Every finding on record at Trinity Village Medical Center

Based on interviews, record reviews, and facility policy review, the facility failed to ensure Care Plans were updated for two (Resident #11 and Resident #12) of two residents reviewed for Care Plan accuracy. The findings include: Resident #11 A review of an admission Record indicated the facility admitted Resident #11 on 01/23/2017, with diagnoses which included stroke. A review of Bed Rail Assessments dated 01/21/2025 and 05/15/2025 indicated Resident #11 had expressed a desire to have siderails/assist bar for safety and/or comfort. The annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/15/2025, revealed Resident #11 had a Brief Interview for Mental Status (BIMS) score of 5 which indicated the resident had severe cognitive impairment. The MDS did not indicate the resident used side rails. A review of Resident #11’s Care Plan, revised on 02/24/2025, did not indicate the resident used bed rails. During an observation on 07/22/2025 at 10:16AM, Resident #11 was lying in bed with eyes closed. Resident #11’s bed was in lowest position with 1/4 sized rails up on both sides of the bed. During an interview on 07/23/2025 at 11:56AM, Certified Nursing Assistant (CNA) #4 stated Resident #11 used side rails for an enabler. “[Resident #11] helps us turn when we do care and feels safer with them.” During an interview on 07/24/2025 8:53AM, Licensed Practical Nurse (LPN) #5 indicated, “The Care Plan should have everything about the patient. If someone new comes in they should be able to look at the Care Plan and know everything about the resident. Code status and bed rails should be on the Care Plan.” During an interview on 07/24/2025 10:11 AM, the Director of Nursing (DON) indicated, Care Plans should have the resident’s activities of daily living (ADLS), bowel and bladder status, and anything pertinent to the resident’s specific care. Code status, fall mat, and bed rails should all be on the Care Plan. The DON stated side rail assessments are done on admission and “a lot of families ask for side rails. If families insist, the family has to sign a risk vs benefits form.” The DON also stated Resident #11 had side rails to help maneuver in bed for ADLs. The DON was not aware that some items were not on the Care Plan. The DON stated the Care Plans were important because they let the staff know how to care for the residents. During an interview on 07/24/2025 at 10:30 AM, the MDS Coordinator indicated, “I do the Care Plans. Care Plans should be a description of the residents and their care. The resident’s code status and side rails should be on the Care Plan. Any pertinent information about their care should be addressed. I did not know Resident #11 had side rails. Side rails should be on the Care Plan. The Care Plans tell staff how to specifically care for that resident.” Resident #12 A review of an admission Record indicated the facility admitted Resident #12 on 06/30/2025 with diagnoses which included cancer of the left lung. The admission MDS, with an ARD of 07/02/2025 revealed Resident #12 had a BIMS score of 15 which indicated Resident #12 was cognitively intact. A review of Resident #12’s Care Plan revised on 07/22/2025, did not indicate the resident smoked. During an interview on 07/23/2025 at 10:34 AM, Resident #12 indicated having smoked for 50 years. During an interview on 07/23/2025 at 1:52 PM, the Assistant Director of Nursing indicated that smoking was not on Resident #12’s Care Plan and the MDS coordinator was responsible for completing the Care Plan. During an interview on 07/24/2025 at 12:30 PM, the MDS coordinator indicated that Resident #12 stated they smoked when admitted to the facility. The MDS coordinator indicated that she forgot to put smoking on Resident #12’s Care Plan. A review of a policy titled, “Smoking Policy-Residents” revealed, “Prior to, and upon admission, residents are informed of the facility smoking policy, including designated smoking areas, and the extent to which the facility can accommodate their smoking or non-smoking preferences. The staff consults with the attending physician and the director of nursing services to determine if safety restrictions need to be placed on a resident’s smoking privileges based on the Safe Smoking Evaluation.

Based on observation, interview, and facility policy review, the facility failed to ensure food stored in the freezer and dry storage area were covered or sealed, one of one ice scoop holder was maintained in a sanitary manner, and dietary staff washed their hands between dirty and clean tasks and before handling clean equipment for one of one meal observed. The findings include: During an observation and interview on 7/23/25 at 9:46 AM, loose coffee filters were observed on top of a bag on the tea maker, which exposed them to air and potential pests. Dietary [NAME] (DC) #8 stated they were supposed to be in a sealed bag. During an observation and interview on 7/23/25 at 9:53 AM, DC #8 was observed wearing gloves on her hands when she turned off the stove, which contaminated the gloves. Without changing gloves and washing her hands, she used her gloved hand to sprinkle shredded cheese on top of the pasta to be served to the residents for lunch. DC #8 stated that it was cross contamination, and she should have removed her gloves and washed her hands. During a concurrent observation and interview on 7/23/25 at 9:57 AM, DC #8 was wearing gloves on her hands when she pushed the blender motor to the edge of the counter, contaminating the gloves. Without changing gloves and washing her hands, she used her hand to pick up a clean blade and attached it to the base of the blender to be used in pureeing food items for the residents who required pureed diets. DC #8 stated she should have removed the gloves and washed her hands after touching dirty objects and before handling clean equipment. During a concurrent observation and interview on 7/23/25 at 10:20 AM, the ice scoop holder located on the counter by the ice machine leading to the kitchen had approximately 1/4 cup of water standing it, with yellow flaky residue floating on the water, and the ice scoop resting in it. DC #8 stated the kitchen staff were supposed to clean it every day. She also verified that the Certified Nursing Assistants used the ice in water pitchers for the residents’ rooms, and the ice was also used to fill beverages served to the residents at mealtimes. During an observation and interview on 7/23/25 at 10:24 AM, Dietary Aide #10 (DA) opened a bag of lettuce while wearing gloves. Without changing gloves and washing her hands, DA #10 used the same gloved hand to remove lettuce from the bag and placed the lettuce into a pan intended to be used for salad. DA #10 stated she should have removed the gloves and washed her hands prior to removing the lettuce from the bag. On 07/23/25 at 10:36 AM, the following observations were made on a shelf in the walk-in freezer: An opened box of broccoli was not covered or sealed, which exposed it to freezer burn. An opened box of vegetable blend was not covered or sealed, exposing it to freezer burn. DA #9 stated that it would cause freezer burn if the box was not tightly sealed. During a concurrent observation and interview on 7/23/25 at 11:53 AM, DA #11 turned off the sink faucet while wearing gloves on her hands, contaminating the gloves. Without changing gloves and washing her hands, DA #11 then picked up glasses with beverages in them by their rims and placed them on the trays to be served to the residents during the lunch meal. DA #11, stated she should have removed the gloves and washed her hands after touching dirty objects and before handling clean equipment. During a concurrent observation and interview on 7/23/25 at 11:54 AM, DC #8 placed the blender bowl, lid and blade on the dirty rack and pushed the rack into the dishwashing machine to wash. After the dishwashing machine stopped washing, DC #8 without washing her hands, picked up a clean blade with her bare hand and attached it to the base of the blender to be used in pureeing food items for lunch. When DC #8 was ready to use the blender, this surveyor immediately stopped DC #8. DC #8 stated she should have washed her hands after touching dirty objects and before handling clean equipment. A review of a facility policy titled “Hand Washing,” indicated kitchen staff should wash their hands when entering the kitchen at the start of a shift, during food preparation, as often as necessary to remove soil or contamination and to prevent cross contamination when changing tasks and after engaging in other activities that contaminate the hands.

Based on observation, record review, interview, and facility policy review, the facility failed to ensure Enhanced Barrier Precautions (EBP) were followed during high contact care to prevent the risk of cross contamination and infection for one (Resident #41) of one resident observed. Specifically, nursing staff failed to wear a gown while administering medication, feeding, and flushing a gastrostomy tube with water. The findings include: A review of a Physician Order for Resident #41, dated 03/21/2022, revealed a medication for inflammation of the stomach was to be given through [percutaneous endoscopic gastrostomy] PEG tube. A review of a Physician Order for Resident #41, dated 05/06/2022, revealed a [nothing by mouth] NPO diet. A review of a Physician Order for Resident #41, dated 07/26/2023, revealed an order for water flushes before and after medications and feedings. A review of a Physician Order for Resident #41, dated 04/15/2025, revealed Resident #41 received supplemental feedings four times a day. A review of Resident #41’s Care Plan with a revision date of 02/05/2025, revealed the resident was on EBP related to the PEG tube. A review of a Medical Diagnosis Report revealed Resident #41 had diagnoses which included brain cancer, epilepsy, and diabetes mellitus type II. A review of Resident #41’s quarterly Minimum Data Set with an Assessment Reference Date of 04/18/2025, revealed a Staff Assessment for Mental Status score of 3 which indicated the resident’s cognitive skills for daily decision making were severely impaired. The MDS also indicated that Resident #41 had a feeding tube. On 07/23/2025 at 11:47 AM, Licensed Practical Nurse (LPN) #1 was observed pulling Resident #41’s gown up revealing Resident #41’s PEG tube then aspirated to check for placement. LPN #1 was observed administering water, stomach medication in 6 ounces of water, tube feeding, and then water to Resident #41’s feeding tube without wearing a gown. LPN #3 entered the room during the medication administration and stood beside LPN #1 without wearing a gown or gloves. During an interview with LPN #1 on 07/23/2025 at 11:52 AM, LPN #1 revealed, I forgot to put the gown on, EBP are outside the door, and we know PEG tubes require a gown and gloves. We have had in-services about that.” LPN #3 said, We wear a gown and gloves when opening the PEG tube to prevent infections. During an interview with Certified Nursing Assistant (CNA) #2 on 07/03/2025 at 12:00 PM, CNA #2 stated she recognized EBP because residents “have signs up above their bed, and some have a little red stop sign outside the door.” CNA #2 revealed that residents on EBP may “have a PEG tube, a wound, catheter, or urine infections” and staff receive “annual in-services or as needed.” A review of an in-service titled “Infection Control, EBP” revealed LPN #3 attended. A presentation titled “Infection Prevention and Control in Long Term Care” revealed goals for infection control are to protect the residents, staff and visitors. During an interview on 07/23/2025 at 12:08 PM, the Director of Nursing (DON) stated, “Nursing staff were expected to aspirate stomach contents to check placement before anything, and flush before and after medications, and EBP should be in place.” The DON confirmed staff have all been in-serviced on EBP. There would be a red stop sign outside the door and there would be personal protective equipment (PPE) inside the room. The DON stated PPE was used to protect the residents and staff from anything like wound blood or body orifice liquids coming out of a PEG tube. During an interview on 07/23/2025 at 12:15 PM, the Administrator said, “It is my understanding that staff would have to wear gloves and use universal precautions, but I am not sure staff would require a full dress out. The Administrator was asked for the last EBP in-service and policy. A review of in-serviced titled “EBP in Long Term Care,” dated 05/07/2025, revealed staff must wear gown and gloves during high contact care. Nursing will wear gown and gloves during device care including feeding tubes. Small stop signs are posted outside the door of residents identified as EBP. A flyer from the Centers for Disease Control identified EBP are required for device care including feeding tubes, central lines, catheters and tracheostomies. An article used in an in-service titled “Frequently Asked Questions about EBP in nursing homes,” revealed EBP reduce or prevent the transfer of multi drug resistant organisms and include the use of gown and gloves during high contact resident care.

Based on record reviews, interviews, and facility policy review, the facility failed to ensure a smoking assessment was completed for one (Resident #12) of two residents reviewed for smoking safety. The findings include: A review of Resident #12’s admission Record indicated the facility admitted the resident on 06/30/2025, with diagnoses which included lung cancer. A review of Resident #12’s admission Minimum Data Set (MDS) with an Assessment Reference Date of 07/02/2025, revealed a Brief Interview for Mental Status score of 15, which indicated the resident was cognitively intact. A review of Resident #12’s Care Plan, revised on 07/22/2025, indicated the resident had alteration in comfort related to lung cancer, depression, and generalized pain. The resident’s Care Plan revealed they required supervision or touching assistance to walk 10 feet. Resident #12’s Care Plan did not indicate the resident smoked tobacco products. A review of Resident #12’s Electronic Medical Record, on 07/23/2025 at 10:26 AM, revealed a smoking assessment had not been completed for the resident. During an interview on 07/23/2025 at 10:34 AM, Resident #12 stated they had smoked for 50 years and was not sure if they were going to smoke today. During an interview on 07/23/2025 at 1:52 PM, the Assistant Director of Nursing (ADON) confirmed Resident #12 smoked. She looked in the electronic health records system and verified Resident #12 did not have a smoking assessment completed. The ADON revealed the nurses that worked the halls were responsible for completing the resident’s smoking assessments. She also verified smoking was not on Resident #12’s Care Plan and revealed the MDS Coordinator was responsible for completing the Care Plans. During an interview on 07/23/2025 at 3:12 PM, Resident #12 stated the staff took them out to smoke during smoke breaks. During an interview on 07/24/2025 at 12:16 PM, the Director of Nursing (DON) indicated she did not know Resident #12 smoked, when they were admitted . The DON stated when she found out the resident smoked the staff failed to complete a smoking assessment. During an interview on 07/24/2025 at 12:30 PM, the MDS Coordinator stated Resident #12 told her that they smoked when they were admitted . The MDS Coordinator verified she forgot to put smoking on Resident #12’s Care Plan. A review of a policy titled, “Smoking Policy-Residents” documented, “Prior to, and upon admission, residents are informed of the facility smoking policy, including designated smoking areas, and the extent to which the facility can accommodate their smoking or non-smoking preferences. The staff consults with the attending physician and the director of nursing services to determine if safety restrictions need to be placed on a resident’s smoking privileges based on the Safe Smoking Evaluation.

