per physician order; assess lung sounds as needed; monitor oxygen saturations per facility policy, position upright when possible . Record review of Resident # 29's MDS (minimum data set) revealed the following, in part: Section C showed a BIMS (brief interview for mental status) score of 13 which would indicate the rsident is cognitively intact. Section O showed the resident was receiving oxygen therapy. Record review of Resident # 29's MAR (medication administration record) for November and December 2023 revealed the following, in part: Oxygen at 2 liters per minute (LPM) per nasal cannula at hour of sleep was marked completed every day from November 1st through December 4th of 2023. Observation on 12/05/2023 at 8:39 a.m. revealed Resident # 29 lying in bed with eyes open. Nasal cannula was placed to nostrils, oxygen was flowing at 2LPM with humidifier. Oxygen concentrator did not have a filter placed on the intake port of the concentrator and brown dusty substance was noted all around the intake port. Observation on 12/05/2023 at 2:55 p.m. revealed Resident # 29 lying in bed with eyes open. Nasal cannula was placed to nostrils, oxygen was flowing at 2LPM with humidifier. Oxygen concentrator did not have a filter placed on the intake port of the concentrator and brown dusty substance was noted all around the intake port. During an interview on 12/05/2023 at 3:15 p.m., S5LPN (licensed practical nurse) verified Resident # 29's oxygen concentrator did not have a filter in place and also verified a generous amount of brown dusty substance was in the intake port of the concentrator. During an interview on 12/05/2023 at 3:20 p.m., S2DON (director of nursing) verified Resident # 29's oxygen concentrator did not have a filter in place and brown dusty substance was in the intake port of the concentrator. S2DON verified the filter should have been in the concentrator.

Based on interviews and record reviews, the facility failed to protect the residents' right to be free from verbal abuse by staff. The facility failed to ensure residents were free from verbal abuse by staff for 1 (#1) of 6 (#1, #2, #3, #4, #5, #6) sampled residents. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be Past Noncompliance. Findings: Review of the facility's Abuse Prevention Program (revised December 2016) revealed in part: our residents have the right to be free from abuse .this includes but is not limited to verbal abuse .as part of the resident abuse prevention, the administration will protect our residents from abuse by anyone including, but not necessarily limited to facility staff . Review of the facility's Self-Reported Incident Report initiated 8/13/2023 revealed in part: Victim: Resident #1 Accused: S4, Cook Allegation: Verbal Abuse-substantiated Employee S4 Cook was suspended immediately pending investigation. After facility investigation substantiated the allegation of verbal abuse, the employee was terminated. Review of Resident #1's clinical record revealed an admitted [DATE] and diagnoses including but not limited to Generalized muscle weakness, Anxiety disorder, Affective mood disorder, and Major depressive disorder. Review of Resident #1's quarterly Minimum Data Set assessment with and Assessment Reference Date of 07/24/2023 revealed the resident had a BIMS score (Brief Interview for Mental Status) of 15 out of 15 indicating the resident was cognitively intact. Review of witness statement provided by Resident #1 on 08/13/2023 revealed in part: Resident #1 was in the dining room. The menu for supper wasn't on the menu board, so the resident rolled up to kitchen door and asked dietary employee S4 Cook what was for supper and for a glass of juice. Resident #1 voiced that lady S4 Cook told me to get the s**t away from the door and don't come back up here and to carry you're a**. Review of signed witness statement by S5 SLP (Speech Language Pathologist) dated 08/13/2023 revealed in part: S4 Cook was cussing and telling Resident #1 to carry her a** when she asked for cranberry juice. S5 SLP then overheard S4 Cook say F**k this S**t. I need a new job. S4 Cook also cussing in kitchen saying B***h and slamming kitchen door. This behavior is inappropriate towards other residents as well as other employees. Review of signed witness statement by S6 DM (Dietary Manager) dated 08/13/2023 revealed in part: I received call about a resident abuse incident. When I got there I spoke with my staff member and she denied the allegation. I asked her to write a statement to tell her side of the story and she refused to write the statement before she left the premises. Review of ___ Police Department Offense Report revealed in part: On Thursday 17 August I, S7 Police officer, was dispatched at 10:30 hours to the ___ Nursing Home .When I arrived at 10:32 I meet with S3 DON (Director of Nursing) who said she had an issue with one of her staff S4 Cook that had on Sunday 13 August 2023 verbally abused Resident #1 . I interviewed S5 SLP a staff member and witness to the incident who said the same thing, S4 Cook verbally abused Resident #1 by refusing to give her a juice and harshly speaking to her when she told her to get away from the door and not come back. I interviewed Resident #1 who said she was in the dining room and she went to the kitchen door to ask what was for dinner and for a glass of juice. She said that lady S4 Cook told me to get the s**t away from the door and don't come back up here and to carry you're a**. Repeated attempts were made to contact S4 Cook that were unsuccessful. I was unable to interview her for her side of the incident. During an interview on 09/18/2023 at 3:10 p.m. S3 DON confirmed S4 Cook was sent home on 08/13/2023 by S6 DM pending investigation, and had refused to provide a written statement. S3 DON further confirmed S4 Cook was terminated after the facility investigation substantiated verbal abuse. During an interview on 09/19/2023 at 8:49 a.m. S6 DM indicated she received a phone on Sunday 08/13/2023 informing her of an allegation of verbal abuse by S4 Cook against Resident #1. S6 DM indicated she came to the facility and informed the worker she would have to leave the premises pending investigation of the allegation. S6 DM further stated S4 cook refused to provide a written statement. S6 DM reported S3 SLP had been in the kitchen the whole time, reported that she had witnessed the event, and so S4 Cook was terminated for verbal abuse. During an interview on 09/19/2023 at 9:02 a.m. Resident #1 indicated the day S4 Cook cussed her, she had just gone to the kitchen door and asked S4 Cook for some cranberry juice and asked what was for supper, when she told me to get the s**t away from the door and don't come back. Then she told me to carry my a**. During an interview on 09/19/2023 at 9:30 a.m. S1 Administrator confirmed S4 Cook had been terminated after allegations of verbal abuse were substantiated. A telephone interview was attempted with S4 Cook on 09/19/2023 at 11:55 a.m. The following message was received: the number you dialed has been changed, disconnected, or is no longer in service. During an interview on 09/20/2023 at 9:05 a.m. S2 Administrator (a second administrator) confirmed S4 Cook had been terminated after the facility's investigation confirmed verbal abuse had occurred. During a telephone on 09/20/2023 at 12:16 p.m. S5 SLP indicated she was in the dining room feeding another resident on 08/13/2023 when Resident #1 went to the door and asked S4 Cook for a cup of juice and what was for supper, and S4 Cook told her to carry her a** away from the door and not come back, so Resident #1 walked away and out of the dining room. S4 Cook came out of the kitchen into the dining room performing other duties then went back in the kitchen and slammed the door saying b***h, f**k this s**t, I need another job. Throughout the survey from 09/18/2023 to 09/20/2023, staff interviews and observations revealed staff received training on the facility's abuse policies and procedures, were knowledgeable of the types of abuse, and were aware abuse should be reported to administration immediately. Staff were observed interacting with residents and providing care in a calm, supportive, and respectful manner. The facility has implemented the following actions to correct the deficient practice: 1. S4 Cook was immediately removed from resident area and suspended pending investigation. Report to state agency was opened and investigation started. Law enforcement was notified. 2. All residents had the potential to be affected. Residents were interviewed and no other residents were affected. 3. Education on Abuse was provided by S3 DON and Designee to all staff members. Education began on 08/16/2023 and was completed on 08/30/2023. Ambassador rounds 5 days a week by Department Heads for resident interviews for grievances, concerns, or abuse allegations. Rounds are ongoing. 4. Audits/Findings presented to QA (Quality Assurance) for review and discussion of findings on 09/07/2023 and will follow up at each QA meeting. Revisions to plan will be implemented as needed. 5. Date of completion 09/15/2023.