Based on observation, interview, and record review, the facility failed to ensure the use of a physical restraint was used to treat a resident's medical symptoms, and was not being used for staff convenience for 1 (Resident #28) of 2 sampled residents (Residents #1 and #28) reviewed for physical restraint use and failed to perform a side rail assessment prior to installing side rails for 2 (Residents #1 and #28) of 2 (Residents #1 and #28) sampled residents reviewed for side rail use. The findings are: 1. Resident #28 had diagnoses of gastrostomy and pressure ulcer to sacral region. A quarterly Minimum Data Set (MDS) with and Assessment Reference Date (ARD) of 11/29/24 indicated a staff assessment of mental status (SAMS) of severely impaired. Resident #28 had an impairment of both upper and lower extremities, was non- ambulatory, and was totally dependent on staff for bed mobility, turning, positioning and transfers. The MDS indicated Resident #28 has had no falls since entry, reentry, or prior to assessment and bd side rails were not used. Physician orders for January 2025 did not include an order for bedrails. The care plan with a revision date of 08/15/2024 indicated that residents were totally dependent on two (2) staff for turning and repositioning and that resident was bedfast all or most of the time, was at risk for falls and used side rails for pillow positioning and turning. Resident #28 was observed on 01/13/2025, 01/14/2024, 01/16/2025 throughout each day lying in bed with both side rails up. On 01/16/2025 at 10:51 AM Certified Nursing Assistant (CNA) #11 said bed rails were used to protect residents from falling out of bed. She stated Resident #28 did not move on [pronoun] own and required total care from staff. CNA #11 stated the rails were monitored every 2 hours during rounds. On 01/16/2025 at 10:51 AM Licensed Practical Nurse (LPN) #12 said she was not familiar with Resident #28 but bed rails were monitored during rounds by CNAs and nurses. On 01/16/2025 at 11:07 AM LPN #13, who had worked at the facility for 3 years, stated she was familiar with Resident #28 ' s care. She was not sure when bed rails were initiated for the resident but stated they were used for safety. She also indicated the bed rails could be a risk if one of the resident ' s extremities were to get caught on a rail while being turned. LPN #13described Resident #28 as requiring total care and voiced that the resident did not move on their own. On 01/16/2025 at 11:15 AM the Director of Nursing (DON) and Assistant Director of Nursing (ADON) were interviewed in their office. The ADON reported every resident in the facility used side rails to assist with positioning and only 1/3 of rails were used. They went on to explain everyone was evaluated on admission for use of bedrails. The DON stated Resident #28's daughter requests side rails be used. The Electronic Health Record (EHR) did not include a risk versus benefit nor a responsible party notification of bedrail use. The facility policy for bed rails indicated they would only be used after attempted alternatives fail and a risk versus benefit assessment is completed. The inter-disciplinary team must evaluate the alternatives tried and how they failed, input from resident ' s family and consultation with attending physician. 2. On 01/13/2025 at 9:48 AM, Resident #1 was lying in bed awake and there were side rails on both sides of the bed in use. Resident #1's Order Summary Report was reviewed and indicated a diagnosis of seizures accompanied by changes in consciousness or other symptoms (symptomatic epilepsy and epileptic syndromes with complex partial seizures). There was no order indicating the use of side rails. On 01/14/2025 at 3:50 PM, Resident #1's electronic health record (EHR) was reviewed and there was no bed rail assessment located. On 01/16/2025 at 1:29 PM, Resident #1's care plan, dated 12/20/2024, was reviewed and indicated the resident was dependent on staff for meeting emotional, intellectual, physical, and social needs related to physical limitations and requested the assist rails remain down bilaterally. On 01/26/2025 at 2:49 PM, Certified Nursing Assistant (CNA) #15 was interviewed and stated the resident had side rails on her bed to help with turning and to prevent the resident from falling. She stated the resident was able to move in bed but required assistance with some movements, but she did not specify which movements. On 01/16/2025 at 3:09 PM, LPN #1 was interviewed and stated Resident #1 had side rails on the bed to assist with turning and repositioning. She reviewed the resident's electronic health record and confirmed the resident had a history of seizures but stated she had never witnessed the resident having a seizure. On 01/16/2025 at 3:19 PM, the Assistant Director of Nursing (ADON) was interviewed and stated the resident used the side rails to help turn in bed. She stated the side rails should be care planned and documented quarterly. As of 01/16/2025 at 4:20 PM, prior to the exit, neither the DON nor ADON provided a bed rail assessment for this Resident #1. 37925

Based on observations, interviews, record review, and facility policy review, the facility failed to ensure the medication error rate was not greater than 5%. The Medication error occurred with 2 (Resident #44, #6) of 4 sampled residents observed for medication administration. Medication error rate was calculated at 7.14%. The findings include: 1. A review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/11/2024 revealed Resident #44 had a Brief Interview of Mental Status (BIMS) score of 15 indicating cognitively intact. a. A review of the plan of care for Resident #44 (revision date 01/18/2023) revealed Resident #44 had alteration in cardiovascular/circulatory function related to hypertension (high blood pressure) and hyperlipidemia (abnormally high levels of fats in the blood). b. A review of the Medication Administration Record (MAR) revealed Resident #44 had an order for [calcium channel blocker medication name], a medication used to treat hypertension and chest pain, 90 milligrams (MG) of 1 tablet by mouth 1 time a day. c. On 01/15/25 at 08:12 AM, this surveyor observed Licensed Practical Nurse (LPN) #1 administer [calcium channel blocker medication name] 30 mg to Resident #44. d. On 01/15/25 at 09:34 AM, LPN #1 stated Resident #44 had been receiving 30mg of antihypertensive medication, which was not the amount ordered. LPN #1 stated the resident was not receiving enough of the medication. e. On 01/15/2025 at 10:46 AM, the Director of Nursing (DON) stated the error with Resident #44 ' s medication was due to a change in the pharmacy. The DON stated, That is not an excuse, it was still the facility's responsibility to ensure the resident received the accurate doses. 2. A review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/13/2024 revealed Resident #1 had a Brief Interview of Mental Status (BIMS) score of 15 which indicated cognitively intact. a. A review of the plan of care for Resident #1 (revision date 08/16/2023) revealed Resident #1 had a diagnosis of arthritis, the swelling and tenderness of one or more joints, which put the resident at risk for pain. b. A review of the MAR revealed Resident #1 had an order to apply [nonsteroidal anti-inflammatory (NSAID) medication name] to bilateral ankles and knees topically every 4 hours. c. On 01/15/25 at 07:30 PM, this surveyor observed LPN #6 apply [NSAID medication name] to Resident #1 ' s to right lateral leg, right knee, right foot, and left foot. d. On 01/15/25 at 07:30 PM, while applying the medication LPN #6 stated, I apply the cream to the outside of the right leg and knee, right foot. LPN #6 stated on the left side the resident just liked it on the foot. e. On 01/16/25 09:00 AM, LPN #1 stated, I apply the [NSAID medication name] gel from [Resident #1] knee down. f. A policy titled Administering Medications revision date April 2019 noted Medications are administered in a safe and timely manner, and as prescribed. The individual administering the medication checks the label three (3) times to verify the right resident, right medication, right dose, right time, and right method (route) of administration before giving the medication.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure the facility was free of significant medication errors for 1 (Resident #44) of 1 sampled resident who was administered the wrong dose of [calcium channel blocker medication name] for the entire month of January 2025 and failed to ensure [long acting insulin name] insulin was not administered past 28 days of use for 1 (Resident #66) of 1 sampled resident reviewed for insulin use. The findings include: 1. A review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/11/2024 revealed Resident #44 had a Brief Interview of Mental Status (BIMS) score of 15 indicating cognitively intact. A review of the plan of care for Resident #44 (revision date 01/18/2023) revealed Resident #44 had alterations in cardiovascular/circulatory function related to hypertension (high blood pressure) and hyperlipidemia (abnormally high levels of fats in the blood). A review of the Medication Administration Record (MAR) Resident #44 revealed an order for [calcium channel blocker medication name], a medication used to treat hypertension and chest pain, 90 milligram (MG) 1 tablet by mouth 1 time a day. On 01/15/25 at 08:12 AM, this surveyor observed Licensed Practical Nurse (LPN) #1 administer [calcium channel blocker medication name] extended release (ER) 30 mg to Resident #44. On 01/15/25 at 09:34 AM, LPN #1 stated Resident #44 had been receiving 30mg of antihypertensive medication, which was not the amount ordered. LPN #1 stated the resident was not receiving enough of the medication. A review of the Packing Slip dated 12/31/2024 revealed the facility received [calcium channel blocker medication name] extended release (ER) 30 mg from the pharmacy. On 01/15/2025 at 10:46 AM, the Director of Nursing (DON) stated the error with Resident #44 ' s medication was due to a change in the pharmacy. The DON stated, that is not an excuse it is still the facility's responsibility to ensure the resident received the accurate dose. A policy titled Administering Medications, revision date April 2019, was reviewed and indicated medications are administered in a safe and timely manner, and as prescribed. The individual administering the medication checks the label three (3) times to verify the right resident, right medication, right dose, right time, and right method (route) of administration before giving the medication. 2. On 01/16/2025 at 9:29 AM, this surveyor reviewed the medications and biologicals stored in the medication cart for the residents on B Hall. There was a vial of [long-acting insulin name] insulin for resident #66 stored in the drawer with two dates. The date written on the vial was 12/13 and the date written on the label was 12/18/24. Resident #66 ' s Order Summary Report was reviewed and indicated a diagnosis of a condition where the body does not regulate and use sugar properly leading to high blood sugar levels (type 2 diabetes mellitus). A physician's order dated 09/02/2024 indicated insulin [long-acting insulin name] inject 5 unit subcutaneously one time a day. Resident #66 electronic medication administration record (eMAR) was reviewed and indicated insulin [long-acting insulin name] subcutaneous inject 5 unit subcutaneously one time a day. The time on the eMAR indicated 0600 (6:00 AM) and there was a checkmark in the box for 01/16/2025. A checkmark indicated administered according to the chart codes/follow up codes located on the eMAR. On 01/16/2025 at 9:34 AM, Licensed Practical Nurse (LPN) #12 was interviewed with concurrent observations and stated she was not sure if 12/13 or 12/18/24 was the correct date which indicated the vial was accessed for use. On 01/16/2025 at 2:41 PM, LPN #12 was interviewed and stated [long-acting insulin name] insulin can be used for 28 days once the top has been accessed. She stated the vial of insulin was disposed of and reordered once 28 days had been reached. She was asked to look at a calendar and count the number of days [long-acting insulin name] insulin had been in use and she stated yesterday [01/15/2025] was 28 days and the insulin should have been disposed of and reordered. LPN #12 stated Resident #66 did not have another vial of insulin at the facility and she would have to reorder the insulin today. On 01/16/2025 at 3:16 PM, the Director of Nursing (DON) was interviewed and stated the nurses were responsible for checking the dates on the insulin to ensure vial could be used. The Food and Drug Administration (FDA) website (https://www.accessdata.fda.gov/drugsatfda_docs/label/2018/021081s071lbl.pdf) for [long-acting insulin name] insulin was reviewed and page 27 indicated [long-acting insulin name] vials in use should be thrown away after 28 days, even if it still has insulin left in it.

Based on observations, interviews, record review, and facility policy review, the facility failed to ensure medications and biologics were securely stored away at all times to prevent unauthorized individuals from potentially gaining access to the medication and/or biologics and failed to discard insulin after 28 days in use for 1 (Resident #66) 1 sampled resident reviewed for [long-acting insulin name] insulin use. The findings include: 1. On 01/15/25 at 08:39 AM, this surveyor observed Licensed Practical Nurse (LPN) #2 enter a resident's room to administer medication. This surveyor noted LPN #2 turned her back to the unlocked medication cart. On 01/15/25 at 08:56 AM, LPN #2 stated, I did not lock the medication cart. I should have. On 01/15/25 at 07:14 PM, this surveyor observed LPN #5 enter a resident's room to administer medication. This surveyor noted LPN #5 turned her back to the unlocked medication cart. This surveyor also observed LPN #5 walk down the hall while the medication cart remained unlocked. On 01/15/25 at 07:20 PM, LPN #5 stated she did not close or lock the computer screen prior to walking away, and someone could have gotten into the medication cart. On 01/15/25 at 07:28 PM, this surveyor observed LPN #6 walk down the hall while the medication cart remained unlocked. On 01/15/25 at 07:30 PM, LPN #6 stated she did not lock the medication cart prior to walking away. On 01/16/25 01:00 PM, the Director of Nursing (DON) stated the nurse should lock the medication cart prior to walking away, because there are medications and controlled medications no one without authorization should have access to. 2. On 01/16/2025 at 9:29 AM, this surveyor reviewed the medications and biologicals stored in the medication cart for the residents on B Hall. There was a vial of [long-acting insulin name] insulin for resident #66 stored in the drawer with two dates. The date written on the vial was 12/13 and the date written on the label was 12/18/24. Resident #66's Order Summary Report was reviewed and indicated a diagnosis of a condition where the body does not regulate and use sugar properly leading to high blood sugar levels (type 2 diabetes mellitus). A physician's order dated 09/02/2024 indicated insulin [long-acting insulin name] inject 5 unit subcutaneously one time a day. Resident #66's electronic medication administration record (eMAR) was reviewed and indicated insulin [long-acting insulin name] subcutaneous inject 5 unit subcutaneously one time a day. The time on the eMAR indicated 0600 (6:00 AM) and there was a checkmark in the box for 01/16/2025. A checkmark indicated administered according to the chart codes/follow up codes located on the eMAR. On 01/16/2025 at 9:34 AM, LPN #12 was interviewed with concurrent observations and stated she was not sure if 12/13 or 12/18/24 was the correct date which indicated the vial was accessed for use. On 01/16/2025 at 2:41 PM, LPN #12 was interviewed and stated [long-acting insulin name] insulin could be used for 28 days once the top has been accessed. She stated the vial of insulin was disposed of and reordered once 28 days had been reached. She was asked to look at a calendar and count the number of days [long-acting insulin name] insulin had been in use and she stated yesterday [01/15/2025] was 28 days and the insulin should have been disposed of and reordered. She stated Resident #66 did not have another vial of insulin at the facility and she would have to reorder the insulin today. On 01/16/2025 at 3:16 PM, the DON was interviewed and stated the nurses were responsible for checking the dates on the insulin to ensure the vial could be used. An information sheet provided by the DON on 01/16/2025 was reviewed and indicated [long-acting insulin name] insulin in use (opened) could be stored for 28 days. The Food and Drug Administration (FDA) website (https://www.accessdata.fda.gov/drugsatfda_docs/label/2018/021081s071lbl.pdf) for [long-acting insulin name] insulin was reviewed and page 27 indicated [long-acting insulin name] vials in use should be thrown away after 28 days, even if it still has insulin left in it. A Storage of Medications policy, dated as revised November 2020, was reviewed and indicated discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed.