Based on record review, observations, and interviews, the facility failed to ensure 1 (Resident #3) of 20 (#3, #5, #37, #41, #11, #9, #152, #39, #10, #14, #102, #44, #19, #42, #29, #34, #21, #1, #46, #12) residents reviewed for impaired cognition and/or a diagnosis that may increase their risk of elopement was adequately supervised to prevent elopement from the facility. This deficient practice resulted in an Immediate Jeopardy for Resident #3 on 08/21/2022 at 2:48 a.m. when Resident #3 exited from the facility unsupervised and was found across the street from the facility in front of the police station. Resident #3 had a diagnosis of Schizophrenia, Alzheimer's disease and has severe cognitive impairment with a history of confusion and escalating psychotic behaviors. The facility failed to assess Resident #3 as an elopement risk and did not adequately supervise Resident #3 to prevent elopement from the facility. Resident #3 was placed on every 15 minute checks after he eloped on 08/21/2022. Resident #3 eloped again on 08/25/2022, 08/26/2022 and 09/02/2022. The facility received a phone call from a concerned citizen on 09/02/2022 notifying them a resident in a wheelchair was in the middle of the highway a couple of blocks from the facility. The facility failed to provide adequate supervision and assess Resident #3 as an elopement risk after he eloped on 08/21/2022, 08/25/2022, 08/26/2022 and 09/02/2022. The facility's lack of adequate supervision put Resident #3 at risk for the likelihood of serious injury, harm or death. S1 Administrator, S3 Corporate Risk Management, and S4 DON (Director of Nurses) were notified of the Immediate Jeopardy on 12/07/2022 at 7:51 p.m. The Immediate Jeopardy was removed on 12/08/2022 at 3:52 p.m. when the facility Plan of Removal was approved. Through record reviews, interviews and observations, the surveyor confirmed the following components of the Plan of Removal have been initiated and/or implemented prior to exit: 1. On 9/02/22 Resident #3 was placed on the secured unit, where he remains. Facility placed employees in visual proximity to the available exits 24/7 on 12/08/2022 at 1:30 p.m. to monitor residents leaving the facility until door alarms are installed. All employees will monitor residents that are not on the locked unit for any new signs of elopement risk factors or increased confusion and will notify the administrator or DON immediately if any new risks are identified until completion of plan of correction. Employees were educated on appropriate screening for elopement risk. 2. All residents not residing on the secure unit were assessed for elopement risk and evaluated for their BIMS (Brief Interview for Mental Status) score by licensed staff 12/05/2022. Results of audit were completed to ensure that all residents at risk for elopement had adequate supervision and were free from accident hazards by placing them on the secured unit. 3. Risk manager/designee will audit preadmission screening forms daily to ensure appropriate placement prior to anyone admitting to the facility. Risk Manager/designee will audit all new admissions daily to ensure they are interviewed using the BIMS and assessed for elopement risk on day 1 and are placed on secure unit if they are identified as an elopement risk. Elopement Risk Assessment and BIMS score will continue to be completed quarterly, annually, and with any status change to identify any residents who are at risk for elopement. 4. All staff will be educated by regional Risk manager/designee on: Wandering and Elopement Policy and how to identify residents at risk for elopement, BIMS Score Interview tool and Elopement risk assessment, communication to administrator and DON if a resident displays new signs of elopement risk factors. 5. Regional risk manager/designee will document that employees, including new hires, receive above education prior to working with residents. Regional risk manager/designee will conduct staff competency interviews on above topics and document completion. Chief Nursing Officer will audit elopement risk assessments, BIMS and preadmission screening daily for two weeks and weekly thereafter. Auditing results will be brought to QAPI (Quality Assurance Performance Improvement) Committee daily for 2 weeks, weekly for 4 weeks and monthly thereafter. Implementation date 12/08/2022 This deficient practice continued at a potential for harm for 18 current residents who did not reside on the locked Dementia Care Unit, had impaired cognition and/or a diagnosis that may increase their risk of elopement as identified in the facility's Elopement Risk Tools, and were able to either ambulate or propel themselves in their wheelchairs throughout the facility with the potential to elope (#5, #37, #41, #11, #9, #39, #10, #14, #102, #44, #19, #42, #29, #34, #21, #1, #46, #12). Findings: Review of the facility's Wandering and Elopements Policy Revised December 2019 revealed in part: The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. Residents who have been determined to be at risk for wandering/elopement will have immediate interventions put into place according to the resident assessment .If an employee observes a resident leaving the premises, he/she should attempt to prevent the resident from leaving in a courteous manner, get help from other staff members in the immediate vicinity if necessary, and instruct another staff member to inform the Charge Nurse or DON that a resident is attempting to leave or has left the premises. If a resident is missing, initiate the elopement/missing resident emergency procedure .determine if the resident is out on an authorized leave or pass, if the resident was not authorized to leave, initiate a search of the buildings and premises, and if the resident is not located, notify the Administrator and the DON, the resident's legal representative, the attending physician .When the resident returns to the facility, the DON or charge nurse shall examine the resident for injuries, contact the attending physician and report findings and conditions of the resident, notify the resident's legal representative, notify search teams that the resident has been located, complete and file an incident report, and document relevant information in the resident's medical record. Review of Resident #3's record revealed an admitted [DATE] and diagnoses including but not limited to: Schizophrenia, Major depressive disorder, Insomnia, Anxiety disorder, and Alzheimer's disease. Review of Resident #3's December 2022 Physician orders revealed orders including: 11/07/2022-monitor anti-psychotic medication use-observe resident closely for significant side effects 09/05/2022-admit to secure care unit 09/03/2022-monitor for behaviors while resident on psychotropic medications every shift 06/18/2022- Geodon 60 mg (milligrams) twice daily for schizophrenia 06/18/2022-Depakote 750 mg every day for behavior-document number of target behavior episodes 06/16/2022-Escitalopram (for depression) 20 mg every day 06/16/2022-Clonazepam 1mg twice daily for anxiety disorder Review of Resident #3's admission MDS (Minimum Data Set) assessment dated [DATE] revealed a BIMS score of 5 out of 15 indicating severe cognitive impairment. Further review revealed the resident was independent for bed mobility, transfers, and locomotion on unit with the use of a wheelchair. Further review of Resident #3's MDS assessments revealed no reassessment was done after the resident's elopements from the facility on 08/21/2022, 08/25/2022, 08/26/2022 and 09/02/2022. Review of the Resident #3's Elopement Risk Tools revealed an elopement risk assessment dated [DATE]. The summary of the assessment indicated the resident was not been found to be at risk for elopement at that time. Further review revealed no other Elopement Risk Tools were completed after the resident's elopements on 08/21/2022, 08/25/2022, 08/26/2022 and 09/02/2022. No reassessment of elopement risk was performed until 09/27/2022 after the resident was placed on the locked dementia care unit. Review of Resident #3's Comprehensive Care Plan revealed the resident was care planned for elopement risk starting with a previous admission beginning 04/15/22 with interventions including Evaluate elopement risk on admission, quarterly and or with improvement in cognition, monitor resident for tailgating following visitors thru exits, place resident information in elopement book, encourage activities of resident interest. Further review revealed no updates to the care plan after the resident's elopements from the facility on 08/21/2022, 08/25/2022, 08/26/2022 and 09/2/2022 when he was placed on the locked dementia unit. Further review revealed the care plan was not updated until 11/07/2022 for placement on the memory care unit. Review of Resident #3's nursing notes revealed in part the following notes: 08/21/22 at 3:52 a.m. by S12 LPN (Licensed Practical Nurse)-Resident seen in lobby at 2:40 a.m. when writer headed down hall for routine rounds. At 2:48 a.m. co-worker came rushing by stating that her daughter called and stated one of the residents was across the street from the facility in front of the police station. We immediately headed that way and observed resident in wheelchair propelling self on the road still in front of police station. Resident appeared stable and denied any pain or injury and agreed to let me bring him back to facility. I then performed assessment and skin/body audit that showed no new issues .While continuously observing resident I then notified S4 DON, and then the medical doctor and was given new order to admit to secure unit .Resident was then taken to secure unit. Attempted to notify resident's responsible party with no answer. Resident does not want to go to bed at this time and is currently in dining room of secure unit with CNA (Certified Nursing Assistant) stating he is going to leave again tomorrow. 08/22/2022 at 10:58 a.m. by S13 LPN- MD (Medical Doctor) updated on resident's behavior today . He was placed in secure unit for immediate safety. He is currently at hospital to have Magnetic Resonance Imaging of his foot and toes. After returning from his appointment, we have new order for him to be back in general population. We will do 15 minute checks on him and document his whereabouts. Staff will notify MD with any changes in behavior. 08/24/2022 at 8:04 p.m. by S14 LPN -Resident yelling and cussing at other residents. Talking about kicking someone's ass, and shooting them. Thinks the police are coming after him. Really acting up tonight. Demanding cigarettes and money . 08/25/2022 at 1:22 p.m. by S15 LPN- at 9:16 a.m. resident heading down sidewalk. Resident said he was going to haul logs. Resident redirected by staff, resident entered the building cussing at unseen people . 08/26/2022 at 7:14 a.m. by S15 LPN-Resident observed outside on the sidewalk by the civic center (which is across the street). Staff redirected him inside facility. Resident told staff he was looking for a smoke. 08/27/2022 at 10:27 a.m. by S15 LPN-Resident ambulating from hallway to front lobby cussing at unseen people, staff attempted to redirect resident without success. Resident continued to cuss and threatening unseen people. 08/28/2022 at 8:47 p.m. by S 14-Resident returned to facility via ambulance from behavioral hospital .Behavioral Hospital will not accept resident. Says he does not meet criteria . 09/02/2022 at 6:50 p.m. by S13 LPN Received phone call from concerned citizen. Resident had left out front door and propelled self up to main highway (Highway 157) and was going down the road. Writer immediately went to get him. When I got to him he was smiling and laughing. I ask him what in the world are you doing: He said he was going after a pulp wood truck. Used my cell phone and called DON. Staff from facility met me down the road and brought him back to facility and I drove my vehicle back. After I returned I called MD. She said to discontinue the 15 minutes checks and put him in the secure unit permanently. There was no documentation the resident's RP was notified of the elopement or the placement on the secure unit. Review of the facility's incident reports revealed no incident reports with investigations for Resident #3's elopement episodes. Observations during the survey from 12/05/2022 to 12/07/2022 revealed all exit doors were unlocked with no sound alerting when they were opened with the exception of the doors leading out the north and west sides of the Hall B, the door out the south side of the dining room, and the doors on the locked dementia care unit. There were chairs on the front porch. The building was located in a commercial area surrounded by sidewalks. With the exception of a fence around the patio of the locked dementia unit, there was no was no fence, gate, or barrier of any kind around the building between the sidewalk and the roads. The police station was directly across the street on the West side, there was a park and the civic center across the street on the North side, and commercial buildings across the street on the South and East sides of the building. During an observation and interview on 12/07/2022 at 10:58 a.m. on the locked dementia unit, Resident #3 was seated with other residents in the day area with staff supervision. The resident was clean and well groomed, and was dressed seasonally appropriate. Resident #3 self-propelled his wheelchair across the room and said he likes it back here and was doing better than when he was out there. During an interview on 12/07/2022 at 2:07 p.m. S4 DON confirmed no incident reports were done related to Resident #3's multiple elopements from the facility and should have been. S4 DON indicated management did do an investigation after Resident #3 left on 09/02/2022, but was unable to produce investigation notes or witness statements. S4 DON indicated she had contacted the Corporate Director of Nursing and was told the resident had a purpose, an intent and knew where he was going when he left the faciity on [DATE]. The surveyor asked S4 DON if that was the case with a resident who had a BIMS score of 5 out of 15 at that time. S4 DON responded that was what corporate told her. S4 DON indicated the facility did have a process for cognitive residents and family members to sign residents out when they left on outings and confirmed Resident #3 had never signed himself out. S4 DON confirmed the facility did not have cameras or video footage of the hallways and facility exit doors. S4 DON confirmed staff doing every 15 minute checks on Resident #3 should have noticed him leaving or noticed that he was gone before receiving a phone call from a concerned citizen and did not. During an interview on 12/07/2022 at 3:33 p.m. S4 DON indicated Resident #3 was found on 09/02/2022 on Highway 157 a few blocks east of the facility. S4 DON confirmed nurses did not do incident reports each time Resident #3 had been found outside of the facility and should have. S4 DON further confirmed the staff was not retrained on monitoring residents for elopement risk or on completing incident reports and should have been. S4 DON further indicated the front door of the facility was always unlocked except late at night. S4 DON further confirmed Resident #3 was not reassessed for elopement risk and his care plan was not updated after each of his 4 elopement episodes. During an interview on 12/07/2022 at 3:36 p.m. S16 LPN on the locked dementia care unit indicated Resident #3 says he is going to get out of here all of the time. During an interview on 12/07/2022 at 3:45 p.m. S17 CNA confirmed she had worked with Resident #3 and was familiar with him. S17 CNA indicated she had never witnessed Resident #3 trying to leave the facility, but he had made comments that he was going to get out of here. S17 CNA indicated Resident #3 was placed on every 15 minute checks before he was placed on the locked unit. Indicated she checks all of her assigned residents at least once an hour, but she and the nurses assigned to Resident #3 were supposed to check on him every 15 minutes. During an interview on 12/07/2022 at 3:52 p.m. S14 LPN indicated she was familiar with Resident #3, and did remember him saying he needed to get out of here. S14 LPN confirmed Resident #3 was on every 15 minute checks after his elopement on 08/21/2022 and still managed to leave the building 3 more times. During an interview on 12/07/2022 at 3:56 p.m., Resident #3 indicated he wants to get out of here because he is tired of being on lock down. When asked if he used his wheelchair to go down the highway, Resident #3 indicated he did go down the highway to get the pulp wood truck, but it wasn't going to be enough money. Review of Resident #3's log of every 15 minute checks for 08/22/2022 through 09/02/2022 revealed checks of the resident's location and activity every 15 minutes documented by facility LPNs. Further review revealed the last entry on 09/02/2022 was for 5:30 a.m. was asleep in his bed. During an interview on 12/07/2022 at 4:17 p.m. S4 DON indicated she could not find the logs for the rest of the day on 09/02/2022, and could not confirm the resident was observed every 15 minutes prior to being notified by a concerned citizen on 09/02/2022 at 6:50 p.m. that he was in his wheelchair on the highway. During a telephone interview on 12/07/2022 at 4:52 p.m. S13 LPN confirmed she was taking care of Resident #3 the day of 09/02/2022. S13 LPN confirmed nurses were performing every 15 minute checks on Resident #3 because he had gone to the police department across the street looking for a cigarette the week before he eloped on 09/02/2022. S13 LPN indicated she last saw Resident #3 on 09/02/2022 at roughly 5:30 p.m. when she personally took him out to the smoking area to smoke, and remained outside with him while he smoked. S13 LPN indicated she did not know the resident had left the facility until she got a phone call from a citizen at around 6:30 p.m. that he was on the highway in his wheelchair. S13 LPN indicated she drove up to the gas station where he was in the road. S13 LPN further indicated an agency CNA walked the few blocks to the gas station and brought Resident #3 back to the facility in his wheelchair. During an interview on 12/07/2022 at 7:00 p.m. S3 Corporate Risk Management indicated in the presence of S1 Administrator and S4 DON that all residents were not reassessed until 12/05/2022 when she performed an audit on the 39 residents not residing on the locked unit to re-evaluate their BIMS scores and elopement risk. S3 Corporate Risk Management indicated the facility identified one resident at that time who was found to be at risk for elopement that was not already residing on the locked unit. The resident, #152, was moved to the locked unit on 12/05/2022. S3 Corporate Risk Management indicated no other residents were identified by the facility to be at risk of elopement at that time. S3 Corporate Risk Management, S1 Administrator, and S4 DON agreed supervision of Resident #3 every 15 minutes was insufficient to prevent his repeated elopements. S3 Corporate Risk Management, S1 Administrator, and S4 DON further agreed the resident should have been reassessed for elopement risk, and additional interventions should have been put in place and were not. Review of the Elopement Risk Tools performed by the facility on 12/05/2022 revealed the following 19 residents who had cognitive impairments that contribute to poor decision-making skills and/or a diagnosis that may increase the risk of elopement: #5, #37, #41, #11, #9, #152, #39, #10, #14, #102, #44, #19, #42, #29, #34, #21, #1, #46, #12. Review of Resident #5's Elopement Risk Tool performed 12/05/2022 revealed the resident displayed cognitive deficits, disorientation, intermittent confusion, or other cognitive impairments that contribute to poor decision-making skills, and had a diagnosis that may increase the risk of elopement. Review of Resident #37's Elopement Risk Tool performed 12/05/2022 revealed the resident displayed cognitive deficits, disorientation, intermittent confusion, or other cognitive impairments that contribute to poor decision-making skills, and had a diagnosis that may increase the risk of elopement. Review of Resident #41's Elopement Risk Tool performed 12/05/2022 revealed the resident displayed cognitive deficits, disorientation, intermittent confusion, or other cognitive impairments that contribute to poor decision-making skills. Review of Resident #11's Elopement Risk Tool performed 12/05/2022 revealed the resident had a diagnosis that may increase the risk of elopement. Review of Resident #9's Elopement Risk Tool performed 12/05/2022 revealed the resident displayed cognitive deficits, disorientation, intermittent confusion, or other cognitive impairments that contribute to poor decision-making skills, and had a diagnosis that may increase the risk of elopement. Review of Resident #152's Elopement Risk Tool performed 12/05/2022 revealed the resident displayed cognitive deficits, disorientation, intermittent confusion, or other cognitive impairments that contribute to poor decision-making skills. Review of Resident #39's Elopement Risk Tool performed 12/05/2022 revealed the resident displayed cognitive deficits, disorientation, intermittent confusion, or other cognitive impairments that contribute to poor decision-making skills, and had a diagnosis that may increase the risk of elopement. Review of Resident #10's Elopement Risk Tool performed 12/05/2022 revealed the resident displayed cognitive deficits, disorientation, intermittent confusion, or other cognitive impairments that contribute to poor decision-making skills, and had a diagnosis that may increase the risk of elopement. Review of Resident #14's Elopement Risk Tool performed 12/05/2022 revealed the resident displayed cognitive deficits, disorientation, intermittent confusion, or other cognitive impairments that contribute to poor decision-making skills. Review of Resident #102's Elopement Risk Tool performed 12/05/2022 revealed the resident displayed cognitive deficits, disorientation, intermittent confusion, or other cognitive impairments that contribute to poor decision-making skills. Review of Resident #44's Elopement Risk Tool performed 12/05/2022 revealed the resident displayed cognitive deficits, disorientation, intermittent confusion, or other cognitive impairments that contribute to poor decision-making skills, and had a diagnosis that may increase the risk of elopement. Review of Resident #19's Elopement Risk Tool performed 12/05/2022 revealed the resident displayed cognitive deficits, disorientation, intermittent confusion, or other cognitive impairments that contribute to poor decision-making skills, and had a diagnosis that may increase the risk of elopement. Review of Resident #42's Elopement Risk Tool performed 12/05/2022 revealed the resident displayed cognitive deficits, disorientation, intermittent confusion, or other cognitive impairments that contribute to poor decision-making skills, and had a diagnosis that may increase the risk of elopement. Review of Resident #29's Elopement Risk Tool performed 12/05/2022 revealed the resident had a diagnosis that may increase the risk of elopement. Review of Resident #34's Elopement Risk Tool performed 12/05/2022 revealed the resident displayed cognitive deficits, disorientation, intermittent confusion, or other cognitive impairments that contribute to poor decision-making skills. Review of Resident #21's Elopement Risk Tool performed 12/05/2022 revealed the resident displayed cognitive deficits, disorientation, intermittent confusion, or other cognitive impairments that contribute to poor decision-making skills. Review of Resident #1's Elopement Risk Tool performed 12/05/2022 revealed the resident displayed cognitive deficits, disorientation, intermittent confusion, or other cognitive impairments that contribute to poor decision-making skills. Review of Resident #46's Elopement Risk Tool performed 12/05/2022 revealed the resident displayed cognitive deficits, disorientation, intermittent confusion, or other cognitive impairments that contribute to poor decision-making skills, and had a diagnosis that may increase the risk of elopement. Review of Resident #12's Elopement Risk Tool performed 12/05/2022 revealed the resident displayed cognitive deficits, disorientation, intermittent confusion, or other cognitive impairments that contribute to poor decision-making skills.

Based on interviews, the facility failed to administer its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident by failing to: 1. Ensure Resident #3 was adequately supervised to prevent repeated elopements from the facility 2. Complete incident reports, investigations, and train staff on supervision of residents to prevent elopements 3. Ensure Resident #3 was reassessed for elopement risk and update his plan of care with additional interventions to prevent repeat elopements. This deficient practice resulted in an Immediate Jeopardy for Resident #3 on 08/21/2022 at 2:48 a.m. when the facility's administration failed to ensure resources were effectively utilized to prevent Resident #3 from exiting the facility unsupervised and ensure steps were taken to identify other residents at risk for elopement. S1 Administrator, S3 Corporate Risk Management, and S4 DON (Director of Nurses) were notified of the Immediate Jeopardy on 12/07/2022 at 7:51 p.m. The Immediate Jeopardy was removed on 12/08/2022 at 3:52 p.m. when the facility's Plan of Removal was approved. Through record reviews, interviews and observations the surveyor confirmed the following components of the Plan of Removal have been initiated and/or implemented prior to exit. 1. On 09/02/2022 Resident #3 was placed on the secured unit, where he remains. Facility placed employees in visual proximity to the available exits 24/7 on 12/09/2022 at 1:30 p.m. to monitor residents leaving the facility until door alarms are installed. Employees were educated on appropriate screening for elopement risk. DON and Licensed Administrator have acknowledged re-education from Regional Risk Management Director on Wandering and Elopement Policy, how to identify residents at risk for elopement, ensuring education to all staff on communication to Administrator and DON if a resident displays new signs of elopement risk factors. 