Based on observation, record review, and interview, the facility failed to ensure meals were prepared and served according to the planned written menu to meet the nutritional needs of the residents for 1 of 1 meal observed. The findings are: 1. The 1/13/25 Resident meal of the month lunch menu documented the residents who received regular diets, mechanical soft diets, and residents who received chopped diets were to receive 2 slices of pizza. Residents who required pureed diets were to receive 2 #8 scoops (1 cup of pureed pizza and residents on mechanical soft diets were to receive ground pizza. 2. On 1/13/25 at 11:42 AM, during the lunch meal preparation, Dietary [NAME] (DC) #10 placed 6 slices of pepperoni pizza on a pan liner on top of the counter and sliced them into squares. DC #10 then transferred the squares pieces into a pan and stated she did it for the residents who received chopped meat. DC #10 placed the pan in the oven to be served to the residents who received chopped diets, instead of total of 12 slices of chopped pepperoni pizza since the menu indicated 2 slices of pizza for each resident. 3. On 1/13/25 at 12:17 PM, during the lunch meal preparation, DC #10 placed 4 slices of pepperoni pizza on a pan liner on top of the counter and stated we have 4 residents on mechanical soft diets. DC # 10 sliced 4 slices of pepperoni pizza, transferred them into a pan and placed it on the steam table to be served to 5 residents who received mechanical soft diets, instead of a total of 10 slices of ground pizza since the menu indicated 2 slices of pizza for each resident. At 1:19 PM, DC #10 was interviewed and was asked the reason residents on mechanical soft diets and residents on chopped diets only received 1 slice of pizza. DC #10 stated she used one slice because the Dietary Manager instructed, she gave a slice of pizza each. 4. On 1/13/25 at12:45 PM, the following observations were made during the noon meal service. a. DC #9 used a #8 scoop to serve a single portion of pureed pizza to the residents who received pureed diets, instead of 2#8 scoops. On 1/16/25 at 10:46 AM, DC #9 was interviewed and was asked what scoop size she had used to serve pureed pepperoni pizza at the lunch meal on 01/13/25 and how many servings she gave to each resident. She stated she used a #8 scoop, and she gave a serving each. DC #9 was interviewed and was asked if she reviewed the menu before deciding on how much pureed pizza to serve to the residents on pureed diets and she stated she didn't review the menu. 5. DC #9 used a #10 scoop (1/3 cup) to serve a single portion of pepperoni pizza cut in the shape of cubes, a total of 10 pieces, to the residents on mechanical soft diets, instead of ground pizza. At 01:14 PM, DC #9 was interviewed and was asked what scoop size she had used to serve mechanical soft pepperoni pizza and how many pieces of cut pizza were in the scoop served to the residents who received mechanical soft diets, and she stated she used a #10 scoop and there were about 10 pieces of cut pizza in the scoop she gave to each resident. She stated she gave a serving each.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure food items in the refrigerator, freezer and storage room were covered, and sealed; leftovers meat products were used in a manner to maintain food quality; dented cans were promptly removed from stock; 1 of 2 ice machines was maintained in clean and sanitary condition; dietary staff washed their hands before handling food or clean equipment; ceiling tiles, air vents, dish washer wall , kitchen door frames were free of, debris, dirt, rust, stains, baseboards were secured, and hot food items were maintained at temperature of 135 degrees or above for 1 of 1 meal observed. The Findings are: 1. On 1/13/25 at 8:41 AM, the following observations were made in the kitchen areas. a. A bag of coffee filters with loose coffee in it to be brewed was on the counter by the coffee machine. b. An opened bag of pizza was on the counter by the steam table. The bag was not sealed. c. An opened box of apple pie was on top of the plate warmer. The box was not covered. 2. On 1/13/25 at 8:43 AM, the following observations were made in the refrigerator. a. A bag of leftover sausage dated 01/13/2025 and a bag of leftover scrambled eggs dated 01/13/25 were in a pan on a shelf in the refrigerator. Dietary [NAME] (DC) #7 was interviewed and was asked what leftover sausage and leftover eggs were used for. She stated she used them at the breakfast meal the next day for mechanical soft diets and pureed diets. b. An opened bag of shredded cheese was on a shelf. The bag was not sealed. c. A pan of leftover spaghetti dated 01/11/2025 was on a shelf. The pan was not fully covered, exposing the food items to air. 3. On 1/13/25 at 8:51 AM, the following observations were made on a shelf in the walk-in freezer located outside the kitchen: a. An opened box of corndogs. The box was not covered or sealed. b. An opened box of steak fingers. The box was not covered or sealed. c. An opened box of dough sheets. The box was not covered. 4. On 1/13/25 at 9:00 AM, the following observations were made in the storage room: a. There were 3 dented cans of English peas on a shelf in the storage room: b. An opened bag of flour tortillas. The bag was not sealed. 5. On 1/13/25 at 9:21 AM, the area in the ice machine panel where ice forms before dropping into the ice collector had wet black, and brown, slimy residue on it. The Dietary Manager was interviewed and was asked if she could wipe the area where the residue mixtures were observed. She did so, and the black, and brownish slimy residue easily transferred to the tissue. She was asked to describe the appearance of what was observed. The Dietary Manager confirmed it was black with brownish, slimy and grungy. The Dietary Manager was interviewed and stated the maintenance man cleaned the ice machine every 3 months, the CNAs [Certified Nursing Assistants] use it for the water pitchers in the residents' rooms and sometimes it is used in the kitchen to fill beverages. 6. On 1/13/25 at 9:27 AM, DC #7 placed gloves on her hands and opened a bag of shredded lettuce with a knife and emptied it into a pan, which contaminated the gloves. Using the same contaminated gloves, DC #1 leveled the shredded lettuce in the pan, then proceeded to cut the tomatoes and cucumbers and place them on top of the lettuce to be served to the residents for lunch meal. DC #2 was interviewed and was asked what she should have done after touching dirty objects and before handling clean equipment. She stated she should have removed the gloves and washed her hands. 7. On 1/13/25 at 9:38 AM, the following observations were made in the kitchen: a. The ceiling tiles throughout the kitchen had stains on them. b. Ceiling vents in the dish room had rust stains on them. c. A ceiling tile in the storage room was loose. d. The wall on the clean side of the dish washing machine room was chipped and exposing the cement. e. The door frame leading to the dishwashing machine had rust stains on it. f. The ceiling vent above the dishwashing machine and the panels around ceiling tiles had rusty colored stains. g. The wall paint by the dirty dish window was peeling. The area exposed had stains on it. The wall below the dirty dish window had sage color stains on it. h. The baseboard under the dish washing machine was loose, the area that was exposed had sage color. 8. On 1/13/25 At 9:44 AM, Dietary Aide (DA) #8 lifted the lid of the trash can to dispose of gloves, contaminating her hands by touching the trash can lid. After disposing of the gloves, DA #8 pulled a new pair from the glove box and placed them on her hands, contaminating with her hands while handling the outside of the gloves. DA #8 then used the contaminated gloves to pick up clean plates from the clean side of the clean rack and when she was about to place them on the plate warmer. DA #8 was interviewed and was asked what she should have done after touching dirty objects and before handling clean equipment. She stated she should have washed her hands. 9. On 1/13/25 at 11:34 AM, Dietary [NAME] #9 wore gloves on her hands to open boxes of pecan pies, removing the pies and placing them on a cutting board. However, using the same contaminated gloves, without changing gloves and washing her hands, DC #9 cut the pecan pies and placed each slice into individual plates to be served to the residents for lunch. 10. On1/13/25 at 12:24 PM, the temperatures of the food items when checked and read by DC # 7 were: a. Pureed pizza 105.9 degrees Fahrenheit. b. Mechanical soft pizza 104.3 degrees Fahrenheit. c. Chopped crusted pizza 109.5 degrees Fahrenheit. The above food items were not reheated before being served to the residents. 11. A review of facility policy titled, Use of Leftovers, initiated 2019, provided by the Dietary Manager on 1/16/2025 indicated, leftover foods should not be used for pureed diets. 12. A review of a facility policy titled, Handwashing and Glove Usage in Food service, initiated 2016 and provided by the Dietary Manager on 1/8/2025 indicated food handlers should wash their hands before starting work, after touching dirty dishes or clothing and after touching anything else such as dirty equipment.

Based on observation, interview, record review and facility policy review the facility failed to ensure enhanced barrier precautions (EBP) were being followed to prevent the spread of possible infection for one (Resident #28) of four sampled residents who were on EBP. The findings are: Resident # 28 had diagnoses of gastrostomy, cerebral infarction, bipolar disorder, diabetes mellitus type 2, and Alzheimer's disease. The review of Physician Orders for January 2025 did not indicate an order for enhanced barrier precautions. On 01/13/2025 at 9:12 AM, EBP signage was observed on Resident #28's door and a stocked personal protective equipment (PPE) cart was on Resident 28's side of the room. On 01/13/25 at 09:13 AM, Certified Nursing Assistant (CNA) #3 was observed at Resident #28's bedside, preforming incontinent care, without PPE on. When asked, CNA #3 stated she had changed the resident without donning PPE. On 01/13/2025 at 1:22 PM, Hospice CNA #4 was observed bathing Resident #28 without PPE on. When questioned, CNA #4, responded it was her first time working with the resident and she was not aware Resident #28 was on EBP. The Quarterly minimum data set (MDS) with an assessment reference date (ARD) of 11/29/24 indicated a staff assessment of mental status (SAMS) score of severely impaired, and was dependent for eating (tube fed), toileting, bathing, turning and positioning, and was always incontinent of bowel and bladder. The MDS also indicated one stage 3 pressure ulcer. On 01/16/2025 at 10:51 AM, CNA #11 verified she had been educated on EBP. She was able to correctly explain why it is used, where supplies were located and said she identified residents with EBP by the signage on the door and by looking at the electronic medical record (EMR) tasks. On 01/16/2025 at 10:57 AM, LPN #12 verified education on EBP, was able to identify which residents were on EBP, how they were identified, and correctly respond that EBP is used for infection control. On 01/16/2025 at 11:00 AM, LPN #13 reported education on EBP and reported it was to protect staff, resident, and other residents from infection. She explained how residents with EBP were identified and which PPE was required. Review of the facility's Policy for Enhanced Barrier Precautions indicated EBP are used for infection prevention and control. The EBP policy stated gloves and gowns are to be used during high contact with residents such as bathing, incontinent care, transferring, wound care and when a resident has an indwelling device such as a urinary catheter or feeding tube. The policy went on to state that signs are posted outside the resident ' s room and PPE is available outside resident ' s room.

51885 Based on interviews, record review, and facility policy review, it was determined that the facility failed to ensure care plans were revised to reflect residents' most recent care needs for 2 (Residents #24 and #45) of 18 sampled residents whose care plans were reviewed. The findings are: 1. Resident #24 had diagnoses of diabetes mellitus with foot ulcer, adjustment disorder with depressed mood and myocardial infarction. The annual minimum data set (MDS) with an assessment reference date (ARD) of 10/18/24 indicated Resident #24 had a brief interview of mental status (BIMS) score of 15, indicating the resident was cognitively intact. The MDS indicated the resident had no impairment to upper or lower extremities, used a wheelchair for ambulation, was dependent on staff for toileting, dressing and personal hygiene, and required partial assistance with transfers from bed to chair and back and had no falls since previous assessment. On 01/13/25 at 12:36 PM a review of the electronic health record (EHR) revealed a progress note from 12/13/2024 by the nurse Practitioner (NP) that addressed a fall Resident #24 had sustained after falling asleep in [pronoun] wheelchair at bedside, and that the resident was falling more frequently. The note documented the NP had talked to Resident #24 and the resident agreed to stay in bed if in [pronoun] room and if up in wheelchair the resident would sit at nurse's station or in an area where staff could monitor closer to prevent falls. A review of the EHR disclosed a fall risk assessment dated [DATE] indicating Resident #24 was at risk for falls. Review of the Care Plan with a revision date of 12/20/2023 indicated Resident #24 was at risk for fall due to history of falls at previous nursing facility, poor safety awareness and incontinence. The care plan was not updated with any new interventions after the fall on 12/13/2024. On 01/16/2025 at 1:57 PM Licensed Practical Nurse (LPN) #14, the MDS Coordinator, stated the care plans were updated as necessary and at least quarterly. She reported she gathered her information for any changes at morning meeting and by review of the residents ' orders. When asked if incidents and accidents were monitored and interventions added or changed, she replied yes, and that incidents and accidents were discussed during the morning meetings. The facility policy for Care Plan, Comprehensive Person-Centered, revised March 2022, indicated assessments are ongoing care plans will be revised as information about the resident and residents condition change. The policy goes on to say the care plan will be updated after a significant change, when desired outcome is not met, after readmission and at least quarterly 2. A review of Resident #45 ' s Order Summary indicated a diagnosis of depression. An antipsychotic medication was ordered [antipsychotic medication name] Oral (1) 2 milligram (mg) tablet 1 time a day for depression with an order date of 11/29/2024 and start date of 11/30/2024. An order for [antidepressant medication name] (1) 40 milligram (mg) tablet 1 time a day was ordered for depression on 12/02/2024 with a start date 12/03/2024. A review of Resident #45's admission Minimum Data Sheet (MDS), with an Assessment Reference Date (ARD) of 12/04/2024, indicated a Brief Interview for Mental Status (BIMS) score of 15, which indicated cognitively intact. The MDS indicated Resident #45 was taking an antipsychotic medication, [antipsychotic medication name]. A review of Resident #45's Care Plan, dated 12/05/2024, indicated the resident was taking [antidepressant medication name] and [antipsychotic medication name] for depression. The care plan did not indicate [antipsychotic mediation name] was an antipsychotic medication. The care plan did not indicate to monitor for signs or symptoms of an adverse reaction to an antipsychotic medication. On 01/16/2025 at 11:16 AM, the MDS Coordinator was interviewed with concurrent observations, and she produced the Resident Assessment Instrument (RAI) with the most recent update of October 2024. The MDS Coordinator reviewed the resident ' s most recent MDS, Section N (medication section) and stated the resident was on antipsychotic medication. The MDS Coordinator stated she was responsible for the care plans. She reviewed the resident's most recent care plan dated 12/04/2024 and stated she documented the [antipsychotic medication name] under depression because that was what it was ordered for. She stated the [antipsychotic medication name] should have been documented under an antipsychotic medication because that is what the medication is categorized as. She stated the care plan should have indicated to monitor for signs and symptoms of adverse reactions to the medication. A Care Plans, Comprehensive Person-Centered policy, dated as revised March 2022 and provided by the Director of Nursing (DON) was reviewed and indicated the care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem area and their causes, and relevant clinical decision making.

Based on observations, interviews, record review, and facility policy review the facility failed to ensure the personal and medical information was protected for 3 (Resident #1, #40, #236) of 4 sampled residents potentially violating the Health Insurance Portability and Accountability Act (HIPPA). The findings include: 1. A review of the plan of care for Resident #236 revealed the resident had an admitted [DATE]. a. On 01/15/25 at 08:39 AM, this surveyor observed Licensed Practical Nurse (LPN) #2 enter Resident #236's room to administer medication. LPN #2 turned her back to the door. This surveyor observed the open unlocked laptop, on top of the medication cart in the hallway, open displaying Resident #236 ' s personal and medical information including name, date of birth, code status, and physician's orders. b. On 01/15/25 at 08:56 AM, LPN #2 stated, I did not lock or close the laptop. I waited for the computer to timeout. 2. A review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/29/2024 revealed Resident #40 had a Brief Interview of Mental Status (BIMS) score of 09 indicating moderately impaired cognition. a. A review of the plan of care for Resident #40 revealed Resident #40 had an admitted [DATE]. b. On 01/15/25 at 07:14 PM, this surveyor observed LPN #5 enter Resident #40's room to administer medication. LPN #5 turned her back to the door. This surveyor observed the open unlocked laptop, on top of the medication cart in the hallway, displaying Resident #40 ' s personal and medical information including name, date of birth, code status, and physician's orders. This surveyor also observed LPN #5 walk down the hall to retrieve oxygen tubing leaving the computer screen open and unlocked. c. On 01/15/25 at 07:20 PM, LPN #5 stated she did not close or lock the computer screen prior to walking away, and someone could have seen the resident's information. 3. A review of the quarterly MDS with an ARD of 12/13/2024 revealed Resident #1 had a BIMS score of 15, indicating cognitively intact. a. A review of the plan of care for Resident #1 (revision date 6/20/20223) revealed Resident #1 was a full code. b. On 01/15/25 at 07:28 PM, this surveyor observed LPN #6 walk away to get an over-the-counter medication leaving the laptop on and displaying Resident #1 ' s personal and medical information such as name date of birth, code status, and physician's orders. c. On 01/15/25 at 07:30 PM, LPN #6 stated she did not lock or close the computer screen prior to walking away. LPN #6 stated I knew better and should have closed the computer screen. 4. On 01/16/25 01:00 PM, the Director of Nursing (DON) stated the nurses should lock or close the computer screen prior to walking away from their computers, because if the computer screen is open to the resident personal and medical information it is a Health Insurance Portability and Accountability Act (HIPPA) violation. 5. A review of the policy titled HIPPA Basics for Providers: Security, & Breach Notification Rules dated February 2023 noted the privacy rules require you to: secure patient records containing PHI, so they aren't readily available to those who don't need to see them. PHI information includes common identifiers, such as name, address, birth date, and social security number.

Based on observation and interview, the facility failed to ensure pureed food items were blended to a smooth, lump free consistency to minimize the risk of choking or other complications for those residents who required pureed diets for 1 of 1 meal observed. The findings are. 1. On 1/13/25 at 11:22 AM, DC #7 used a 4-ounce spoon to put 9 servings of boiled, seasoned squash into a blender and poured the juice from the squash over it, covering the squash. As DC #7 began to puree the squash the consistency of the pureed squash was too runny. DC #7 added a cup of thickener and pureed it some more. At 11:23 AM, DC #7 poured the pureed squash into a pan, and placed it in a pan of hot water on the stove. The consistency was still runny. The pureed squash remained thin when it was served to the residents who required pureed diets. At 1:15 PM, DC #7 was interviewed and was asked if she could describe the consistency of the pureed squash served to the residents on pureed diets, and DC #7 stated she thought it was a little thin, and she should have added more thickener. 2. On 1/13/25 at 11:51 AM, DC #7 placed 16 servings of pepperoni pizza into the blender, added 3 cups of tomato sauce, pureed. The pureed pizza was still thick, so DC #7 added 8 -5 oz. cans of tomato juice and pureed it some more. At 12:03 PM, DC #7 poured the pureed pizza into a pan and placed it in a pan of hot water on the stove. The consistency of the pureed pizza was not smooth. There were pieces of pizza in the mixture. At 1:15 PM, DC #7 was interviewed and was asked if she could describe the consistency of the pureed pizza. DC # 7 stated the pureed pizza had a couple pieces of pizza in it and she should have pureed it longer.