2. All residents not residing on the secure unit were assessed for elopement risk and evaluated for their BIMS (Brief Interview for Mental Status) score by licensed staff 12/05/2022. Results of audit were completed to ensure that all residents at risk for elopement had adequate supervision and were free from accidents hazards by placing them on the secured unit. 1 resident was identified at that time to be an elopement risk and moved to the locked unit immediately. 3. Regional Risk manager/designee will audit preadmission screening forms daily to ensure appropriate placement prior to anyone admitting to the facility. Risk Manager/designee will audit all new admissions daily to ensure they are interviewed using the BIMS and assessed for elopement risk on day 1 and are placed on secure unit if they are identified as an elopement risk. Elopement Risk Assessment and BIMS score will continue to be completed quarterly, annually, and with any status change to identify any residents who are at risk for elopement. 4. All staff, including administrator and DON, will be educated by regional Risk manager/designee on Wandering and Elopement Policy and how to identify residents at risk for elopement, BIMS Score Interview too, and Elopement risk assessment, Communication to administrator and DON if a resident displays new signs of elopement risk factors. 5. Regional risk manager/designee will document that employees, including new hires, receive above education prior to working with residents. Regional risk manager/designee will conduct staff competency interviews on above topics and document completion. Chief Nursing Officer will audit elopement risk assessments, BIMs and preadmission screening daily for two weeks and weekly thereafter. Auditing results will be brought to QAPI (Quality Assurance Performance Improvement) Committee daily for 2 weeks, weekly for 4 weeks and monthly thereafter. 6. Regional risk manager/designee will provide oversight over administration to ensure staff are taking the appropriate measures. Implementation Date: 12/08/2022 This deficient practice continued at a potential for harm for 18 current residents who did not reside on the locked Dementia Care Unit, had impaired cognition and/or a diagnosis that may increase their risk of elopement as identified in the facility's Elopement Risk Tools, and were able to either ambulate or propel themselves in their wheelchairs throughout the facility with the potential to elope (#5, #37, #41, #11, #9, #39, #10, #14, #102, #44, #19, #42, #29, #34, #21, #1, #46, #12). Findings, Cross Reference F689: During an interview on 12/07/2022 at 2:07 p.m. S4 DON confirmed no incident reports were done related to Resident #3's multiple elopements from the facility, but indicated they did investigate when he left. S4 DON was unable to produce investigation notes or witness statements related to Resident #3's elopements from the facility. S4 DON indicated she had contacted the Corporate Director of Nursing (was a different corporation at that time) and was told the resident had a purpose, an intent and knew where he was going when he left the faciity on [DATE]. The surveyor asked S4 DON if that was the case with a resident who had a BIMS score of 5 out of 15 at that time. S4 DON responded that was what corporate told her. S4 DON confirmed the facility did not have cameras or video footage of the hallways and facility exit doors. During an interview on 12/07/2022 at 3:33 p.m. S4 DON confirmed nurses did not do incident reports each time Resident #3 had been found outside of the facility and should have. S4 DON further confirmed no staff training was done after Resident #3's elopements from the facility related to completing incident reports, the wandering resident, or supervision of residents to prevent elopement and should have been. S4 DON further confirmed Resident #3 was not reassessed for elopement risk and his care plan was not updated after each of his 4 elopement episodes. During an interview on 12/07/2022 at 4:17 p.m. S4 DON indicated she could not confirm staff observed Resident #3 every 15 minutes as directed prior to being notified by a concerned citizen on 09/02/2022 at 6:50 p.m. that he was in his wheelchair on the highway. During an interview on 12/07/2022 at 7:00 p.m. S3 Corporate Risk Management in the presence of S1 Administrator and S4 DON indicated all residents were not reassessed until 12/05/2022 when she performed an audit on the 39 residents not residing on the locked unit to re-evaluate their BIMS scores and elopement risk. S3 Corporate Risk Management indicated the facility identified one resident at that time who was found to be at risk for elopement that was not already residing on the locked unit. The resident, #152, was moved to the locked unit on 12/05/2022. S3 Corporate Risk Management agreed the processes in place to date did not prevent Resident #3 from eloping. S3 Corporate Risk Management further confirmed thorough investigations were not performed after each of Resident #3's elopements, and the resident was able to elope 3 additional times after being placed on every 15 minute checks. S3 Corporate Risk Management further confirmed no processes had been changed/implemented and no updates to policies had been done to ensure no other residents at risk were able to elope from the facility. 40015

Based on record review and interviews, the facility failed to ensure adverse actions checks were completed monthly for 5 CNAs (certified nursing assistant) (S5 CNA, S6 CNA, S7 CNA, S8 CNA, S9 CNA) of 5 CNA (S5 CNA, S6 CNA, S7 CNA, S8 CNA, S9 CNA) personnel files reviewed. The facility also failed to ensure S9 CNA's criminal background/sex offender registry checks were reviewed by facility staff before S9 CNA started working at the facility on 5/30/2022. Findings: Review of S5 CNA's personnel file failed to reveal adverse actions checks were completed monthly. Review of S6 CNA's personnel file failed to reveal adverse actions checks were completed monthly. Review of S7 CNA's personnel file failed to reveal adverse actions checks were completed monthly. Review of S8 CNA's personnel file failed to reveal adverse actions checks were completed monthly. Review of S9 CNA's personnel file failed to reveal adverse actions checks were completed monthly. The review also failed to reveal a criminal background/sex offender registry check was completed. During an interview on 12/06/2022 at 2:27 p.m., S1 Administrator confirmed the facility did not have a process in place for verifying contract/agency CNA's criminal background checks and Adverse Actions website checks prior to them working in the facility. During an interview on 12/07/22 at 1:44 p.m., S4 DON (director of nursing) verified Adverse Actions checks for S5 CNA, S6 CNA, S7 CNA, S8 CNA, and S9 CNA were not checked monthly and should have been. S4 DON further verified S9 CNA's criminal background/sex offender check was not reviewed by facility staff prior to S9 CNA's start date of 5/30/2022.

Based on record review, interviews, and observation, the provider failed to ensure comprehensive care plans had been revised for 2 (#19, #46) residents out of a total of 29 sampled residents. Findings: Resident #19 Review of Resident #19's advanced directives revealed a code status of DNR (Do Not Resuscitate). Review of Resident #19's medical record revealed a LaPOST (Louisiana Physician Orders for Scope of Treatment) signed on 03/03/2022 indicating Resident #19 was a DNR. Review of Resident #19's December 2022 physician's orders revealed an order for DNR with a start date of 03/04/2022. Review of Resident #19's comprehensive care plans revealed a care plan with the following description, goals and interventions. Care plan description- I have an advanced directive, I am a full code. Goals- full code will be honored at the appropriate time through the next review. Interventions- Make staff aware of my advanced directives; Notify MD (medical doctor) and RP (responsible party) of resident's condition; perform full code at the appropriate time. During an interview on 12/06/2022 at 3:45 p.m., S4 DON (Director of Nursing) reviewed Resident #19's medical record and confirmed Resident #19's care plan had not been revised to reflect resident #19's wishes for DNR and should have been. Resident #46 Review of resident #46's medical record revealed Resident #46 was originally admitted to the facility on [DATE] and had diagnoses that included, in part, Stage 4 pressure ulcer to right hip, unspecified dementia, atherosclerotic heart disease, and essential hypertension. Review of Resident #46's physician orders revealed: 10/27/2022 - clean stage 4 pressure ulcer to right hip with acetic acid 0.25% and pat dry. Skin prep perimeter of wound, apply white foam over bone, then black foam. Cover with drape. Wound vacuum settings at 120 mm (millimeters)/hg (mercury) continuous suction. Change two times weekly and prn (as needed). Review of Care Plan failed to reveal Resident #46 was care planned for pressure ulcer. Observation on 12/05/2022 at 12:40 p.m. revealed Resident #46 was positioned slightly on right side with wound vacuum noted to right hip area and set at 120mm/hg. During an interview on 12/07/2022 at 10:05 a.m. S4 DON reviewed Resident #46's Care Plan and reported Resident #46 had not been care planned for right hip stage 4 pressure ulcer and should have been. 40957

Based on observation and interviews, the facility failed to ensure dietary services were provided in a sanitary environment for 50 out of 50 residents served a meal tray from the kitchen as reported by the dietary manager. The facility failed to ensure pans and serving utensils were stored in a sanitary manner. Findings: Observation of the kitchen on 12/05/2022 at 9:38 a.m. revealed 5 pans stored wet and dirty with food particles stuck to the pans. During an interview on 12/05/2022 at 9:38 a.m., S10 Dietary Manager, agreed the pans were stored wet and dirty and should not have been. A repeat observation of the kitchen with the S11 Dietitian and S10 Dietary Manager on 12/7/2022 at 10:10 a.m. revealed 5 pans stored wet and dirty with food particles stuck to the pans and 8 serving utensils stored dirty. During an interview on 12/07/2022 at 10:10 a.m. S11 Dietitian and S10 Dietary Manager acknowledged the 5 pans were stored wet and dirty and 8 serving utensils were stored dirty and should not have been.

Based on observations, interviews, and record reviews the facility failed to ensure patient care equipment was maintained in a safe operating condition as evidenced by Resident #11's toilet leaking at the base and no operational whirlpool in the facility. The census was 52 according to the Resident Census and Conditions of Residents form dated 01/04/2022. Findings: Observation of Resident #11's bathroom on 01/03/2022 at 11:40 AM revealed wet white linens with orange brown colored stains around base of toilet with ants crawling on and around linens at base of toilet. During an interview on 01/03/2022 at 11:40 AM, Resident #11 reported the toilet had been leaking for a while. During an interview on 01/03/2022 at 11:45 AM S5 Maintenance Supervisor reported he did not know who placed linens around the toilet. S5 Maintenance Supervisor further reported he thought he had repaired the leak around the bottom of Resident #11's toilet. Observation of Resident #11's toilet on 01/03/2022 at 11:45 AM S5 Maintenance Supervisor removed wet linens from toilet base, flushed toilet, and observed water leaking around base of toilet. During an interview on 01/03/2022 at 11:50 AM S7 Housekeeper reported she had not cleaned Resident #11's room today. S7 Housekeeper further reported wet linens were around the base of the toilet on 01/02/2022. Review of Maintenance Request Log Book revealed request to repair Resident #11's leaking toilet dated 12/25/2021. Review of Resident #11's quarterly MDS (Minimum Data Set) dated 10/4/2021 revealed BIMS (Brief Interview for Mental Status) score of 12 out of 15 indicating moderately impaired cognition. Review of Resident #11's functional status revealed independent with transfer, mobility, and toilet use. Further review of MDS revealed Resident #11 was occasionally incontinent of urine and always continent of bowel. Observation on 1/5/2022 at 12:10 PM revealed the door to the whirlpool room on the 200 hall was locked. During an interview on 1/5/2022 at 12:10 PM S8 LPN (Licensed Practical Nurse) reported the door to the whirlpool room on the 200 hall was locked since the whirlpool was no longer in use. S8 LPN further reported the whirlpool on the 200 hall was outdated and the lift to the whirlpool was not working properly. During an interview on 1/5/2022 at 2:00 PM S9 CNA (Certified Nurse Assistant) reported the whirlpool on the 100 hall was not currently in use and residents' were unable to recieve a whirlpool bath. S9 CNA reported she had informed the S2 DON (Director of Nursing) of the leak in the whirlpool on the 100 hall. During an interview on 1/5/2022 at 2:10 PM S5 Maintenance Supervisor reported there was not an operational whirlpool in the facility. S5 Maintenance Supervisor reported the whirlpool on the 100 hall had a leak and required a seal. S5 Maintenance Supervisor further reported the whirlpool had been leaking for a while. During an interview on 1/5/2022 at 2:20 PM S1 Administrator reported the part to repair the whirlpool leak had not been ordered.

Based on record reviews, an observation and interviews, the facility failed to ensure 1 (#17) out of 2 (#17, #49) sampled residents were free from verbal abuse. This deficiency had the potential to affect 9 residents who resided on the memory care unit. Findings: Review of Resident #17's Medical Records revealed an admitted [DATE] with the following diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #17's MDS (Minimum Data Set) assessment dated [DATE] revealed: Section C: Cognitive Patterns - BIMS (Brief Interview for Mental Status) 99 (unable to complete interview) Record review of Resident #17's Comprehensive Care Plan revealed: - Cognitive loss related to dementia - I ask that the staff promote dignity, talk to me and ensure my privacy when providing care. - Risk for ineffective communication related to inability to understand and to be understood by others - speak to me using simple to understand words. Review of Resident # 17's Nurses Note revealed the following entry dated 12/15/21 - Confused as usual. Speech mumbled. Long/short term memory poor . Review of S3 TNA's statement from the incident on 11/26/21 revealed the following: - I S3 TNA was in Resident #17's room on my phone I seen a text message due to personal reasons. Pissed me off so I started cussing I said I hate that I'm new to the back. Cause yall act like yall don't understand s**t when yall really f*****g do. Review of S4 LPN's (Licensed Practical Nurse) statement from the incident on 11/26/21 revealed the following: On 11/26/21 at approximately 7pm, I S4 LPN entered the secure unit to administer medications. Upon entry to unit, S3 TNA was not visible. As I began to pass pills, I began to hear loud conversation emanating from resident room. I immediately heard a male's voice and realized S3 TNA was talking loudly over speaker phone. As I continued to prepare/pass meds I heard S3 TNA say pull the d**n jacket off. My f*****g hand hurts and your old a** ain't making it any better. S3 TNA began laughing and again yelled at the resident to take the mother f*****g jacket off. I went to the door at this time and knocked and opened the door. Upon entry to the room, S3 TNA's eyes widened and she appeared shocked to see me. I then asked S3 TNA if she was having difficulties providing care and informed her that the language and tone she was using with resident was not appropriate. S3 TNA apologized and said she was just stressed out. I told S3 TNA to refrain from speaking to residents in such a manner and informed her that yelling and cursing at a patient with dementia/Alzheimer's would not be effective due to this resident not being able to follow verbal commands. I immediately sent S3 TNA on break to calm self .I informed S2 DON (Director of Nursing) immediately after checking on resident and was told to send S3 TNA home pending investigation which I did immediately upon her returning from break. Review of S3 TNA's Personnel Files revealed: Hire date: 09/21/21 and Termination date: 12/03/21 (last day worked 11/26/21). Observation on 01/04/2022 at 10:45 am revealed Resident #17 sitting in dining area and was unable to engage verbally when asked his name. During an interview on 01/05/22 at 2:20 pm S4 LPN confirmed the events that occurred on 11/26/21 and acknowledged she heard S3 TNA yelling and cursing at Resident #17. S4 LPN intervened and removed S3 TNA from the unit and notified the S2 DON. During an interview on 01/05/2022 at 9:40 am S6 CNA (Certified Nurse Assistant) reported Resident #17 is unable to verbalize. During an interview on 01/05/22 at 2:20 pm S4 LPN confirmed the events that happened on 11/26/21 and reported she heard S3 TNA yelling and cursing at Resident #17 saying pull the d**n jacket off, your old a*s ain't making it any better and take the mother f*****g jacket off. S4 LPN intervened and removed S3 TNA from the unit and notified the S2 DON. During an interview on 01/05/22 at 9:20 am S2 DON acknowledged S3 TNA was interviewed about the incident on 11/26/21 and S3 TNA admitted to yelling and cursing at Resident #17. S2 DON further reported S3 TNA was sent home on 11/26/21 and terminated.

Based on observation, interviews and record reviews the facility failed to ensure an effective Infection Prevention and Control Program was followed to prevent the development and transmission of COVID-19. Staff failed to don full PPE (Personal Protective Equipment) before entering 1 out of 1 resident (Resident #15) room that was COVID-19 positive. Findings: Review of Facility Policy Novel Coronavirus Prevention and Response revealed in part Policy: This facility will respond promptly upon suspicion of illness associated with a novel coronavirus in efforts to identify, treat, and prevent the spread of the virus. 5. Interventions to prevent the spread of respiratory germs within the facility: f. Promote easy and correct use of personal protective equipment (PPE) . Review of Resident #15's Rapid COVID-19 [MEDICATION(S)] test revealed positive results on 1/4/2022. Observation on 1/5/2022 at 12:00 PM revealed S9 CNA (Certified Nurse Assistant) entered Resident #15's room wearing only a cloth face mask. During an interview on 1/5/2022 at 12:05 PM S9CNA confirmed she did not put on full PPE (personal protective equipment) and full PPE should have been put on before entering Resident #15's room. During an interview on 1/5/2022 at 12:05 PM S8 LPN (Licensed Practical Nurse) confirmed full PPE should be worn when providing care for COVID-19 positive residents and S9 CNA should have been put on full PPE before entering Resident #15's room. During an interview on 1/5/2022 at 12:20 PM S2 RN (Registered Nurse), DON (Director of Nursing) confirmed staff should wear full PPE when entering a COVID-19 positive resident room to provided care.

Based on observation, record review, and interviews, the facility failed to ensure the residents' environment remains as free of accident hazards as possible for each resident who is transported in the facility's van via wheelchair. The facility's staff failed to have a system in place which followed the manufacturer's operating instructions in the loading and unloading of wheelchair residents for 1 (#1) of 8 residents (#1, #2, #3, #4, #5, #6, #7, #8). The facility failed to have a system in place to: 1. Ensure transportation staff were trained according to manufacturer specifications in the proper procedures for loading and unloading wheelchair residents on and off of the van lift. 2. Ensure staff followed the manufacturer Operating Instructions for loading and unloading residents in wheelchairs using the van lift. 3. Ensure residents in wheelchairs were properly secured on the van lift before lowering the lift platform. The immediate jeopardy began for resident #1 on 11/27/17 at 11:50 a.m. when S3 Van Driver improperly secured and positioned resident #1's wheelchair for unloading him from the van by pulling the resident's wheelchair onto the lift facing backward. S3 Van Driver failed to secure the resident's wheelchair on the lift by locking both wheels and securing the safety strap to the wheelchair before S2 Van Driver initiated the operation of lift to lower the platform. The unsecured wheelchair began to move causing S3 Van Driver to lose her balance and fall off of the lift with resident #1 from a height of approximately 2 feet. Resident #1 was transported to a local hospital emergency room (ER) for evaluation and treatment. Review of resident #1's radiology report for Computerized Tomography (CT) Spine cervical without contrast dated as performed on 11/27/17 at 2:14 p.m. revealed acute appearing fractures of the spinous processes of C6, C7, T1, and T2. Resident #1 was transported to hospital in Shreveport, LA in serious condition for Cervical spine fractures. Review of the Shreveport hospital physicians History and Physical note dated 11/28/17 at 22:47 a.m. revealed resident #1 was transferred to the hospital due to cervical spinal fracture. Review of Computerized Tomography scan spine cervical without contrast performed at Shreveport hospital and signed by radiologist on 11/28/17 at 10:26 a.m. revealed displaced fractures present involving the spinous processes C5, C6, C7, and T1. S1 Administrator was notified on 12/12/17 at 4:01 p.m. of the Immediate Jeopardy situation regarding resident #1's fall from the van lift that began on 11/27/17 at 11:50 a.m. The immediate jeopardy ended on 12/13/17 at 12:52 p.m. when S1 Administrator provided a written plan of removal which reads as follows: 1. What was done for residents affected by the stated deficient practice? The resident was assessed by the nurse and was sent to the ER. His family was notified, the MD was called. The staff member was also sent to the ER. As of 12/12/17, there are only 2 staff members who are allowed to transport residents and/or operate the lift. Those staff members have been trained per the manufacturer's guidelines. 2. How other residents affected by the potential deficient practice will be identified and what will be done for them? Any resident who is transported in the van and requires use of the lift could be affected by the potential deficient practice. There have been no other incidents. The two staff members have been trained. 3. Measures put in place to ensure deficient practice does not recur: The training for use of the lift has been updated as of now to include a video from the lift manufacturer of how to load and unload someone on the lift. The driver has received a personal inservice and has demonstrated to the Administrator the correct way to load and unload residents with the lift. The approved van attendant has been trained per the same guidelines. Any new van driver/attendant will have to go through same training before he/she will be able to operate the van or the lift. 4. How facility plans to monitor to ensure solutions are sustained: The Administrator or designee will monitor use of lift once weekly to watch the driver loading and unloading residents using the lift. The Administrator will maintain a log that includes these monitors and will provide additional training any time the correct procedure is not followed. The monitors will remain in effect for 6 weeks. Results of the monitors will be taken to the monthly QAPI (Quality Assurance Performance Improvement) meeting, the team will determine when the monitors can be DC'd (discontinued) based on compliance. Continued monitoring will occur monthly with monthly safety meeting once compliance is met. The deficient practice remained at a scope and severity of Isolated Actual Harm for resident #1 and potential for more than minimal harm for the remaining 7 residents (#2, 3, 4, 5, 6, 7, 8) . Findings: Review of resident #1's MDS (Minimum Data Set) dated 10/11/17 (30 day) revealed resident #1 was coded for moderate difficulty hearing and impaired vision, had a BIMS (Brief Interview for Mental Status) score of 13 of 15 indicating resident #1 was cognitively intact, and required total dependence for transfers with 2 person physical assist. Review of facility incident investigation for resident #1 dated 11/27/17 at 11:50 a.m. revealed the following: Incident occurred 11/27/17 at 11:50 a.m. ; Equipment in use: van mobile lift; Activity: transferring resident; Location: Behind facility kitchen in parking lot; Reported by S5LPN (Licensed Practical Nurse), Resident mobility: Chair bound; Mental: mild mental [MEDICAL CONDITION]; Other current conditions: Fall history, [MEDICAL CONDITION] history, confusion/disorientation, incontinency; Narrative of incident and description of injuries: S2 Van Driver and S3 Van Driver, assistant were assisting resident off the van. Resident was rolled onto lift and S3 Van Driver pulled resident onto the lift while standing on the lift with resident, S3 Van Driver lost her balance and resident sitting in w/c (wheelchair) rolled back and both fell off the lift. S3 Van Driver told writer the resident fell on her. Writer observed resident lying on the ground on his back. Neck fracture C6, C7, T1, and T2. Immediate Actions Taken: assessed resident, did not move resident vital signs, called Local EMS (Emergency Medical Services), stayed with resident until EMS arrived. Review of the nurses note attached to the written incident investigation revealed the following: .The cook from the kitchen came and instructed S5 LPN to go the parking lot behind the kitchen. S6 Kitchen Cook told writer that her resident fell off van lift while it was in the air. When writer walked outside observed 2 people on the ground lying on their back. Several staff members was outside standing near both people. S1 Administrator was also outside with staff and resident at the scene of accident. Resident assessed and ambulance called for transport to emergency room (ER). Medical Doctor (MD) was notified, and attempts to notify family. Received call from local ER to inform that resident being transferred to Shreveport hospital with diagnosis (dx) of neck fracture, MD, DON (Director of Nursing), and family notified. Review of the written incident investigation dated 11/27/17 and the OTIS (Online Tracking Incident System) report dated 12/8/17 failed to reveal any further investigation by the facility or witness statements. During an interview on 12/11/17 at 2:14 p.m. S1 Administrator stated he only had 2 van drivers, S2 Van Driver and S3 Van Driver. Stated S3 Van Driver had not yet returned to work since the incident and had not been re-trained. S1 Administrator stated only S9 CNA (Certified Nursing Assistant), S10 CNA, and S11 CNA were approved to ride as aides on the van but do not do any loading or unloading from the lift or any operation of the lift. S1 Administrator stated only the 2 drivers are trained to load and unload residents from the van lift or to operate the lift. S1 Administrator stated the approved staff and the process for loading residents on and off of the van was the same now as it was before the incident. Stated staff re-training after the incident stressed the importance of locking the wheelchair brakes and using the lift safety strap. S1 Administrator stated he was in the facility on 11/27/17 and went outside to the scene of the accident and took pictures. During an interview on 12/11/17 at 2:21 p.m. S2 Van Driver stated she was trained by S8 CNA on the facility's old van with a checklist when she was hired. Stated the current van and lift was obtained about