Based on record review, interview, and facility policy review the facility failed to ensure gradual psychotropic (anti-anxiety) dose reductions (GDR) were attempted in the absence of a physician's documented evaluation of the specific risks versus benefits of continuing the as needed (PRN) medication past 14 days and a documented explanation as to why a dose reduction attempt would be contraindicated, in order to ascertain the smallest effective dose and minimize the potential for adverse drug effects for 1 (Resident #27) of 5 sampled residents reviewed for unnecessary medications. The findings include: A review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/17/2024 revealed Resident #27 has a Brief Interview of Mental Status (BIMS) score of 15 which indicated cognitively intact. A review of the plan of care for Resident #27 (revision date 04/05/2024) revealed Resident #27 used anti-anxiety medications. A review of the Note to Attending Physician/Prescriber printed date 08/25/2024 noted Resident #27 had an order for [benzodiazepine medication name] (a medication used to treat anxiety disorders) 2 milligram (MG)/milliliter (ML) every (Q) 4 hours as needed (PRN). A review of Resident #27 ' s electronic medical recorded did not reveal documentation related to gradual dose reduction attempts or justification. On 01/16/2025 at 02:00 PM, the Director of Nursing (DON) stated the facility would just have to accept the tag for Resident #27 taking an antianxiety medication past 14 days without documentation from the physician to extend the medication. A review of the policy titled Drug Regimen Review noted drug regimen review consists of a review and analysis of prescribed medication therapy and medication use review, including nursing documentation of medication ordering and administration. The consultant pharmacist reviews the medication regimen of each resident at least monthly. Findings and recommendations are reported to the Administrator, Director of Nursing, the responsible physician, and the Medical Director, where appropriate.

Based on observations, interviews, record review, and facility policy review the facility failed to ensure the care planned positioning device was in place to prevent further contracture for 1 of 1 sampled (Resident #27) resident reviewed for positioning. The findings include: A review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/17/2024 revealed Resident #27 had a Brief Interview of Mental Status (BIMS) score of 15 that indicated cognitively intact. A review of a plan of care for Resident #27 (revision date 01/04/2023) revealed Resident #27 had an Activities of Daily Living (ADL) self-care performance deficit related to cerebrovascular accident (CVA) with left non-dominant side. An intervention in place noted place carrot in left hand. On 01/13/25 at 10:51 AM, this surveyor observed contracture to Resident #27's hand with no positioning device in place and noted a hand roll on the nightstand. Resident #27 stated the facility used to place a carrot in each hand, but the resident did not know what happened to them. On 01/14/25 at 09:07 AM, this surveyor observed Resident #27 lying in bed. This surveyor noted there was no device in place to prevent further contracture. On 01/15/25 at 10:15 AM, this surveyor observed Resident #27 lying in bed. This surveyor noted there was no device in place to prevent further contracture. On 01/15/25 at 10:46 AM, Licensed Practical Nurse (LPN) #1 stated Hospice had instructed them to no longer use the carrot due to a past fracture of the index finger but could not provide any documentation noting this order. On 01/15/25 at 01:39 PM, the Director of Nursing (DON) provided this surveyor with a care plan from hospice. The DON stated the care plan did not address the contracture. A review of the policy Range of Motion Exercise revision date October 2010 did not contain any pertinent information regarding the deficient practice.

Based on observation and interview, the facility failed to ensure dirty trash cans were stored away from the food storage racks; kitchen sink was free of leaks; the walk-in freezer floor was free of ice buildup; the ice machine and ice scoop were maintained in clean and sanitary conditions to prevent potential growth of harmful bacteria that could be transferred to the residents food; opened food items in the refrigerator, freezer and storage room were covered, sealed, and dated; and expired foods were promptly removed from stock to maintain freshness and prevent potential cross contamination; dietary staff practiced good hand hygiene to prevent potential cross contamination of food and clean dishes; and hot food item was maintained at the required temperature on the steam table and serving line to prevent potential foodborne illness. These failed practices had the potential to affect 75 residents who received meals from the kitchen (Total Census: 78), as documented on a list provided by the Dietary Manager on [DATE] at 3:11 PM. The findings are: 1. On [DATE] at 9:38 AM, in the storage room there was a trash can with various black and brownish stains pushed up against a food prep area and a cart to hold food items. 2. On [DATE] at 9:39 AM, in the storage room there was a blue bucket underneath the three (3) compartments sink for an open pipe from the sink. The bucket was three-quarters of the way full of unknown oblong objects on top of the dirty grey water. 3. On [DATE] at 9:42 AM, a pan that contained two partially frozen rolls of ground beef was on the top shelf of the glass door refrigerator to thaw. The pan of ground beef was above a box of raspberry/peach yogurt, a watermelon, and fresh tomatoes. 4 On [DATE] at 9:50 AM, there was a trash can with trash in it, covered with an unknown white and brown substance, touching the dry food storage shelves that held food for resident's meals. 5. On [DATE] at 9:50 AM, the dry goods storage had a container of flour not fully sealed, without an open date. 6. On [DATE] at 9:52 AM, outside of the back kitchen door to the left was a cart full of black trash bags and empty cardboard boxes and to the right were broken down cardboard boxes on top of bread crates. 7. On [DATE] at 9:52 AM, the floor to the freezer outside the kitchen was covered in ice. Icicles were hanging from all three (3) shelving units and attached to numerous boxes containing food. 8. On [DATE] at 9:54 AM, the chest freezer did not have a thermometer, the entire inside was covered with ice. 9. On [DATE] at 9:33 AM, the following observations were made on a shelf in the freezer outside the kitchen. a. An opened box of fish patties, no date was on the box. b. An opened box of hamburger patties, no date was on the box. c. An opened box garlic bread. The box was not covered or sealed and no date was on the box. d. An opened of Italian vegetables. The box was not covered or sealed and no date was on the box. e. An opened box of omelets. The box had no opened date on it. f. An opened box of turkey bacon. The bacon had freezer burn. The surveyor asked the Dietary Manager to describe the appearance of the bacon. She stated, They have freezer burn on them. g. An opened box of waffles. The box was not covered or sealed, and there was no opened date on it. h. An opened box of chicken strips. The box was not covered or sealed, and there was no opened date on it. i. An opened box of oriental vegetables. The box was not covered or sealed. The opened was not marked on the box. 10. On [DATE] at 9:59 AM, the area in the ice machine panel where ice touches before dropping into the ice collector had wet brownish, black, and beige colors on it. The surveyor asked the Dietary Manager to wipe the area. The brownish, black, and beige residue easily transferred to the tissue. She stated, It was sage and brown residue. The surveyor asked the Dietary Manager who uses the ice from the ice machine and how often do you clean it? She stated, We clean it every month. That's the ice the CNAs [Certified Nursing Assistants] use for the water pitchers in the residents' rooms and we use it sometimes in the kitchen to fill beverages served to the residents at mealtimes. 11. On [DATE] at 10:00 AM, the scoop holder on top of the counter by the ice machine had wet pink residue all around the corner and the ice scoop was resting on it. The surveyor asked the Dietary Manager to wipe the wet pink residue. She did so, wet pink residue easily transferred to the tissue. The surveyor asked Dietary Manager to describe what was observed at the bottom of the scoop holder, how often do you clean the scoop holder and who uses the ice from the ice machine? stated, It was pink slimy residue. The CNAs [Certified Nursing Assistants] use it for the water pitchers in the residents' rooms. 12. On [DATE] at 10:05 AM, the ceiling tiles in the kitchen had dust on them. The ceiling air vent panels between the 2 door refrigerator had rust on them. The ceiling air vent panels around the food preparation counter and the stove had rust on them. 13. On [DATE] at 10:07 AM, the following observations were made on a shelf in the 2 door refrigerator in the kitchen: a. An opened bag of biscuits. There was no date on the bag. b. An opened box of bacon. The box was not covered or sealed. 14. On [DATE] at 10:11 AM, Dietary [NAME] (DC) #19 was wearing gloves on her hands when she opened a drawer and removed a knife. Without changing gloves and washing her hands, she picked up slices of cornbread and placed them into a pan to be served to the residents for lunch meal. 15. On [DATE] at 10:13 AM, the surveyor asked the Dietary Manager who uses the ice from the ice machine? She stated, We use it in the kitchen to fill beverages served to the residents at mealtimes, and the residents use it. 16. On [DATE] at 10:16 AM, the area in the ice machine where ice forms before dropping into the water pitcher or cups had thick accumulation of wet black residue on it. The surveyor asked the Maintenance Supervisor to wipe the area. He did so, solid black residue easily transferred to the tissue. At 3:12 PM, the surveyor asked the Maintenance Supervisor to describe what was observed in the area where ice forms. He stated it was slimy solid black residue. We sanitize the area two times a year. We are going to start cleaning it more than two times a year. 17. On [DATE] at 10:21 AM, in the kitchen an opened box of bacon was on a shelf in the 2 door refrigerator. The box was not covered or sealed. 18. On [DATE] at 10:27 AM, the following observations were made on the shelf in the storage room: a. An opened bag of sugar. The bag was not covered. b. A container of flour had a measuring cup directly on it. c. A container of the sugar had a measuring cup directly on it. d. A container of fish meal had a measuring cup directly on it. e. A container of salt had a measuring cup directly on it. f. A container of cornmeal had a measuring cup directly on it. g. A container of the meal had a measuring cup directly on it. The surveyor immediately asked the Dietary Manager the reason cups should not be inside the food items. She stated, It's cross contamination. h. A bag of tortilla chips. The bag had an expiration date of [DATE]. 19. On [DATE] at 10:31 PM, the following observations were made on the pan under the food preparation counter: a. An opened container of paprika. The was not covered. b. An opened container of cinnamon. The container was not covered. 20. On [DATE] at 10:57 AM, the following observations were made in the freezer: a. An opened box of cookie and cream ice cream in the freezer was fuzzy, there was no name to indicate who it belonged to and no opened or received date on the box. b. Two bags of cheeseburgers had no name or receive date on them. c. A box of shrimp stir fry rice had no name or date on it. The refrigerator was dirty with spilled liquid brown stains on it. 21. On [DATE] at 11:11 AM, Dietary [NAME] (DC) #19 used a rag to wipe food items that spilled on the counter. She then picked up the water hose with her bare hand, used it to spray leftover food from inside of the dishes, contaminating her hands. She placed the dirty dishes in the dirty racks and pushed the racks into the dish washing machine to wash. After the dishes stopped washing, she moved to the clean side of the dishwasher area and picked up the clean blade and attached it to the base of the blender, then used a rag to dry inside of the blender bowl. As she was about to use it to puree food items to be served to the residents on pureed diets. The surveyor immediately asked DC #19 what should you have done after touching dirty objects or before handling clean equipment? She stated, I should have washed my hands. 22. On [DATE] at 11:19 AM, Dietary [NAME] (DC) #19 was wearing gloves on her hands when she turned on the food preparation sink and obtained a pitcher. She then turned off the faucet with her gloved hand, contaminating the glove. She removed the gloves from her hands, and placed new gloves on, contaminating the gloves. Without changing gloves and washing her hands. She used her contaminated glove hand to attach a clean blade to the base of the blender, placed 6 servings of polish sausage and ground and poured into a pan to be served to the residents who received mechanical soft diets for lunch. 23. On [DATE] at 11:37 AM, Dietary [NAME] (DC) #19 took out a pan of oven roasted potatoes from the oven and emptied it into a different pan. Without washing her hands, she picked up a clean blade and attached it to the base of the blender to be used in pureeing food items to be served to the residents on pureed diets. The surveyor asked DC #19 what she should have done after touching dirty objects and before handling clean equipment? DC #19 stated, Washed my hands. 24. On [DATE] at 11:49 AM, Dietary Aide (DA) #21 went to the ice machine outside the kitchen and obtained ice into a pitcher and walked back into the kitchen. Without washing her hands, she removed gloves from the glove box and placed them on her hands, contaminating the gloves. She used her contaminated gloved hands to pick up glasses by their rims and poured ice cubes, then water, and placed them on the trays to be served to the residents for lunch. At 12:20 PM, the surveyor asked DA #21 what she should have done after touching dirty objects and before handling clean equipment? DA #21 stated, I should have washed my hands. 25. On [DATE] 12:12 PM, the temperature of the pureed chicken tender when checked and read by the Dietary Aide (DA) #20 at the edge of the steam table was 116 degrees Fahrenheit. The above meat item was reheated before being served to the resident. 26. On [DATE] at 12:12 PM, Dietary Aide (DA) #20 used her finger which she had used to pick up an alcohol pad, to sanitize a temperature gauge, then pushed the chicken tender off the gauge into a pan on the steam table to be served to the residents who asked for it with their lunch meal. During the noon meal preparation, there was no gravy prepared for the residents on pureed diets. There was no chopped meat prepared to serve to the residents on chopped meat diets. 27. On [DATE] at12:26 PM, Dietary [NAME] (DC) #1, who was on the tray line assisting with the lunch meal service, wore gloves on her hands when she picked up tray cards and placed them on the trays. Without changing gloves and washing her hands, she picked up a bag of hamburger buns, untied it, and removed a bun from the bag. She placed the bun on a plate and used a tong to place a hamburger patty on one side of the opened bun, then topped the hamburger with shredded lettuce and sliced tomatoes with her contaminated gloved hand to create a hamburger sandwich to be serve to the resident who asked for it. 28. A facility policy titled, Hand Washing, provided by the Dietary Manager on [DATE] at 3:11 PM documented, .1. When to wash hands: a. When entering the kitchen at the start of a shift.g. During the food preparation as often as necessary to remove soil or contamination and to prevent cross contamination when changing task.j. After engaging in other activities that contaminate the hands .

Based on observation, record review, and interview, the facility failed to ensure a refund was received by the resident or responsible party within 30 days from the date of discharge for 2 (Residents #230 and #231) sampled residents within 30 days from the date of discharge. The findings are: On [DATE] at 2:21 PM, during an interview with Business Office (BO) #12, the Surveyor requested the last 2 quarter bank statements for Resident #230 and Resident #231. The statements were provided showing Resident #230 had a balance of $1,510.87, and Resident #231 had a balance of $407.00, with no charges coming out of the accounts. On [DATE] at 03:20 PM, per record review Resident #231's medical record revealed the resident passed away in the facility on [DATE], and Resident #230 passed away in the facility on [DATE]. The Administrative Assistant was asked to provide documentation and proof that the facility had attempted to contact the family regarding the remaining funds. On [DATE] at 10:15 AM, the Surveyor met with BO #12, BO #13, and the Business Office Manager (BOM). BO #13 confirmed there had been a process failure in returning funds to deceased Resident #230 and Resident #231. The BOM confirmed refunds should be sent immediately. The Surveyor requested a copy of the facilities policy or procedure for personal funds. A review of a policy and procedure titled, Resident Trust Fund/Personal Fund In Long Term Care Facilities provided by the Administrator on [DATE] at 10:46 AM revealed, .Review Closed Records of Residents Who Have died .Is there evidence the facility conveyed the resident's funds within 30 days of the residents death and provided a final accounting to the individual/probate jurisdiction for the resident's estate .