a year ago. Stated she did not receive re-training with the current van and lift because all of the lifts work basically the same way. Stated the checklist for the old van was the same checklist still being used after the incident on 11/27/17. S2 Van Driver stated that on 11/27/17 at 11:50 a.m. she and S3 Van Driver were unloading resident #1 in a wheelchair from the van. Stated she was on the ground next to the lift operating the lift and S3 Van Driver was on the lift with the resident. Stated S3 Van Driver got on the lift and pulled the resident out (facing the van) and onto the lift. Stated S3 Van Driver was standing behind resident #1 on the back of the lift, locked the left W/C (wheelchair) brake but not the right W/C brake. S2 Van Driver stated she began lowering the lift before S3 Van Driver applied the safety strap, and as soon as the lift started moving S3 Van Driver lost her balance and fell off the back of the lift pulling resident #1 in the wheelchair out on top of her. S2 Van Driver stated she does not have and has not ever seen an owner's manual, only the check off sheet that was used for training her when she was hired. S2 Van Driver stated she was the employee who trained S3 Van Driver when she was hired and training was done with the same checklist. During an observation on 12/11/17 at 2:30 p.m. S2 Van Driver observed the lift with surveyor and confirmed the lift make and model number. During an interview on 12/11/17 at 2:45 S1 Administrator stated the Job Description and Performance Standards for the position of Facility Van Driver, the Van Driver Orientation, and the Authorized Driver Basic Skills Validation were collectively considered to be the facility's policy for loading residents on and off of the van and lift. When S1 Administrator was asked for a copy of the manufacturer's operator manual he stated he did not have an operator manual for the lift and had never had an operators manual. Review of an online version of the manufacturer's Operator Manual dated 4/12/10 revealed the following: - Page 1-3- Read and thoroughly understand the operating instructions before attempting to operate the lift. - Page 2-1-Refer to figure 2-2. Wheelchair occupant should preferably face outward on platform when entering or exiting vehicle to minimize the possibility of the large rear wheels rolling up and over the front rollstop. - Page 2-2- Figure 2-2: NEVER ENTER OR EXIT VEHICLE WHILE FACING BACKWARDS ON THE LIFT with a picture of resident in wheelchair facing van with circle and line through it indicating incorrect procedure, and a picture of resident in wheelchair facing away from van with a circle around it indicating the correct positioning - Page 2-2-It is never safe for a wheelchair occupant to exit a vehicle backwards. When exiting vehicle verify that platform is at same height as floor and front rollstop is up and locked - Do not place equipment or furniture inside vehicle that may prevent pivoting of your wheel chair. Being able to pivot assures that you can safely exit facing outward. - Do not allow an untrained person to operate lift - Be certain wheelchair fits safely on platform; it must not exceed beyond edges or interfere with operation of rollstop. - Page 2-3-Lock wheelchair brakes before moving platform. - Read and understand these safety precautions. Review them periodically and ask other operators to read them as well. - Page 2-9 Section E Normal Lift operation-Warning box: IMPROPER USE OF LIFT CAN RESULT IN PERSONAL INJURY. USERS MUST READ AND FOLLOW OPERATING INSTRUCTIONS. - Page 2-9-Step 1 Entering Vehicle: Deploy platform. Lower Platform. Carefully place wheelchair in center of platform, preferably facing outward (away from vehicle) and lock wheelchair brakes. - Page 2-10- Step 2. Exiting Vehicle: Deploy Platform. Warning-Verify that platform is at vehicle floor level and that front rollstop is up and locked in position. Carefully place wheelchair in center of platform, preferable facing outward (away from vehicle) and lock wheelchair brakes. Observation with S2 Van Driver on 12/12/17 at 8:10 a.m. revealed S2 Van Driver giving surveyor a demonstration of van lift operation with S4 Activity Director in wheelchair acting as a mock resident. S2 Van Driver rolled S4 Activities Director onto lift facing forward (facing front of van), applied w/c brakes, applied safety strap behind w/c and raised lift to van level, rollstop raised automatically. S2 Van Driver then went inside the van and pulled w/c onto van and secured w/c in position. S2 Van Driver then unloaded S4 Activities Director in the W/C by deploying the lift, rollstop raised automatically, rolled w/c onto platform backward (facing the front of the van), applied w/c brakes and safety strap behind w/c. S2 Van Driver then exited the van and operated the lift to lower it to the ground. Further observation revealed a printed decal with manufacturer's operating instructions affixed to the left side vertical bar of the lift. The decal contained the following: S-Series private use wheelchair lift Operator Instructions (Also read owner manual) with the following instructions to enter vehicle: 1) Enter platform centrally facing outward and lock wheelchair brakes; and instructions to exit vehicle 1) Enter platform centrally facing outward and lock wheelchair brakes. During an interview on 12/12/17 at 8:17 a.m. immediately after demonstration of lift operation, S2 Van Driver reviewed her training check off sheet dated 3/10/16 with items 1-22 dated 3/13/16 with surveyor. S2 Van Driver acknowledged step 8 was to Correctly position and secure the wheelchair on the lift, and step 9 was to Position & fasten the lift safety belt. When asked how she knew what the correct position was she stated she was trained to have the resident facing the van for entry and exit procedures. S2 Van Driver stated resident #1 was facing the van during exit of the vehicle on 11/27/17, only the left brake was applied, and the lift safety belt was not in position before she began lowering the lift. S2 Van Driver stated she was talked to after the incident on 11/27/17 but had not had any retraining or been required to give a repeat demonstration using the competency checkoff. During an interview on 12/12/17 at 8:20 a.m. with S1 Administrator and S2 Van Driver, S1 Administrator stated drivers were trained to position residents facing the front of the van. S1 Administrator and S2 Van Driver were shown the printed decal of operating instructions affixed to the left vertical bar of the lift and agreed it instructed the operator to position the resident facing outward. S1 Administrator and S2 Van Driver stated they had never seen the decal. S1 Administrator and S2 Van Driver also reviewed the operator manual printed by surveyor from the manufacturer's website dated 4/12/10 and acknowledged it instructed to position resident facing outward for safety. S1 Administrator stated I've never seen this, this is my first time to see this, Oh my God, how could we have missed that? All this time we've been doing it wrong. S2 Van Driver then produced an operator manual from the glove box dated 2004 which she acknowledged she did not know was there. S1 Administrator further stated that the write up of S2 Van Driver was the documentation of driver re-training since she was not available when he did the staff inservice, but that he would have to re-do it now since it was all wrong. S1 Administrator pointed out the left and right rear seats of the van, and stated there wasn't enough room to load residents facing outward and then turn them around so they could travel facing forward. Pointed S1 Administrator to page 2-2 of the operator manual and the statement do not place equipment or furniture inside the vehicle that may prevent pivoting of your wheelchair. Being able to pivot assures that you can safely exit facing outward. S1 Administrator further stated he had never seen that before and didn't know it. S1 Administrator stated S3 Van Driver would be re-trained when she returns to work. Review of Job Description and Performance Standards, Van Driver Orientation, and Authorized Driver Basic Skills Validation for S2 Van Driver and S3 Van Driver failed to reveal training included loading and unloading residents on the van lift according to manufacturer specifications. Review of facility inservice dated 12/5/17 failed to reveal staff re-training included loading and unloading residents on the van lift according to manufacturer specifications. Review of Notice of Disciplinary Action for S2 Van Driver dated 11/28/17 failed to reveal staff re-training included loading and unloading residents on the van lift according to manufacturer specifications. Review of the facility's van transportation logs from 9/4/17 to 12/12/17 revealed the following residents had been transported in the van in a wheelchair since 11/27/17: Resident #1, #2, #3, #4, #5, #6, #7, and #8. During an interview on 12/12/17 at 10:05 a.m. S9 CNA stated she was sometimes assigned to ride as an aide on the van. Stated she would roll residents in wheelchairs on and off of the lift if the driver needed help. Stated she would position the wheelchair residents on the lift facing the front of the van. S9 CNA stated she had not worked as an assistant on the van in the last one or two months. S9 CNA stated she had not received any retraining on van or lift procedures since the incident on 11/27/17. During an interview on 12/12/17 at 10:10 a.m. S8 CNA Supervisor stated CNAs did not position residents on the lift since they were not trained to do so. During an interview on 12/12/17 at 10:35 a.m. S1 Administrator stated the inservice on 12/5/17 was not a formal inservice with face to face training of attendants, but was a posting of written information for staff to read and sign. During an interview on 12/12/17 at 12:20 p.m. S6 Kitchen Cook stated she did not witness the incident on 11/27/17 but S7 Kitchen Cook had stuck her head out the back door and saw it happen. S6 Kitchen Cook stated S7 Kitchen Cook yelled for her to go get the nurse and tell her resident #1 had fallen off the van lift. During an interview on 12/12/17 at 12:22 p.m. S5 LPN stated she was resident #1's nurse on 11/27/17. S5 LPN stated she did not witness the event, but was called to the scene by the S6 Kitchen Cook. S5 LPN stated when she got outside she found resident #1 on his back on the ground with the attendant. Stated resident #1 was complaining of pain in his head and kept repeating that he just wanted to go to his room and go back to bed. S5 LPN stated resident #1 was transported to a local ER for evaluation and treatment. S5 LPN further stated it looked like the resident had gone one way and the wheel chair went the other way. During an interview on 12/12/17 at 1:25 p.m. S1 Administrator was asked if he had any further investigative documents related to incident on 11/27/17 or any witness statements. S1 Administrator stated he had no other notes or investigation with witness statements. During a telephone interview on 12/13/17 at 09:15 a.m. S3 Van Driver stated she was an attendant on the van on 11/27/17 with resident #1. S3 Van Driver stated when unloading resident #1 she pulled him out onto the lift backward (facing the front of the van) with her standing behind him next to the rear roll plate. S3 Van Driver stated she could not reach the controls so S2 Van Driver started to lower the lift. S3 Van Driver stated the foot rest of the wheelchair was sticking out over the lip of the lift and pushed the w/c backwards pushing her and the resident backwards. S3 Van Driver stated she fell backward over the rear rollplate and landed on the ground. S3 Van Driver stated everything after that is a blur and does not remember anything about where the resident or the wheelchair landed since she was in so much pain with her arm. During a telephone interview on 12/13/17 at 09:25 a.m. S11 CNA stated he sometimes helps the driver roll residents onto the lift. Stated he positions residents on the lift facing the front of the van. During an telephone interview on 12/13/17 at 09:35 a.m. S7 Kitchen Cook stated she had stuck her head out the back door on 11/27/17 and saw resident #1 in a wheelchair facing the front of the van and an attendant standing behind him on the van lift. Stated the attendant slipped and fell back off the lift and the resident fell and ended up on top of her. S7 Kitchen Cook stated resident #1's wheelchair fell off and landed next to them on the ground. Observation on 12/13/17 at 11:40 a.m. revealed S1 Administrator on speaker phone with S2 Van Driver asking where her written statement was. S2 Van Driver responded she re-wrote it and gave it to Human Resources. Statement was not included in original complaint investigation documents provided to surveyor. Review of S2 Van Driver's written statement provided by S1 Administrator on 12/13/17 at 11:56 a.m. and dated 11/27/17 revealed she, S3 Van Driver, and resident #1 arrived at the facility at approximately 11:50 a.m. I went through the side door of the van to unstrapped the front ties from the wheel chair S3 Van Driver unstrapped the back ties and seat belt from the back of the wheel chair. She wheeled the wheel chair backwards onto the van lift with resident in the wheel chair. She was unable to reach the remote to the lift so I started to lower the lift. The lift was approximately 2 feet in the air and S3 Van Driver started yelling the wheelchair rolling and she started falling backwards holding the wheel chair as she was falling backwards off the van lift with resident in chair. Resident and staff both fell on ground. S3 Van Driver only lock the left side of the wheelchair the right side of the wheel chair was unlock which caused it to start rolling backwards. During a telephone interview on 12/13/17 at 12:15 p.m. the manufacturer contact stated he was the technical support supervisor for the manufacturer and confirmed he had already spoken to the facility. The technical support supervisor reviewed pages 2-1, 2-2, 2-9, and 2-10 of the Operator Manual and stated the manufacturer's Best practice for facility use is for the wheelchair to be facing outward during loading and unloading with the seatbelt fastened securely. Technical support supervisor further stated the manual and terminology of preferably was intended to include a person living in the community who would independently self load.

Based on observation, record review, and interviews the facility failed to be administered in a manner that used resources effectively and efficiently to prevent avoidable accidents for 1 (#1) of 8 residents (#1, #2, #3, #4, #5, #6, #7, #8) who was transported in the van via wheelchair. The facility failed to have a system in place to: 1. Ensure transportation staff were trained according to manufacturer specifications in the proper procedures for loading and unloading wheelchair residents on and off of the van lift. 2. Ensure staff followed the manufacturer Operating Instructions for loading and unloading residents in wheelchairs using the van lift. 3. Ensure residents in wheelchairs were properly secured on the van lift before lowering the lift platform. The immediate jeopardy began for resident #1 on 11/27/17 at 11:50 a.m. when S3 Van Driver improperly secured and positioned resident #1's wheelchair for unloading him from the van by pulling the resident's wheelchair onto the lift facing backward. S3 Van Driver failed to secure the resident's wheelchair on the lift by locking both wheels and securing the safety strap to the wheelchair before S2 Van Driver initiated the operation of lift to lower the platform. The unsecured wheelchair began to move causing S3 Van Driver to lose her balance and fall off of the lift with resident #1 from a height of approximately 2 feet. Resident #1 was transported to a local hospital emergency room (ER) for evaluation and treatment. Review of resident #1's radiology report for Computerized Tomography (CT) Spine cervical without contrast dated as performed on 11/27/17 at 2:14 p.m. revealed acute appearing fractures of the spinous processes of C6, C7, T1, and T2 Resident #1 was transported to hospital in Shreveport, LA in serious condition for Cervical spine fractures. Review of the Shreveport hospital physicians History and Physical note dated 11/28/17 at 22:47 a.m. revealed resident #1 was transferred to the hospital due to cervical spinal fracture. Review of Computerized Tomography scan spine cervical without contrast performed at Shreveport hospital and signed by radiologist on 11/28/17 at 10:26 a.m. revealed displaced fractures present involving the spinous processes C5, C6, C7, and T1. S1 Administrator was notified on 12/12/17 at 4:01 p.m. of the Immediate Jeopardy situation regarding resident #1's fall from the van lift that began on 11/27/17 at 11:50 a.m. The immediate jeopardy ended on 12/13/17 at 12:52 p.m. when S1 Administrator provided a written plan of removal which reads as follows: 1. What was done for residents affected by the stated deficient practice? The resident was assessed by the nurse and was sent to the ER. His family was notified, the MD was called. The staff member was also sent to the ER. As of 12/12/17, there are only 2 staff members who are allowed to transport residents and/or operate the lift. Those staff members have been trained per the manufacturer's guidelines. 2. How other residents affected by the potential deficient practice will be identified and what will be done for them? Any resident who is transported in the van and requires use of the lift could be affected by the potential deficient practice. there have been no other incidents. The two staff members have been trained. 3. Measures put in place to ensure deficient practice does not recur: The training for use of the lift has been updated as of now to include a video from the lift manufacturer of how to load and unload someone on the lift. The driver has received a personal inservice and has demonstrated to the Administrator the correct way to load and unload residents with the lift. The approved van attendant has been trained per the same guidelines. Any new van driver/attendant will have to go through same training before he/she will be able to operate the van or the lift. 4. How facility plans to monitor to ensure solutions are sustained: The Administrator or designee will monitor use of lift once weekly to watch the driver loading and unloading residents using the lift. The Administrator will maintain a log that includes these monitors and will provide additional training any time the correct procedure is not followed. The monitors will remain in effect for 6 weeks. Results of the monitors will be taken to the monthly QAPI (Quality Assurance Performance Improvement) meeting, the team will determine when the monitors can be DC'd (discontinued) based on compliance. Continued monitoring will occur monthly with monthly safety meeting once compliance is met. The deficient practice remained at a scope and severity of Isolated Actual Harm for resident #1 and potential for more than minimal harm for the remaining 7 residents (#2, 3, 4, 5, 6, 7, 8) . Findings: Cross refer to F689 Review of facility incident report for resident #1 dated 11/27/17 at 11:50 a.m. revealed the following: Incident occurred 11/27/17 at 11:50 a.m. ; Equipment in use: van mobile lift; Activity: transferring resident; Location: Behind facility kitchen in parking lot; Reported by S5LPN (Licensed Practical Nurse), Resident mobility: Chair bound; Mental: mild mental [MEDICAL CONDITION]; Other current conditions: Fall history, [MEDICAL CONDITION] history, confusion/disorientation, incontinency; Narrative of incident and description of injuries: S2 Van Driver and S3 Van Driver, assistant were assisting resident off the van. Resident was rolled onto lift and S3 Van Driver pulled resident onto the lift while standing on the lift with resident, S3 Van Driver lost her balance and resident sitting in w/c (wheelchair) rolled back and both fell off the lift. S3 Van Driver told writer the resident fell on her. Writer observed resident lying on the ground on his back. Neck fracture C6, C7, T1, and T2. Immediate Actions Taken: assessed resident, did not move resident vital signs, called Local EMS (Emergency Medical Services), stayed with resident until EMS arrived. During an interview on 12/11/17 at 2:14 p.m. S1 Administrator stated he only had 2 van drivers, S2 Van Driver and S3 Van Driver. Stated S3 Van Driver had not yet returned to work since the incident and had not been re-trained. S1 Administrator stated only S9 CNA (Certified Nursing Assistant), S10 CNA, and S11 CNA were approved to ride as aides on the van but do not do any loading or unloading from the lift or any operation of the lift. S1 Administrator stated only the 2 drivers are trained to load and unload residents from the van lift or to operate the lift. S1 Administrator stated the approved staff and the process for loading residents on and off of the van was the same now as it was before the incident. Stated staff re-training after the incident stressed the importance of locking the wheelchair brakes and using the lift safety strap. S1 Administrator stated he was in the facility on 11/27/17 and went outside to the scene of the accident and took pictures. During an interview on 12/11/17 at 2:45 S1 Administrator stated the Job Description and Performance Standards for the position of Facility Van Driver, the Van Driver Orientation, and the Authorized Driver Basic Skills Validation were collectively considered to be the facility's policy for loading residents on and off of the van and lift. When S1 Administrator was asked for a copy of the manufacturer's operator manual he stated he did not have an operator manual for the lift and had never had an operators manual. During an interview on 12/12/17 at 8:20 a.m. S1 Administrator stated drivers were trained to position residents facing the front of the van. S1 Administrator was shown the printed decal of operating instructions affixed to the left vertical bar of the lift and agreed it instructed the operator to position the resident facing outward. S1 Administrator stated he had never seen the decal. S1 Administrator reviewed the operator manual printed by surveyor from the manufacturer's website dated 4/12/10 and acknowledged it instructed to position resident facing outward for safety. S1 Administrator stated I've never seen this, this is my first time to see this, Oh my God, how could we have missed that? All this time we've been doing it wrong. S1 Administrator stated he would have to re-do the van driver's re-training and the staff inservice since it was all wrong. S1 Administrator pointed out the left and right rear seats of the van, and stated there wasn't enough room to load residents facing outward and then turn them around so they could travel facing forward. Pointed S1 Administrator to page 2-2 of the operator manual and the statement do not place equipment or furniture inside the vehicle that may prevent pivoting of your wheelchair. Being able to pivot assures that you can safely exit facing outward. S1 Administrator further stated he had never seen that before and didn't know it. S1 Administrator stated S3 Van Driver would be re-trained when she returns to work. During an interview on 12/12/17 at 10:35 a.m. S1 Administrator stated the inservice on 12/5/17 was not a formal inservice with face to face training of attendants, but was a posting of written information for staff to read and sign. During an interview on 12/12/17 at 1:25 p.m. S1 Administrator was asked if he had any further investigative documents related to incident on 11/27/17 or any witness statements. S1 Administrator stated he had no other notes or investigation with witness statements. During a telephone interview on 12/13/17 at 12:15 p.m. the manufacturer contact stated he was the technical support supervisor for the manufacturer and confirmed he had already spoken to the facility. The technical support supervisor reviewed pages 2-1, 2-2, 2-9, and 2-10 of the Operator Manual and stated the manufacturer's Best practice for facility use is for the wheelchair to be facing outward during loading and unloading with the seatbelt fastened securely. Technical support supervisor further stated the manual and terminology of preferably was intended to include a person living in the community who would independently self load.