Based on observation, record review, and interview, the facility failed to ensure the G Hall shower room and the beauty shop were locked to prevent residents from being harmed from the ingestion of the chemicals present. The findings are: 1. On 07/15/2024 at 11:45 AM, while walking down the G Hall the surveyor observed the shower room door, near the common area, was slightly open. The surveyor observed open, uncapped gallon jugs of shampoo and personal cleanser. On 07/16/2024 at 2:03 PM, Certified Nursing Assistant (CNA) #14 accompanied the surveyor to the G Hall shower room and read from the personal cleanser, Keep out of reach of children. If swallowed, get medical help or contact a Poison Control Center Immediately from the open gallon jug of personal Cleanser. CNA #14 confirmed residents are showered on G Hall, and it sits outside the E, F, and G Hall common area and a resident could come into the unlocked shower room and drink from the shampoo or personal cleaner jugs that do not have caps. 2. On 07/15/2024 at 11:52 AM, the surveyor walked into the unlocked beauty shop and observed disinfectant spray, shampoo, and uncapped hairspray resting on the counters. Setting lotion, shampoo, and hairspray were in the unlocked upper cabinets. On 07/16/2024 at 8:42 AM, Restorative Aide #10 was observed unlocking and entering the beauty shop with a resident. During an interview on 07/16/2024 at 8:45 AM, Restorative Aide #10 confirmed the beauty shop should be kept locked and there are open cans of hair spray, and chemical products that someone might spray or consume. During an interview with the Director of Nursing (DON) on 07/17/2024 at 12:23 PM, the DON said chemicals should always be kept behind a locked door to prevent residents from drinking or eating it. On 07/18/2024 at 10:25 AM, the DON said there is not a policy or procedure for the shower rooms, or beauty shop. 48977 On 07/16/2024 at 1:03 PM, this surveyor observed Dakin's solution, oxy cleaner and wound cleanser in an open closet and antimicrobial soap on the floor in an open unattended office. On 07/16/2024 at 1:06 PM, this surveyor asked Licensed Practical Nurse (LPN) #3 if she normally closes and/or locks the door to her office. She confirmed that she never closes it and there was no key to lock the door. This surveyor and LPN #3 looked in the closet and LPN #3 was asked to state what she saw in the closet. LPN #3 confirmed there was [brand name] wound cleanser, the cleaner inside the closet. This surveyor asked LPN #3, What about the soap on the floor by the chair? LPN #3 stated, What the heck! This surveyor asked LPN #3 if any of the chemicals could be harmful to a resident and she confirmed they could and stated, We are caught. It is what it is.

Based on observation, record review and interview, the facility failed to ensure oxygen was administered at the physician ordered rate to prevent respiratory complications for 2 (Residents #25 and #60) of 2 sampled residents who received oxygen. The findings are: 1. Review of the Medical Diagnosis noted Resident #60 had diagnoses of chronic obstructive pulmonary disease (COPD), heart failure, and atrial fibrillation. Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/11/2024 suggested a Brief Interview for Mental Status (BIMs) score of 12 (8-12 suggests moderate cognitive impairment). Section O0110, C1 shows the resident is on oxygen. Review of Resident #60's Order Summary Report noted an order for oxygen at 3 liters via nasal cannula related to shortness of breath. Review of Resident #60's Care Plan with a revision of 10/12/2023, revealed Resident #60 was to receive oxygen per doctor orders. On 07/15/2024 at 11:37 AM, during a concurrent observation and interview, Resident #60 was sitting in a wheelchair receiving 2 liters of oxygen. Resident #60 told the surveyor, I am supposed to be on three liters, I have COPD. On 07/15/2024 at 1:11 PM, during an observation Resident #60 was lying in bed, eyes open and the oxygen concentrator was setting on 2 liters. On 07/16/2024 at 1:25 PM, the Surveyor accompanied Licensed Practical Nurse (LPN) #3 to Resident 60's room. During an interview, LPN #3 verified Resident #60's concentrator was on 2 liters. LPN #3 confirmed Resident #60 should have been on 3 liters to prevent shortness of breath, and good air flow. The Surveyor asked if there is a process for checking the oxygen settings on the concentrators. LPN #3 said the supervising Registered Nurse (RN) should round and check oxygen settings. On 07/17/2024 at 12:40 PM, during an interview the Director of Nursing (DON) said nursing staff should look at the oxygen orders and check the concentrators to make sure they are on the right setting. Nurses are responsible for oxygen, and it should be checked every day when nurses go into a resident's room. 48977 2. Review of the Order Summary Report indicated Resident #25 had diagnoses of Chronic Obstructive Pulmonary Disease (COPD) with acute exacerbation (worsening), acute respiratory failure with hypercapnia (excessive carbon dioxide in the bloodstream preventing blood cells from carrying oxygen), and shortness of breath. A review of the Physician's Order revealed Resident #25 had an order for oxygen at three liters per nasal cannula as needed every shift related to COPD with acute exacerbation, start date 06/05/2024. The quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/19/2024 revealed Resident #25 had a Brief Interview of Mental Status (BIMS) score of 12, which indicated the resident was moderately impaired, and Resident #25 was receiving oxygen therapy. A review of Resident #25 Care Plan (revision date 10/20/2023) revealed Resident #25 was at risk for impaired gas exchange diagnosis of COPD, acute respiratory failure and shortness of breath. Intervention noted administer oxygen as prescribed or per standing order. On 07/15/2024 at 11:09 AM, Resident #25 was observed lying in bed with the head of bed elevated, oxygen (O2) was in use and set at 2.5 liters/minute and a humidifier with clear liquid inside. On 07/16/2024 at 8:43 AM, Resident #25 was observed sitting in a wheelchair in the room and O2 was in use at 2.5 liters. On 07/17/2024 at 1:26 PM, Resident #25 was observed lying in bed receiving oxygen therapy at 2.5 liters from a concentrator. On 07/17/2024 at 3:50 PM, during an interview, Licensed Practical Nurse (LPN) #2 was asked what rate was Resident #25's oxygen at and she confirmed it was under 3 liters. LPN #2 was asked what should Resident #25's oxygen rate be according to the physician's order, and she confirmed it should have been 3 liters. On 07/17/2024 at 4:00 PM, a policy titled, Oxygen Administration indicated, The purpose of this procedure is to provide guidelines for safe oxygen administration. 1. Verify that there is a physician's order for this procedure. Review the physician's order of facility protocol for oxygen administration .

Based on record review and interview, the facility failed to ensure professional standards of practice for fall protocols were followed to prevent accidents for 1 (Resident #2) of 3 (Residents #1, #2 and #3) sampled residents who had a history of falling. This failed practice resulted in Immediate Jeopardy that caused or could have caused serious harm, injury or death to Resident #2 who was assisted to the floor by 2 staff members and sustained a fracture to the left femur and a subdural hematoma and had the potential to affect all 67 residents in the facility as documented on the Daily Census Report provided by the Activity Director on 11/21/22 at 8:02 AM. The Administrator was notified of the Immediate Jeopardy condition on 11/21/22 at 1:00 PM. The findings are: 1. Resident #2 had a diagnosis of Peripheral Vascular Disease. The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/18/22 documented the resident scored 14 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS) and required limited physical assistance from one person for bed mobility and transfers and had no falls since admission and had a surgical wound. a. The Progress Note dated 10/31/22 at 11:21 AM documented, .Resident c/o [complained of] right foot and left hip. Request to go to the emergency room . b. The Radiology Report dated 10/31/22 documented, .PROCEDURE: 3 view left hip . Acute comminuted intertrochanteric femur fracture . PROCEDURE: CT [Computerized Tomography] BRAIN WITHOUT CONTRAST . HISTORY: Fall. Head trauma . subdural hemorrhage . intraventricular hemorrhage . c. The Witness Statement dated 10/31/22 written by Licensed Practical Nurse (LPN) #6 attached to a Reportable dated 11/11/22 documented, .I was passing 0600 [6:00 AM] medications . [Certified Nursing Assistant (CNA) #11] came up to me and stated, 'I went in [Resident #2's] room to make rounds . when I opened the door, she was in the middle of the floor walking to the restroom. I think I scared her . I just sat her down on the floor . and then I came got you.' .Assisted to bed per 2 person assist and gait belt . d. The Witness statement dated 10/31/22 written by CNA #11 attached to a Reportable dated 11/11/22 documented, .I was making my last round. I went in resident's room. She was standing in the middle of the floor . She started like she was stumbling . She started getting weak and too heavy for me. So, I sat her down in the floor . e. The Care Plan with a revision date of 11/02/22 did not address risk for falling or actual falls. f. The Progress Note written by LPN #7 dated 11/14/22 at 11:19 AM documented, .Late entry for 11/11/22 . subdural hematoma and left femur fracture due to s/p (status post) fall . g. On 11/21/22 at 5:55 AM, the Surveyor asked CNA #1, What do you do if a resident is on the floor? She answered, Find a nurse. h. On 11/21/22 at 6:00 AM, the Surveyor asked CNA #2, What do you do if a resident is on the floor? She answered, Call the nurse, stay with them, don't get them up. i. On 11/21/22 at 6:05 AM, the Surveyor asked LPN #1, What do you do if a resident is on the floor? She answered, Assess. If no complaints, help them up. If complaints, send to the ER [emergency room ]. Notify the Director of Nursing [DON], Administrator, family, and MD [Medical Doctor]. j. On 11/21/22 at 6:10 AM, the Surveyor asked CNA #4, What do you do if a resident is on the floor? She answered, Call the nurse, stay with them, don't get them up. k. On 11/21/22 at 6:15 AM, the Surveyor asked CNA #6, What do you do if a resident is on the floor? She answered, Call the nurse, stay with them, don't get them up, put pillow under their head. l. On 11/21/22 at 6:20 AM, the Surveyor asked LPN #2, What do you do if a resident is on the floor? She answered, Assess, get witness statements, call family, DON, Administrator, and doctor or APN [Advanced Practice Nurse]. If fall is unwitnessed, send to the ER. m. On 11/21/22 at 6:25 AM, the Surveyor asked LPN #3, Have you taken care of [Resident #2]? She answered, Yes but not when she fell . The Surveyor asked, What do you do if there is an incident with a resident? She answered, Assess, call MD and APRN [Advanced Practice Registered Nurse] do an I&A [Incident and Accident Report], call family call DON and Administrator. n. On 11/21/22 at 9:40 AM, the I&A Book was reviewed. There were no documented falls in October or November 2022 for Resident #2. o. On 11/21/22 at 10:15 AM, the Surveyor asked LPN #5 about Resident #2's hospital transfer on 10/31/22. She stated, I came in at 7:00 AM and her son came later. She told me she had fallen during the night. I didn't have a report of a fall. I assessed her and did a body audit. We were concerned about the right foot because she has gangrene. I got an order to send her to the ER for the gangrene. The Surveyor asked, Was there ever a time when you thought she did not need to go to the ER? No. The Surveyor asked, There are witness statements that document that the LPN and CNA on duty assisted her to the floor, should a I&A be done when a resident is assisted to the floor? She stated, We usually do an I&A on that. The Surveyor asked, Do you usually do an I&A if a resident reports to you that they fell ? She stated, It depends on her level of confusion. She said it happened before I came in. If she had fallen, we would have been doing neuro checks on her. The Surveyor asked, The progress notes from 10/31/22 written by you, documented left hip pain and bruising to her back. Do you remember this? She stated, I don't remember writing that but if my name is on it, I wrote it. p. On 11/21/22 at 11:00 AM, the Surveyor asked CNA #10 about Resident #2's hospital transfer on 10/31/22. She stated, I came in between 6:20 and 7:00 that morning. I walked past her room, and I saw her on the floor on her left side and a pillow was under her head. There was a lady in there with her. I don't know who she was. She worked here. I haven't seen her anymore. My nurse told me they were going to send her to the hospital and asked me to make sure she was clean. That's all I know. The Surveyor asked, Has anyone from the facility asked you about what happened? She stated, No. The Surveyor asked, Has anyone asked you to fill out a witness statement? She stated, No. q. On 11/21/22 at 2:20 PM, the Surveyor asked the DON, Who is responsible for completing Incident Reports? She answered, The Charge Nurses. The Surveyor asked, If a resident is lowered to the floor, is that considered a fall? She answered, Yes. The Surveyor asked, How do you determine who is at risk for falls? She answered, The majority of our residents are at risk for falls. r. On 11/22/22 at 8:52 AM, the Surveyor asked LPN #6, Please tell me what you remember about the morning when [Resident #2] was on the floor? She stated, As far as I knew, the resident did not fall. The aide told me that the resident was trying to go to the bathroom. We usually keep a bedside commode near the bed, and she transferred herself. That morning the bedside commode was moved, and she was walking toward the bathroom when the aide entered the room. The aide startled the resident, and she became unsteady. The aide went to assist her with walking, and she started walking heavy. The aide sat her on the floor. She came to get me and told me what happened. The Surveyor asked, In your training, have you ever been told that assisting a resident to the floor is also considered a fall? She answered, I never knew that until another nurse told me a few days later when we were talking at the nurses station. s. On 11/22/22 at 10:30 AM, the Surveyor asked the MDS Coordinator was asked, How do you determine if a resident is at risk for falls? She answered, Their history, or the fall assessment, or sometimes therapy. The Surveyor asked, What does [Resident #2's] Fall Assessment document? She reviewed the electronic record and stated, I don't see one. I've been off for a week and a half. The Surveyor asked, Should risk for falls or an actual fall be documented on the care plan? She answered, Yes. The Incident Reports trigger me to document the actual fall. The Surveyor asked, If an Incident Report was never done, how do you know when a resident falls? She answered, I probably wouldn't know. The Surveyor asked, If a resident is assisted to the floor, is that considered a fall? She answered, Yes. t. The Policy titled Accidents and Incidents Investigating and Reporting provided by the DON on 11/22/22/ at 8:25 AM documented, .All accidents or incidents involving residents . occurring on our premises shall be investigated and reported to the administrator . The nurse supervisor/charge nurse and/or department director or supervisor shall promptly initiate and document investigation of the accident or incident . 2. The Immediate Jeopardy was removed on 11/21/22 at 3:50 PM, when the facility implemented the following Plan of Removal: November 21, 2022 IJ - FAILURE TO REPORT & INVESTIGATE BRUISES OF UNKNOWN ORIGIN AND FALL WITH MAJOR INJURY Effective Date: 11-21-2022 Completion date: 11-21-22 1. All residents will have a body audit completed by facility staff to ensure there are no discolorations of unknown origins on any part of the resident's body. Effective Date: 11-21-22 Completed by: 2. Any discolorations of unknown origins on any resident will be completely investigated, documented on the appropriate form or in the HER [EHR] (Electronic Health Record). Effective Date: 11-21-22 Completed by: 3. Any discolorations of unknown origins on any resident will be immediately noted and will be immediately reported to the residents PCP, Family member/POA, Administrator and DON. Effective Date: 11-21-22 Completed by: 4. All residents will be 1:1 interviewed by facility staff for any trips, falls, skin tears or injury that resident has not reported to any staff member. Effective Date: 11-21-22 Completed by: 5. The DON or her designee will check 3 residents 3 times weekly for 8 weeks for documentation is completed, notifications are completed, any orders are carried out, and any follow up that is necessary has been carried out. Any negative finding are to be corrected immediately. All findings will be reported to the QAA weekly for review. Effective Date: 11-21-22 Completed by: [Name], RN/DON Completion Date: 01-16-2023 [Name], RN/ADON 6. All nursing staff will be in-serviced on the following: when and what to document, who you should report any I/A to, completion of any documentation on trips, slips, falls, skin tears, any discoloration areas on resident's body, any follow up to any I/A example labs, x-rays, etc. Effective Date: 11-22-22 Completed by: [Name], RN/DON Completion Date: 11-27-23 [Name], RN/ADON

Based on interview and record review, the facility failed to ensure injuries of unknown origin were properly investigated for 2 (Residents #1 and #2) of 3 (Residents #1, #2 and #3) sampled residents who had a history of falling. This failed practice resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury, or death to Resident #1 who had an abrasion of unknown origin on 10/29/22 and to Resident #2 who had bruises of unknown origin on 10/27/22. The failed practice had the potential to affect all 67 residents in the facility as documented on the Daily Census Report which was provided by the Activity Director on 11/21/22 at 8:02 a.m. The Administrator was notified of the Immediate Jeopardy on 11/21/22 at 1:00 PM. The findings are: 1. Resident #1 had a diagnosis of Chronic Obstructive Pulmonary Disease. The Significant Change in Status Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/7/22 documented the resident scored 8 (8-12 indicates moderately cognitively impaired) on a Brief Interview for Mental Status (BIMS) and required total physical assistance one person for bed mobility and limited physical assistance from one person for transfers and had two falls since last assessment - one with no injury and one with injury and had a skin tear. a. The Skin and Wound Note dated 10/28/22 documented, .No skin issues noted at this time . b. The Care Plan dated 10/29/22 documented, .superficial abrasion to left midline back . Check skin daily with care for redness or other discoloration, rashes, blisters, breaks in skin etc. and report to charge nurse. Weekly skin audit and prn (as needed) . c. The QA (Quality Assurance) Unusual Occurrence Log entry dated 10/29/22 documented, .Resident #1 . Brief description of Occurrence . c/o [complaint of] back pain - 4 in [inch] x 1.5 in superficial abrasion left midline back . Causative Factor . R [Resident] has history of self-ambulation . Intervention . BIL [Bilateral] hip, L spine, bilateral knee x-rays . d. The Nursing Progress Note dated 10/29/22 at 5:52 PM documented, .Note Text: 1720 [5:20 PM]- Resident sitting in room chair, present with continuous complaints of back hurting. Approx. [approximately] 4 inch x [by] 1.5 inch edematous superficial abrasion to left midline back with no drainage noted at this time . Complaints of bilateral knees - reddened appearance . e. The Investigation Follow Up form documented, .Date of Incident 10/29/22 Date of Investigation 10/31/22 . R told nurse his back was hurting. 4 in x 1.5 in superficial abrasion to L [left] midline back, no drainage noted . f. The Radiology Report dated 11/3/22 documented, .CT [Computerized Tomography] Chest with Contrast . Upper Back Pain . There are acute nondisplaced fractures in the posterior left l0th and 11th ribs. There are acute nondisplaced fractures in the left transverse processes of T10 and T11 . g. On 11/21/22 at 11:30 AM, the I&A (Incident and Accident) Book was reviewed. There was no Incident Report completed to document and investigate the area on Resident #1's back. h. On 11/21/22 at 1:00 p.m., the Surveyor asked the Director of Nursing (DON) to provide a copy of an Incident Report for Resident #1 from 10/29/22. She provided a photocopy of a typed page. She stated, This is all I have. The nurse who wrote it texted it to me. Is that good enough? The text message documented, .While lying in bed, resident states, 'Be careful now, my back is hurting me.' This nurse observed a superficial abrasion to left side lower mid-back . There was no documentation of an investigation to determine the cause of the abrasion to Resident #1's back. 2. Resident #2 had a diagnosis of Peripheral Vascular Disease. The Admission MDS with an ARD of 10/18/22 documented the resident scored 14 (13-15 indicates cognitively intact) on a BIMS and required limited physical assistance from one person for bed mobility and transfers and had no falls since admission and had a surgical wound. a. The Nursing Note dated 10/27/22 at 10:13 AM documented, .CNA [Certified Nursing Assistant] reported bruise to right side middle of resident's back. Bruise reddish purple in color with yellow green discoloration around it . b. The Skin and Wound Note dated 10/28/22 documented, .Gangrene in Rt [right] foot . Will continue to observe for any skin issues that may arise . c. The Radiology Reports dated 10/31/22 documented, .Hip 2 Views .HISTORY: Pain after trauma . FINDINGS: There is an acute comminuted intertrochanteric left femur fracture . PROCEDURE: CT BRAIN WITHOUT CONTRAST .HISTORY: Fall. Head trauma . FINDINGS: infratentorial subdural hemorrhage . d. The Care Plan with a revision date of 11/02/22 did not address bruising. e. On 11/21/22 at 5:50 AM, the Surveyor asked Licensed practical Nurse (LPN) #2, Have you taken care of [Resident #1] or [Resident #2]? She answered, No. The Surveyor asked, What do you do if there is an incident with a resident? She answered, Assess, get witness statements, call family, DON, Administrator, and doctor or APN [Advanced Practice Nurse]. If fall is unwitnessed, send to the ER [emergency room ]. f. On 11/21/22 at 5:55 AM, the Surveyor asked LPN #3, Have you taken care of [Resident #1] or [Resident #2]? She answered, Yes, but not when they fell . The Surveyor asked, What do you do if there is an incident with a resident? She answered, Assess, call MD [Medical Doctor] and APRN [Advanced Practice Registered Nurse], do an I&A, call family call DON and Administrator. g. On 11/21/22 at 8:15 a.m., a review of the facility's last 4 reportables did not reveal a reportable that documented this injury of unknown origin. h. On 11/21/22 at 9:40 AM, the I&A Book was reviewed. There were no incidents logged in the book for Resident #2. i. On 11/21/22 at 2:30 PM, the Surveyor asked the DON, Who is responsible for completing Incident Reports? She answered, The Charge Nurses. The Surveyor asked, If a resident has an injury of unknown origin, what should be done? She answered, They have to do an Incident Report and notify me and the Administrator. The Surveyor asked, How do you determine who is at risk for falls? She answered, The majority of our residents are at risk for falls. The Surveyor asked, Do you have a Fall Risk Assessment? She answered, The charge nurses are supposed to do those. The Surveyor asked, Are you aware that [Resident #1] does not have one? She answered, That's another thing I am going to have to start doing myself. j. On 11/22/22 at 9:00 AM, the Surveyor asked LPN #7, On 10/27/22 you entered a progress note for [Resident #2] that documented the presence of bruising on her back, do you remember this? She answered, Yes. She had been out for a PICC [Peripherally Inserted Central Catheter] line and those bruises had been there for a long time. The Surveyor asked, Did you do an I&A on the bruising? She answered, No. I only made that note because the aide reported the bruising to me. I didn't want anyone to say that they reported something to me, and I didn't do anything about it. The Surveyor asked, Is there any other documentation in the record about bruising on her back? She answered, No. The Surveyor asked, Looking back, should you have completed an I&A on the bruises on her back? She answered, Yes. A head to toe assessment should have been done and an I&A should have been completed. k. The facility policy titled, Accidents and Incidents - Investigating and Reporting, provided by the DON on 11/22/22 at 8:25 a.m. documented, .All accidents or incidents involving residents . occurring on our premises shall be investigated and reported to the administrator . The nurse supervisor/charge nurse and/or department director or supervisor shall promptly initiate and document investigation of the accident or incident . 3. The Immediate Jeopardy was removed on 11/21/22 at 3:50 PM, when the facility implemented the following Plan of Removal: November 21, 2022 IJ - FAILURE TO REPORT & INVESTIGATE BRUISES OF UNKNOWN ORIGIN AND FALL WITH MAJOR INJURY Effective Date: 11-21-2022 Completion date: 11-21-22 1. All residents will have a body audit completed by facility staff to ensure there are no discolorations of unknown origins on any part of the resident's body. Effective Date: 11-21-22 Completed by: 2. Any discolorations of unknown origins on any resident will be completely investigated, documented on the appropriate form or in the HER [EHR] (Electronic Health Record). Effective Date: 11-21-22 Completed by: 3. Any discolorations of unknown origins on any resident will be immediately noted and will be immediately reported to the residents PCP, Family member/POA, Administrator and DON. Effective Date: 11-21-22 Completed by: 4. All residents will be 1:1 interviewed by facility staff for any trips, falls, skin tears or injury that resident has not reported to any staff member. Effective Date: 11-21-22 Completed by: 5. The DON or her designee will check 3 residents 3 times weekly for 8 weeks for documentation is completed, notifications are completed, any orders are carried out, and any follow up that is necessary has been carried out. Any negative finding are to be corrected immediately. All findings will be reported to the QAA weekly for review. Effective Date: 11-21-22 Completed by: [Name], RN/DON Completion Date: 01-16-2023 [Name], RN/ADON 6. All nursing staff will be in-serviced on the following: when and what to document, who you should report any I/A to, completion of any documentation on trips, slips, falls, skin tears, any discoloration areas on resident's body, any follow up to any I/A example labs, x-rays, etc. Effective Date: 11-22-22 Completed by: [Name], RN/DON Completion Date: 11-27-23 [Name], RN/ADON

Based on interview and record review, the facility failed to ensure injuries of unknown origin were reported to the Office of Long Term Care (OLTC) and other agencies in accordance with state law, to enable those agencies to provide any necessary oversight of the facility's investigations and protective measures for 2 (Residents #1 and #2) of 3 (Residents #1, #2 and #3) sampled residents who had a history of falling. This failed practice resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury, or death to Resident #1 who had an abrasion of unknown origin on 10/29/22 and Resident #2 who had bruises of unknown origin on 10/27/22. The failed practice had the potential to affect all 67 residents in the facility as documented on the Daily Census Report which was provided by the Activity Director on 11/21/22 at 8:02 a.m. The Administrator was notified of the Immediate Jeopardy on 11/21/22 at 1:00 PM. The findings are: 1. Resident #1 had a diagnosis of Chronic Obstructive Pulmonary Disease. The Significant Change in Status Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/7/22 documented the resident scored 8 (8-12 indicates moderately cognitively impaired) on a Brief Interview for Mental Status (BIMS) and required total physical assistance from one person for bed mobility and limited physical assistance from one person for transfers and had two falls since the last assessment - one with no injury and one with injury and had a skin tear. a. The Skin and Wound Note dated 10/28/22 documented, .No skin issues noted at this time . b. The Care Plan dated 10/29/22 documented, .superficial abrasion to left midline back . Check skin daily with care for redness or other discoloration, rashes, blisters, breaks in skin etc. and report to charge nurse. Weekly skin audit and prn (as needed) . c. The QA (Quality Assurance) Unusual Occurrence Log entry dated 10/29/22 documented, .Resident #1 . Brief description of Occurrence . c/o [complaint of] back pain - 4 in [inch] x 1.5 in superficial abrasion left midline back . Causative Factor . R [Resident] has history of self-ambulation . Intervention . BIL [Bilateral] hip, L spine, bilateral knee x-rays . d. The Nursing Progress Note dated 10/29/22 at 5:52 PM documented, .Note Text: 1720 [5:20 PM]- Resident sitting in room chair, present with continuous complaints of back hurting. Approx. [approximately] 4 inch x [by] 1.5 inch edematous superficial abrasion to left midline back with no drainage noted at this time . Complaints of bilateral knees - reddened appearance . e. The Investigation Follow Up form documented, .Date of Incident 10/29/22 Date of Investigation 10/31/22 . R told nurse his back was hurting. 4 in x 1.5 in superficial abrasion to L [left] midline back, no drainage noted . f. The Radiology Report dated 11/3/22 documented, .CT [Computerized Tomography] Chest with Contrast . Upper Back Pain . There are acute nondisplaced fractures in the posterior left l0th and 11th ribs. There are acute nondisplaced fractures in the left transverse processes of T10 and T11 . g. On 11/21/22 at 11:30 AM, the I&A (Incident and Accident) Book was reviewed. There was no Incident Report completed to document and investigate the area on Resident #1's back. h. On 11/21/22 at 1:00 p.m., the Surveyor asked the Director of Nursing (DON) to provide a copy of an Incident Report for Resident #1 from 10/29/22. She provided a photocopy of a typed page. She stated, This is all I have. The nurse who wrote it texted it to me. Is that good enough? The text message documented, .While lying in bed, resident states, 'Be careful now, my back is hurting me.' This nurse observed a superficial abrasion to left side lower mid-back . There was no documentation of an investigation to determine the cause of the abrasion to Resident #1's back. 2. Resident #2 had a diagnosis of Peripheral Vascular Disease. The Admission MDS with an ARD of 10/18/22 documented the resident scored 14 (13-15 indicates cognitively intact) on a BIMS and required limited physical assistance from one person for bed mobility and transfers and had no falls since admission and had a surgical wound. a. The Nursing Note dated 10/27/22 at 10:13 AM documented, .CNA [Certified Nursing Assistant] reported bruise to right side middle of resident's back. Bruise reddish purple in color with yellow green discoloration around it . b. The Skin and Wound Note dated 10/28/22 documented, .Gangrene in Rt [right] foot . Will continue to observe for any skin issues that may arise . c. The Radiology Reports dated 10/31/22 documented, .Hip 2 Views .HISTORY: Pain after trauma . FINDINGS: There is an acute comminuted intertrochanteric left femur fracture . PROCEDURE: CT BRAIN WITHOUT CONTRAST .HISTORY: Fall. Head trauma . FINDINGS: infratentorial subdural hemorrhage . d. The Care Plan with a revision date of 11/02/22 did not address bruising. e. On 11/21/22 at 5:50 AM, the Surveyor asked Licensed practical Nurse (LPN) #2, Have you taken care of [Resident #1] or [Resident #2]? She answered, No. The Surveyor asked, What do you do if there is an incident with a resident? She answered, Assess, get witness statements, call family, DON, Administrator, and doctor or APN [Advanced Practice Nurse]. If fall is unwitnessed, send to the ER [emergency room ]. f. On 11/21/22 at 5:55 AM, the Surveyor asked LPN #3, Have you taken care of [Resident #1] or [Resident #2]? She answered, Yes, but not when they fell . The Surveyor asked, What do you do if there is an incident with a resident? She answered, Assess, call MD [Medical Doctor] and APRN [Advanced Practice Registered Nurse], do an I&A, call family call DON and Administrator. g. On 11/21/22 at 8:15 a.m., a review of the facility's last 4 reportables showed no reportable Resident #2 ' s injury of unknown origin. h. On 11/21/22 at 9:40 AM, the I&A Book was reviewed. There were no incidents logged in the book for Resident #2. i. On 11/21/22 at 2:30 PM, the Surveyor asked the DON, Who is responsible for completing Incident Reports? She answered, The Charge Nurses. The Surveyor asked, If a resident has an injury of unknown origin, what should be done? She answered, They have to do an Incident Report and notify me and the Administrator. The Surveyor asked, How do you determine who is at risk for falls? She answered, The majority of our residents are at risk for falls. The Surveyor asked, Do you have a Fall Risk Assessment? She answered, The charge nurses are supposed to do those. The Surveyor asked, Are you aware that [Resident #1] does not have one? She answered, That's another thing I am going to have to start doing myself. j. On 11/22/22 at 9:00 AM, the Surveyor asked LPN #7, On 10/27/22 you entered a progress note for [Resident #2] that documented the presence of bruising on her back, do you remember this? She answered, Yes. She had been out for a PICC [Peripherally Inserted Central Catheter] line and those bruises had been there for a long time. The Surveyor asked, Did you do an I&A on the bruising? She answered, No. I only made that note because the aide reported the bruising to me. I didn't want anyone to say that they reported something to me, and I didn't do anything about it. The Surveyor asked, Is there any other documentation in the record about bruising on her back? She answered, No. The Surveyor asked, Looking back, should you have completed an I&A on the bruises on her back? She answered, Yes. A head to toe assessment should have been done and an I&A should have been completed. k. The facility policy titled, Accidents and Incidents - Investigating and Reporting, provided by the DON on 11/22/22 at 8:25 a.m. documented, .All accidents or incidents involving residents . occurring on our premises shall be investigated and reported to the administrator . The nurse supervisor/charge nurse and/or department director or supervisor shall promptly initiate and document investigation of the accident or incident . 3. The Immediate Jeopardy was removed on 11/21/22 at 3:50 PM, when the facility implemented the following Plan of Removal: November 21, 2022 IJ - FAILURE TO REPORT & INVESTIGATE BRUISES OF UNKNOWN ORIGIN AND FALL WITH MAJOR INJURY Effective Date: 11-21-2022 Completion date: 11-21-22 1. All residents will have a body audit completed by facility staff to ensure there are no discolorations of unknown origins on any part of the resident's body. Effective Date: 11-21-22 Completed by: 2. Any discolorations of unknown origins on any resident will be completely investigated, documented on the appropriate form or in the HER [EHR] (Electronic Health Record). Effective Date: 11-21-22 Completed by: 3. Any discolorations of unknown origins on any resident will be immediately noted and will be immediately reported to the residents PCP, Family member/POA, Administrator and DON. Effective Date: 11-21-22 Completed by: 4. All residents will be 1:1 interviewed by facility staff for any trips, falls, skin tears or injury that resident has not reported to any staff member. Effective Date: 11-21-22 Completed by: 5. The DON or her designee will check 3 residents 3 times weekly for 8 weeks for documentation is completed, notifications are completed, any orders are carried out, and any follow up that is necessary has been carried out. Any negative finding are to be corrected immediately. All findings will be reported to the QAA weekly for review. Effective Date: 11-21-22 Completed by: [Name], RN/DON Completion Date: 01-16-2023 [Name], RN/ADON 6. All nursing staff will be in-serviced on the following: when and what to document, who you should report any I/A to, completion of any documentation on trips, slips, falls, skin tears, any discoloration areas on resident's body, any follow up to any I/A example labs, x-rays, etc. Effective Date: 11-22-22 Completed by: [Name], RN/DON Completion Date: 11-27-23 [Name], RN/ADON