Based on record review, policy review, and interviews, the #S1 Administrator failed to ensure the facility was administered in a manner that uses resources effectively and efficiently to attain or maintain the highest practicable physical well-being for 1 (#2) of 3 (#1, 2, 3) residents transported on the van at the time of the accident out of a total sample of 5 residents reviewed. Administration failed to: 1. Ensure the transportation van had enough seat belts to accommodate all of the passengers being transported on 9/21/12. There were 6 available seats and only 4 seat belts available in the van on 9/21/12. 2. Have policies and procedures in place for tansportation van drivers to follow in the event of an accident/incident involving resident (s) in the transportation van. 3. Ensure transportation van staff were trained in procedures for securing residents in transportation van. 4. Have a system in place to ensure staff that transported residents were supervised to ensure residents safety. The Immediate Jeopardy began for resident #2 on 09/21/12 at 7:30 a.m. when #S2, driver of the van, failed to place a seat belt on her while in a wheelchair prior to putting the van in motion. During the trip to the [MEDICAL TREATMENT] center on 9/21/12 at 8:00 a.m. #S2 van driver slammed on the van's brakes causing resident #2 to fall out of her wheelchair hitting both legs and her mouth on the wheelchair mounts in front of her wheelchair. The Immediate Jeopardy ended when the facility trained staff on seatbelt use during the transport of residents on 9/21/2012. The deficient practice remained at a scope and severity of Isolated Actual Harm for resident #2. Findings: Review of resident #2 incident report dated 9/21/12 at 8:00 a.m. revealed a copy of the facility report as follows: Van traveling south on highway 371 at approximately 45 miles per hour. A tan and white truck traveling west on intersecting LA. Highway 160. The truck pulled onto Highway 371 in front of the van. (#S2's name, driver of the van), saw the truck and to avoid a collision, he slammed on his brakes. The truck accelerated and drove away. Resident #2 was sitting in a wheelchair behind the driver. She had no seat belt on. When the driver slammed on his brakes, she (resident #2) slides out of her chair forward hitting her mouth and struck her legs on wheelchair mounts in front of her wheelchair. (#S2 van driver) and (#S3 CNA) lifted resident #2 back into her wheelchair. They applied pressure to her mouth that was bleeding and took her to (local hospital) emergency room for treatment. Review of resident #2's hospital orthopedic physician's notes dated 9/24/12 at 1725 (5:25 p.m.) revealed she had bilateral tibia fractures. During an interview on 10/10/12 at 10:26 a.m. with #S3 CNA Supervisor/Transport she stated that on 9/21/12 she and #S2 van driver were headed to [MEDICAL TREATMENT] with 4 residents in the van when the accident occurred and Resident #2 was injured. During an interview on 10/10/12 at 11:25 a.m. with the #S2 van driver stated the day of the accident (9/21/12) resident #5 was sitting up front with him with a seat belt on. Resident #1 was sitting in the right seat second row in the van with a seat belt on. Resident #2 was sitting beside resident #1 in her wheelchair without a seat belt on. #S3 CNA was seated on the 3rd row on the right side without a seat belt. Resident #3 was seated in a wheel chair on the 3rd row with a shoulder belt on. #S2 van driver further stated if you have two residents in the seats on the 2nd and 3rd rows using the seat belts, the two wheelchairs cannot be secured with a seat belt. An observation at that time revealed only two functioning seat belts were in place on the 2nd and 3rd rows of the van. During an interview on 10/10/12 at 3:20 p.m. #S3 CNA was asked if she had any previous training on securing a wheelchair in the van before the accident on 9/21/12 and she stated she had not been trained. During an interview on 10/11/12 at 10:50 a.m. #S4 Maintanence Supervisor stated that he did not in-service the van drivers on securing seat restraints and did not have any manufacturer's recommendations for the use of the seat belts or the wheel chair four point securement system that the facility van had. During an interview on 10/11/12 at 11:15 a.m. #S5 Social Service Director stated that she had done some training years ago with the van driver #S2 in regards to securing wheelchairs in the van and stated that it would be in the drivers personal file if she had done any training. Review of #S2 Van Driver's personnel record revealed a hire date of 10/31/05 with no documentation of training to secure residents in the facility's van and no documentation of annual in-services. During an interview on 10/10/12 at 1:30 p.m. #S1 Administrator stated that she could not be sure what type of training had been done with the van drivers #S2 and #S3. At that time #S1 Administrator stated that she had no documentation of training for drivers #S2 and #S3, any manufacturers' recommendations for the securement of residents when placed in the facility's van, or any policy and procedure for the securement of resident while in the facility van.

Based on observations, record reviews, and staff interviews, the facility failed to ensure each resident that rode in the facility's van had a seat belt available and received adequate supervision to prevent accidents during transport for 1 resident (#2) of 3 (#1,#2, #3) residents transported on the van at the time of the accident out of a total sample of 5 residents reviewed. The facility failed to: 1. Ensure the transportation van had enough seat belts to accommodate all of the passengers being transportd on 9/21/12. There were 6 available seats and only 4 seat belts available in the van on 9/21/12. 2. Ensure transportation van staff were trained in procedures for securing residents in transportation van. 3. Have policies and procedures in place for transportation van drivers to follow in the event of an accident/incident involving resident (s) in the transportation van. 4. Ensure the transportation van driver called 911 on 9/21/12 after resident #2 fell out of her wheelchair when the driver slammed on his brakes resulting in bilateral tibia fractures and a mouth contusion. 5. Provide training to staff transporting residents in the transportation van regarding loading and securing residents in the facility van or annual in-services on the facility van drivers. 6. Follow Louisiana state statue RS 32:295.1 that requires each occupant of a van to have a safety belt properly fastened about his or her body at all times when the vehicle is in forward motion. 7. Have a system in place to ensure staff that transported residents were supervised to ensure residents safety. The Immediate Jeopardy began for resident #2 on 09/21/12 at 7:30 a.m. when #S2, driver of the van, failed to place a seat belt on her while in a wheelchair prior to putting the van in motion. During the trip to the dialysis center on 9/21/12 at 8:00 a.m. #S2 van driver slammed on the van's brakes causing resident #2 to fall out of her wheelchair hitting both legs and her mouth on the wheelchair mounts in front of her wheelchair. #S2 van driver and #S3 CNA lifted resident #2 back into her wheelchair. They applied pressure to her mouth that was bleeding and took her to (local hospital) emergency room for treatment. Review of resident #2 hospital orthopedic physician's notes dated 9/24/12 at 1725 (5:25 p.m.) revealed she had bilateral tibia fractures. The Immediate Jeopardy ended when the facility trained staff on seatbelt use during the transport of residents on 9/21/2012. The deficient practice remained at a scope and severity of Isolated Actual Harm for resident #2. . Findings: Review of resident #2 incident report dated 9/21/12 at 8:00 a.m. revealed a copy of the facility report as follows: Van traveling south on highway 371 at approximately 45 miles per hour. A tan and white truck traveling west on intersecting LA. Highway 160. The truck pulled onto Highway 371 in front of the van. (#S2's name, driver of the van), saw the truck and to avoid a collision, he slammed on his brakes. The truck accelerated and drove away. Resident #2 was sitting in a wheelchair behind the driver. She had no seat belt on. When the driver slammed on his brakes, she (resident #2) slides out of her chair forward hitting her mouth and struck her legs on wheelchair mounts in front of her wheelchair. (#S2 van driver) and (#S3 CNA) lifted resident #2 back into her wheelchair. They applied pressure to her mouth that was bleeding and took her to (local hospital) emergency room for treatment. Review of resident #2's hospital orthopedic physician's notes dated 9/24/12 at 1725 (5:25 p.m.) revealed she had bilateral tibia fractures. During an interview on 10/10/12 at 10:26 a.m. with #S3 CNA Supervisor/Transport she stated that on 9/21/12 she and #S2 van driver were headed to dialysis with 4 residents in the van when the accident occurred and Resident #2 was injured. . During an interview on 10/10/12 at 11:25 a.m. with the #S2 van driver stated the day of the accident (9/21/12) resident #5 was sitting up front with him with a seat belt on. Resident #1 was sitting in the right seat second row in the van with a seat belt on. Resident #2 was sitting beside resident #1 in her wheelchair without a seat belt on. #S3 CNA was seated on the 3rd row on the right side without a seat belt. Resident #3 was seated in a wheel chair on the 3rd row with a shoulder belt on. #S2 van driver further stated if you have two residents in the seats on the 2nd and 3rd rows using the seat belts, the two wheelchairs cannot be secured with a seat belt. An observation at that time revealed only two functioning seat belts were in place on the 2nd and 3rd rows of the van. During an interview on 10/10 12 at 3:20 p.m. #S3 CNA was asked if she had any previous training on securing a wheelchair in the van before the accident on 9/21/12 and she stated she had not been trained. During an interview on 10/11/12 at 10:50 a.m. #S4 Maintanence Supervisor stated that he did not in-service the van drivers on securing seat restraints and did not have any manufacturer's recommendations for the use of the seat belts or the wheel chair four point securement system that the facility van had. During an interview on 10/11/12 at 11:15 a.m. #S5 Social Service Director stated that she had done some training years ago with the van driver #S2 in regards to securing wheelchairs in the van and stated that it would be in the drivers personal file if she had done any training. Review of #S2 Van Driver's personnel record revealed a hire date of 10/31/05 with no documentation of training to secure residents in the facility's van and no documentation of annual in-services. During an interview on 10/10/12 at 1:30 p.m. #S1 Administrator stated that she could not be sure what type of training had been done with the van drivers #S2 and #S3. At that time #S1 Administrator stated that she had no documentation of training for drivers #S2 and #S3, any manufacturers' recommendations for the securement of residents when placed in the facility's van, or any policy and procedure for the securement of resident while in the facility van.