Based on observation, record review, and interview, the facility failed to ensure G-Hall, which was under construction and was unsecured with multiple hazards, was not accessible to the residents, which resulted in an elopement of Resident #1 due to the fire door being propped opened with a chunk of concrete. This failed practice had the potential to affect 32 residents who were ambulatory by any means as documented on a list provided by the Administrator on 11/04/22 at 9:57 a.m. This failed practice resulted in an Immediate Jeopardy, which caused or could have caused serious harm, injury, or death to Resident #1 who had eloped from the facility on 10/28/22. The Administrator was notified of the current Immediate Jeopardy on 11/02/22 at 4:58 p.m. The findings are: 1. Resident #1 was admitted to the facility on [DATE] and had a diagnosis of Alzheimer's Disease with Late Onset. The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/21/22 documented the resident scored 12 (8-12 indicates moderately cognitively impaired) on a Brief Interview for Mental Status (BIMS) and exhibited no wandering behaviors, requires limited physical assistance of one person with walking in the room, locomotion on and off the unit, supervision of one person with walking in the corridor, and used a wheelchair. a. The Physician's Order dated 10/21/22 documented, .May place wander guard to Right ankle, and Check wander guard battery and placement every shift . b. The Care Plan documented, .attempts unsuccessful attempts to exits from the facility. 10/28/2022: .exit G-Hall door that was let open by maintenance . Follow familiar routines. Wander guard. Check placement of wander guard to right ankle each shift. Date Initiated: 10/20/2022 . Staff inserviced to make sure doors are closed at all times. Date Initiated: 10/20/2022 . c. The Nurse's Note dated 10/28/22 at 12:30 p.m. documented, .Resident has been very agitated this shift. continuously exit seeking and ambulating without assistance. Received in report that resident had been up all night packing clothes and personal belongings in attempt to leave the facility. This nurse has kept close watch on resident majority of shift as much as possible. This nurse at nurse station charting and receive a call from administrator asking where resident was. This nurse stated that she believed resident was up front in dining room because he was just in front of nurses station. administrator stated she thought he was missing and that this nurse needed to go look for him. This nurse along with other staff members searched for resident in facility unable to find resident. This nurse arrived at station 2 and noted DON and Administrator at the nurses station discussing that resident was brought to administrators office. This nurse asked several times who brought resident in. Social Director this nurse that she was standing outside smoking and her and another staff member brought resident in. They found resident in the parking lot . d. The Nurse's Note dated 10/28/22 at 1:19 p.m. documented, .Elopement Evaluation: History of elopement while at home: No. Wandering behavior a pattern or goal-directed: Yes. Wanders aimlessly or non-goal-directed: No. Wandering behavior likely to affect the safety or well-being of self / others: Yes. Wandering behavior likely to affect the privacy of others: No. Recently admitted or readmitted (within past 30 days) and has not accepted the situation: Yes. Elopement Score: 6.0 . e. The Nurse's Note dated 10/28/22 at 1:21 p.m. documented, wander guard was in place at the time of elopement and alarms did not go off . f. The Nurse's Note dated 10/28/22 at 2:14 p.m. documented, .APRN [Advance Practice Registered Nurse] was notified in dining room this am during halloween party of resident's behavior. APRN stated that she would order resident something to help him sleep and PRN [as needed] [MEDICATION(S)]. Resident eloped and APRN was notified of elopement and order one time dose of [MEDICATION(S)] . g. On 11/02/22 at 2:28 p.m., Resident #1 was in his room in his wheelchair (w/c). When this Surveyor attempted to talk to him his words were garbled and did not make sense. h. On 11/02/22 at 3:14 p.m., during initial rounds on the G-Hall, which was under construction, the fire doors were closed. Surveyors pushed the bar on the doors and the doors opened and the Surveyors were able to access the hallway. The hall and rooms had wiring hanging down from the ceiling, a ladder, a metal plate, copious amounts of insulation and steel hex webbing were all up and down the halls and in the resident rooms. i. On 11/02/22 at 4:36 p.m., the Surveyor asked the Administrator, How did [Resident #1] get out of the facility? The Administrator replied, The maintenance man had the fire doors opened, and the video show's him going down the hall, in his w/c. He got to the exit, stood up and walked outside. The exit door was propped opened with a junk of concrete. j. On 11/02/22 at 4:44 p.m., the Surveyor asked Certified Nursing Assistant (CNA) #2, Can you tell me why the hall under construction is accessible to residents? CNA #2 replied, It shouldn't be. The Surveyor asked, Why not? CNA #2 replied, Because of the hazards down there. k. On 11/02/22 at 4:47 p.m., the Surveyor asked Licensed Practical Nurse (LPN) #2, Can you tell me why the hall under construction is accessible to residents? LPN #2 replied, Because it's a fire door and we can't lock fire doors. l. On 11/02/22 at 5:18 p.m., the Surveyor asked Maintenance #4 Why won't the exit doors at the ends of every hall not open after pushing on the bar for greater than 2 minutes? Maintenance #4 replied, You have to have the access code in order for the door to open. If the fire alarm is triggered the doors release. The Surveyor asked, Why won't the exit doors at the ends of the halls not open when pushed on? He stated, You have to enter the code. The Surveyor asked Maintenance #4, How does someone exit the building if there is an emergency? Maintenance #4 replied, The fire alarm disables the system, and the doors will be unlocked. m. On 11/02/22 at 7:07 p.m., the Surveyor asked Maintenance #2 Why were the fire doors on G-Hall left accessible to residents? Maintenance #2 replied, We didn't block it off, we didn't know we could lock it. n. On 11/02/22 at 7:08 p.m., the Surveyor asked Maintenance #1 Why were the fire doors on G-Hall left accessible to residents? Maintenance #1 replied, We had signs, we didn't know we could lock it. o. On 11/02/22 at 7:09 p.m., the Surveyor asked Maintenance #3 Why were the fire doors on G-Hall left accessible to residents? Maintenance #3 replied, We thought closed doors and signs would be enough. p. On 11/02/22 at 7:12 p.m., the Surveyor asked Maintenance #2, Why won't the exit doors at the ends of the halls not open when pushed on? He stated, You have to enter the code. The Surveyor asked, How does someone exit the building if there is an emergency? Maintenance #2 replied, The fire alarm disables the system, and the doors will be unlocked. q. On 11/02/22 at 7:15 p.m., the Surveyor asked Maintenance #1 When will the exit doors at the ends of the halls open? Maintenance #1 replied When the bar is pushed. The Surveyor asked Maintenance #1 to push on the bar, it failed to open after he applied some very aggressive pushing. Maintenance #1 replied, I thought they'd open after 45 seconds of pushing. r. On 11/03/22 at 11:23 a.m., the Surveyor asked the Fire Marshall about the exit doors not opening after being pushed for up to 3 minutes. The Fire Marshall replied, These doors have remained like this since the building was built greater than [AGE] years ago. It's made to release when the fire alarm is set. The Surveyor asked, What if there were an active shooter in the building and I'm a visitor or a staff member so scared that I can't put the code in? The Fire Marshall replied, Oh my I've never thought about that, that is a very valid question. s. On 11/03/22 at 11:35 a.m., the Surveyor asked Maintenance #1, Describe in your words what happened the day [Resident #1] eloped? Maintenance #1 replied, Me and a co-worker were tearing out debris from the remodel of the ceiling in the hall, so we propped the [exit] door open with a chunk of concrete after disabling the alarm system to the door. Our supervisor had another project to go on and needed our help at the lodge in the next building. We had to leave, and I inadvertently left the exit door propped open. The Surveyor asked, How long were you gone? Maintenance #1 replied, For about one to one and half hours. When we came back around the G-Hall, the exit door was shut, and the Administrator informed me and my supervisor of what had happened. t. On 11/03/22 at 12:42 p.m., the Surveyor asked CNA #1, What is a wanderguard? CNA #1 replied, It's a bracelet that alerts you they got too close to the door. The Surveyor asked, Why do some residents have a wanderguard? CNA #1 replied, If they have dementia or are a wanderer. The Surveyor asked, How do you know the wanderguard is working properly? CNA #1 replied, When they get close to a door it goes off and the nurse reports it. The Surveyor asked, Where is the monitoring documentation at? CNA #1 replied, Somewhere in our software system. u. On 11/3/2022 at 12:55 p.m., the Surveyor asked Certified Nursing Assistant (CNA) #1, If a resident elopes, what are you supposed to do? CNA #1 replied, Notify the Charge Nurse and they follow chain of command. The Surveyor asked, What interventions are in place for residents that wander or are an elopement risk? CNA #1 replied, We re-direct and we have wanderguards. v. On 11/03/22 at 1:01 p.m., the Surveyor asked LPN #1, What is a wanderguard? LPN #1 replied, The placement is to notify you they're out of place. The Surveyor asked, Why do some residents have a wanderguard? LPN #1 replied, Due to their state of mind or diagnosis. The Surveyor asked, How do you know the wanderguard is working properly? LPN #1 replied, I have a machine to check the wanderguard and the door sensor. The Surveyor asked, Who is responsible for ensuring placement and functioning? LPN #1 replied, I am, I have a check off in the software every shift. The Surveyor asked, Where is the monitoring documentation at? LPN #1 replied If something is wrong, the system will report it to the DON, who will help me figure out why it's not working. The Surveyor asked, If a resident elopes, what are you supposed to do? LPN #1 replied, Call a Code Silver, notify everyone on our unit, and hopefully they don't get too far, and come up with an intervention. The Surveyor asked, What interventions are in place for residents that wander or are an elopement risk? LPN #1 replied, One had a wanderguard on, but it didn't go off for whatever reasons, we don't really have one on. One, because they aren't care planned. The Surveyor asked, Tell me about the situation that happened with [Resident #1] on 10/28/2022 with the elopement? LPN #1 replied, [Resident #1] was more confused, exit seeking. He had a wanderguard on. I re-directed him at the Halloween party. Every time I walked away from him; I was being paged back to him. Me and a couple other nurses tried to re-direct him, but he was adamant he was going outside to get to his wife. He was there, then he was gone. I received a phone call from the Administrator asking where was [Resident #1]. The Surveyor asked, Why did the Administrator call you? LPN #1 replied, She was in her office, and we left him for five minutes, she asked where is [Resident #1], I said he's right there. The CNA said he was right there. The Administrator said I think he's missing, so I hung up the phone and went looking for him, and he was in her office. The Surveyor asked, How did [Resident #1] end up in the Administrator's Office? LPN #1 replied, I assume he just went out the door, but no one reported to me he was outside, but I was headed to the front and the Social Director/Worker said we were outside smoking, and [Resident #1] came walking through the parking lot. [Resident #1] was sitting in the Administrator's Office, everyone was trying to figure out how he got out. I asked, what was the intervention and the DON said I don't know, I'm going to get with the Administrator. The Surveyor asked, Was the door left open [propped open]? LPN #1 replied, Yes, the outside door was open [G-Hall], but the first set of doors were closed, but accessible and yes there was construction going on the G-Hall. w. On 11/3/2022 at 2:09 p.m., the Surveyor asked the Social Director (SD), If a resident elopes, what are you supposed to do? The SD replied, Bring the resident back to the facility and report to the DON and the Administrator. The Surveyor asked, What interventions are in place for residents that wander or are an elopement risk? The SD replied, Wanderguard system and alarms on the doors. The Surveyor asked, Tell me about the situation that happened with [Resident #1] on 10/28/2022 with the elopement, were you here that day? The SD replied, Yes, I was working, I was outside. When I got ready to come back in, I saw [Resident #1] coming around the building pushing his wheelchair. The Surveyor asked, Did [Resident #1] have a wanderguard on? The SD replied, Not sure. The Surveyor asked, Was the door alarming? The SD replied, No, I ran to him, sat him in his wheelchair, and took him to the Administrator's Office and told her I found him outside coming around the building. The Surveyor asked, Do you know how long he was outside before you found him? The SD replied, I have no idea. The Administrator called back to the Nurses Station 3, where he resides, she tells the nurse that we had brought him in from outside. x. On 11/4/2022 at 8:26 a.m., the Surveyor asked the DON, If a resident elopes, what are you supposed to do? The DON replied, Call a Code Silver, everyone goes looking, we have a protocol. The Surveyor asked, What interventions are in place for residents that wander or are an elopement risk? The DON replied, They have wanderguards, increase activities, like re-direction. The Surveyor asked, Tell me about the situation that happened with [Resident #1] on 10/28/2022 with the elopement, were you here that day? The DON replied, I was here that day, and I'm the one who found the door at the end of G-Hall propped opened with a piece of concrete and automatically shut it. I did not see any residents. I knew he had gotten out. The Surveyor asked, How did you know [Resident #1] got out? The DON replied, The SD was outside and saw him and brought him in. The Surveyor asked, Who left the door propped open? The DON replied, The Maintenance Men. We got him [Resident #1] in, we tried to keep him up front and started the in-service. The Surveyor asked, It documents the facility did one on one, do you have that documentation? The DON replied, I know the wife came and set with him for a while after I called her. I have where she was here, but not when she left. We don't have any documentation that we did one on one because we don't have the staff. The Surveyor asked, Did [Resident #1] have a wanderguard on? The DON replied, Yes, but with the door propped opened, it wouldn't alarm. The Surveyor asked, What are your expectations from your staff regarding following the facilities policy and procedures and the Centers for Medicare and Medicaid [CMS] Guidelines? The DON replied, I expect them to follow them 100 percent. y. On 11/4/2022 at 10:07 a.m., the Surveyor asked the Administrator, If a resident elopes, what are you supposed to do? The Administrator replied, Call a Code Silver, search the perimeter, run a census and account for residents. All departments are involved. Do a man hunt. The Surveyor asked, What interventions are in place for residents that wander or are an elopement risk? The Administrator replied, Every two hour rounds, wanderguards, keypad on the door, we do in-services on rounding. The Surveyor asked, Were you here the day [Resident #1] eloped. The Administrator replied, Yes. The Surveyor asked, Tell me about that? The Administrator replied, I do know it was at the noon hour and the MDS Coordinator and the SD/Worker came into my office pushing [Resident #1] in his wheelchair. The SD said, 'we were out in the parking lot and saw [Resident #1] coming around the corner of the building' and they brought him into my office. I asked [Resident #1] what he was doing, and he said he was, 'Looking for his Volvo or Ford Explorer, he needed to get to [City]'. I asked the SD and MDS Coordinator to go do the Silver Code, the DON said she had started on the end he went out. The Surveyor asked, How did [Resident #1] get out of the building? The Administrator replied, I found out from the DON that the G-Hall door was held open with a chunk of concrete. The Surveyor asked, Who propped the G-Hall exit door open? The Administrator replied, I don't know. I did not witness anyone prop the door open. The Surveyor asked, Did [Resident #1] walk through the G-Hall that was under construction to the exit door? The Administrator replied, He ambulated himself through the G-Hall in his wheelchair, and at the exit door, exited the building pushing his wheelchair and was intercepted by staff at the generator. The Surveyor asked, What are your expectations from your staff regarding following the facilities policy and procedures and the CMS guidelines. The Administrator replied, I expect them to follow them to the letter. z. The facility policy titled, [Facility] Elopement Policy and Procedure . Revision 3, provided by the Director of Nursing (DON) on 11/04/22 at 9:17 a.m. documented, .Purpose: The primary goal of the Elopement Policy and Procedure is to provide a course of action for all personnel to follow in the event of an elopement. Ensure all residents/patients are accounted for and ensure guidelines in identifying and providing safety to all patients/resident at risk of wandering . Elopement: The definition of Elopement used by the American Health Care (AHRQ) is when a resident's location is unknown.Duties of Personnel: The person in Charge: When discovered a Resident is missing, the Alert for a Missing Adult will be paged CODE SILVER by the Charge Nurse if, after a reasonable search by staff for a resident/patient, shows the individual to be unaccounted for . Upon return of the resident/patient to the facility: .Document the elopement incident in the medical record and complete an incident report . aa. The facility policy titled, Accidents and Incidents - Investigating and Reporting, provided by the Administrator on 11/04/2022 at 9:56 a.m. documented, .The nurse supervisor/charge nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident . 3. This facility is in compliance with current rules and regulations governing accidents and/or incidents involving a medical device . bb. The facility policy titled, Hazardous Areas, Devices and Equipment, provided by the Administrator on 11/04/2022 at 9:56 a.m. documented, .All hazardous areas, devices and equipment in the facility will be identified and address appropriately to ensure resident safety and mitigate accident hazards to the extent possible . Identification of Hazards 1. A hazard is defined as anything in the environment that has the potential to cause injury or illness. Examples of environmental hazards include but are not limited to the following: a. Equipment and devices that are left unattended .; .c. Sharp objects that are accessible to vulnerable residents; .f. Objects in the hallways that obstruct a clear path; .j. Furniture that is unstable or position at an improper height for residents; or k. Disabled locks, latches or alarms . 2. The Immediate Jeopardy was removed on 11/02/22 at 7:59 p.m., when the following Plan of Removal was implemented by the facility: a. All residents have been checked/facility wide audit to ensure that no residents were located on the G Hall. There were no residents identified as being on the G Hall. A staff member was placed outside of the G Hall entrance (fire doors) to monitor for any entrances or exits. She/he will be documenting every 15 minutes, every shift. Completion date 11/02/22. b. All items that were located on the floor of the G Hall hallway were removed and placed out of pathway of anyone who needed to use the hallway as an exit for an emergency. Any items left of the hall were placed on the same side of the hall so as not to impede any necessary traffic. Completion date 11/02/22. c. Two staff members walked the G Hall, entered all resident rooms on that hallway searching for any residents. There were no residents found in any of the rooms or in the hallway. Completion date 11/02/22. d. A consultant and facility maintenance supervisor audit all exit doors to ensure all doors have their magnetic strip release and doors open in order to exit the building. Completion date 11/02/22. e. The maintenance staff placed a secured board across the fire doors leading to G Hall, to ensure that no residents or staff had access to the hallway. Coverings on the door were placed on the windows going into the G Hall. Completion date 11/02/22. f. The lighted exit sign attached to the ceiling, outside of fire doors leading G Hall, was covered, therefore rending it out of commission. New exit signs were placed in the common area to re-direct anyone to ensure a quick and safe exit. g. Signs were placed on fire doors that lead to G Hall that read NO EXIT, this was follow by Occupational Safety and Health Administration (OSHA) regulation CFR 1910.31 (b)(5) Completion date 11/02/22. h. A visual inspection of the G Hall door was conducted to ensure that the secured board was still attached to the door to ensure that there is no entrance or exit form that unit. Completion dated 11/03/22. i. The DON or her designee will in-service all staff on the importance of monitoring all egress doors, listening for door alarms, explaining hazards, how to look for hazards, and reporting and removing hazards from hallways, common area and other areas as necessary. j. The facility will address the hazards, how to look for hazards, repotting and removing hazards in a flyer form to be included with all new employee hire packs. The new employee will be required to sign an acknowledgement form which will be kept in their employee file and a copy given to them.

Complaint # (AR 795) was substantiated, all or in part, with these findings: Based on observation, record review, and interview, the facility failed to ensure a planned fall prevention intervention was consistently implemented and a resident who was at risk for falls was not left unattended after being assisted to a sitting position in a wheelchair on the side of the bed, to prevent potential falls for 1 (Resident #1) who had a history of [REDACTED].#1 who had a fall which resulted in injury, and had the potential to affect 2 residents who were Care Planned to not remain in their room when up, and 60 residents who were assessed to be at risk for falls, according to the lists provided by the Director of Nursing on 8/12/2020 at 1:13 p.m. The findings are: : 1. Resident #1 had [DIAGNOSES REDACTED]. A Significant Change of Status Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/16/2020 documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status; was totally dependent with two-person assistance with transfers and toilet use; required extensive two person assistance with bed mobility; had functional limitation in range of motion on one side of the upper and of the lower extremities; had one fall with no injury since admission or prior assessment; and had one fall with injury since admission or prior assessment. a. A facility Fall Screen dated 3/20/2020 documented, .Location of fall . Resident's room . Intervention . Resident to be placed in common area when no one is available to be in her room . (signed by Licensed Practical Nurse (LPN) #6 on 3/4/2020) . b. A facility Incident and Accident Report dated 5/20/2020 documented a fall with injury at 6:54 a.m. and documented, .(Resident #1) was wheeling out of her room and yelled, 'Help, this lady is falling on the floor out of the wheelchair'. I called for assistance. I arrived down there. Resident #1 was lying on the floor on her right side with head bleeding. No other bruises or injuries noted at the time of assessment. AROM (active range of motion) to all extremities with no facial grimaces. Her legs were caught into the wheelchair. I assisted with moving wheelchair so (name) could apply pressure to right side of head while I make all the phone calls and get paperwork ready. Family, DON (Director of Nursing), and Doctor contacted. Resident was sent to ER (emergency room ) . The Nurse's Notes from 5/20/2020 at 3:00 a.m. through 5/21/2020 at 7:00 p.m. documented respiratory assessments, pain assessments, and antibiotic use. The Nurses Notes contained no documentation related to the fall or neurological assessments. c. A Hospital Discharge Instruction Sheet dated 5/20/2020 provided by Licensed Practical Nurse (LPN) #1 documented discharge instructions as, .Sutures out in a week, monitor sugar, and fall precautions . LPN #1 was asked for further discharge information and / or orders. LPN #1 was asked if there were no papers as to how many sutures were required to close the wound? She stated, No ma'am. That's all we have. d. On 6/3/2020 at 2:03 p.m., Certified Nursing Assistant (CNA) #2 was asked, How long have you worked at the facility? She stated, Six weeks. She was asked, Tell me about (Resident #1's) fall on 5/20/2020. She stated, I was told that (Resident #1) was in her chair and that (Name) was being paid by the family to feed her. I was assigned to her that day. I kept making sure (Resident #1) was okay, and in her chair properly and couldn't fall. This was the first time I took care of her. I was handing out trays and cutting food up for residents. Someone asked for something different on their tray, so I went to the kitchen to put that order in and when I came back, I heard that she had fell . So, I immediately went to see what was going on and see how bad she was injured and if she was responsive. They told me not to touch her until they assessed. I got down on the floor next to her to calm her down and got her to focus on me until the ambulance got there. They got towels. She had got tangled up in her wheelchair. We kept compression on her head until the ambulance got here. I was checking on her in between when the ambulance got here. I have never had that happen to me before. Most of the time she is in her bed. But this time she was in a room by herself in quarantine. She normally shared a room with someone else. (Resident #1) has never wobbled in her chair before. I don't know what happened. She was asked, Were you aware she was a fall risk before that fall happened? She stated, Yes, ma'am. She was asked, How did you know that? She stated, I remember training on this floor and was told she was. And that when she is in her chair, she had to be set back some. And she was like that when she fell . The chair was reclined a little bit. She was asked, So, it was a high-back wheelchair that would recline? She stated, I believe so. She was asked, Were you aware she was not supposed to be left alone in her room in a chair? She stated, I have never heard that. I was not aware of that. She was asked, Where do you go to see information like residents who are at risk for falls, and how much transfer assistance is needed? She stated, I know that on our Assignment Paper for who we have for the shift will have stuff written on it. I think the Nurse fills that out. If there's a book I can go to, I've never seen one. I was just told to make sure she was okay in her chair and to keep checking on her. e. On 6/3/2020 at 2:30 p.m., the (Former) Director of Nursing (DON) was asked, (Resident #1's) Care Plan documented after the 3/2/2020 fall as an intervention for staff to put her at the Nurse's Station in the evening until time to put her in bed. Why was she in her room by herself when she fell on [DATE]? She stated, Because of the COVID isolation. She had just come back from the hospital on [DATE] and we have to put residents in isolation by themselves for 14 days. And she doesn't try to get out of the bed. She tries to get out of her chair. She didn't fall out of bed on 5/20/2020. She fell out of her chair. She was asked, What was the intervention to prevent recurrences after the 5/20/2020 fall? She stated, I told staff after the fall to not leave her in there by herself. She was asked, Because of the COVID, and her having to be in isolation after returning from the hospital, what was the intervention to prevent falls for her since she had a history of [REDACTED].? She stated, Rounding and checking on her. She had not been in her chair until that day. She had just returned from the hospital and we felt she was not strong enough on that day for her to get in her chair. f. On 6/3/2020 at 3:10 p.m., Licensed Practical Nurse (LPN) #1 was asked about the resident's fall. She stated, She was on my hall. I was still orientating. (LPN #3) was the nurse. She (the resident) was up and in the wheelchair in her room. When we did our Med (Medication) Pass, she was still up and in the chair. We completed the Med Pass around 5:00 p.m. to 6:00 p.m. We were sitting having lunch. (LPN #3) came and said, 'I need you now. (Resident #1) is in the floor'. So, I jumped up and she was in the floor and there was blood in the floor. I applied pressure like I was told and when the Emergency Medical Technicians (EMTs) got here, they took her to the hospital. My supervisor was (Registered Nurse (RN) #2) and she told me to put pressure on her head. She's an RN. She was asked, 'Were you aware she was a fall risk prior to this fall? She stated, I didn't know. She was asked, Had you taken care of her before? She stated, Yes, but I didn't know she was a fall risk. She was asked, How do they let you know someone is a fall risk? she stated, I don't know, but I will find out and let you know. But I know her daughter left a note in her room on a board that she is to be up at all meals. She was asked, Did you know she wasn't supposed to be up in her room by herself? She stated, No, ma'am. This was my first time to know of her falling. g. On 6/3/2020 at 3:30 p.m., RN #3 was asked, Talk to me about a fall on 5/20/2020. She stated, I didn't work with her that day. I was working at another station but then counted out and went to her hall, but she had already gone to the hospital. I heard about her fall, but I was working the other end of the building. She was asked, Had you ever provided care to her before then? She stated, I had taken care of her before. (Resident #1) is non-verbal. She used to be alert oriented times 3 (person, place and time), could walk, but then had a bad stroke. Now she is dependent. She has to be fed, wears a brief (incontinent brief). She was asked, Did she have a habit of trying to get out of her chair? She stated, Sometimes. She's unaware of what she's doing. She has a tendency to reach down or bend over. She was asked, Has she ever fallen doing that before? She stated, I can't honestly recall because when I did work on the floor all the time, I didn't work on that hall. She was asked, Was she a fall risk before she fell on [DATE]? She stated, Yes. She was asked, Were you aware that if she was up in her chair, she was to be at the Nurse's Station for supervision? She stated, Yes, I was aware of that. h. On 6/3/2020 at 3:47 p.m., CNA #1 was asked, Did you have anything to do with taking care of (Resident #1) when she fell on [DATE]? She stated, She was not my resident. I was working that hall, but I was at the other end. It was around supper time and we were passing out our trays, then we went to feed our residents. I was in a room feeding, and after I got through, I started checking on other residents and I heard that she fell . I went down there to see what happened. There was a lot of blood on the floor, so I asked if there was anything I could do to help, so I went and grabbed towels. Then we tried to get (RN #2) on the intercom. She didn't come as soon as we called, so I went and got her, and she came to see about her. And then the EMTs (Emergency Medical Technicians) came and got her. She was asked, Had you ever taken care of her before? She stated, Yes, I had. When we were passing out trays she was sitting up in her wheelchair in her room. And she had just got back from the hospital earlier that week because she was dehydrated. But yes, I had taken care of her before that happened. She was asked, Were you aware she was a Fall Risk before this last fall? She stated, All I knew, well mostly she stays in bed. Nobody has been getting her up. I mean, I guess. I know she can't stand up on her own. She can't walk. She was asked, How do you find out if someone is a Fall Risk? She stated, Nobody has ever told me she was a Fall Risk. She was asked, Is there a book that would tell you? She stated, They would have it in the record, but I'm sure there is a book that has that, but I've never seen that since I've been here. And when I was being trained, they never said anything about there being a book that says that. She was asked, Is it important to make staff aware if someone is a Fall Risk? She stated, Yes. She was asked, She had a history of [REDACTED]. Did you know that? She stated, No, ma'am. i. On 6/3/2020 at 6:21 p.m., CNA #3 was asked how long she had been employed at the facility. She stated, Two months. She was asked, Tell me about the fall (Resident #1) had on 5/20/2020? She stated, I was on the other end of the hall. I remember hearing that she fell , and she was going to the hospital and when she came back, she was bruised up. One CNA was saying they wanted to take her out of the chair, but someone else said she was supposed to get therapy and that's why they wanted her to stay up. There was a reason for her to still be in the chair, but I don't remember. She was asked, Had you ever taken care of her before? She stated, Yes, when she was on the other end, I had changed her and given her food. She was asked, Had you ever seen her try to get out of her chair before? She stated, No, usually when I come, she be in bed. She was asked, Were you aware she was a Fall Risk before the 5/20/2020 fall? She stated, No, ma'am. She was asked, Where do you find out that type of information? She stated, Other CNAs or a nurse. Sometimes there's signs in the room. There's a book I think at the Nurse's Station. I don't know if it has that kind of information in it. She was asked, What do you do for a resident who is a Fall Risk and they're in the room by themselves? She stated, We have had ladies by the Nurse's Station because they are Fall Risk. j. On 6/4/2020 at 10:00 a.m., LPN #2, MDS / Care Plan Coordinator was asked, How long have you worked here? She stated, Five years. She was asked, Where are the fall interventions documented? She stated, They are listed on the Care Plan. She was asked, I see on (Resident #1's) Care Plan that she fell on [DATE], but I do not see any interventions listed to prevent recurrences after that fall. She stated, I don't see any either. I don't know how it was missed. She really needs two people helping her, but she won't allow it. So, we all do the best we can. I don't know why I don't have an intervention. k. On 6/4/2020 at 12:40 p.m., LPN #3 was asked how long she had worked at the facility? She stated, Almost nine years. She was asked, Were you on duty when (Resident #1) fell on [DATE]? She stated, Yes, I was here when she fell this last time. I was on the hall and a resident said that this lady just fell . I yelled for help, ran down there, and she had fallen out of her chair and hit her head. (CNA #5) was training with me and (RN #2) was there. We all went down there. I called the ER (emergency room ) and the doctor. Everything I was supposed to do once we got the bleeding covered up. The RN Supervisor stayed down there the whole time. She was asked, Did she have a habit of trying to get out of her chair at times? She stated, Usually when she is in her chair, she is sitting back. She had just returned from the hospital and they placed her down there. She will lean forward at times, but not like lean down to try to pick up things to the point that she would fall out. She was asked, What fall intervention was being implemented at that time since she was in quarantine? She stated, When I came in, they had her back, the chair wasn't sitting straight up. It was kind of leaning back. I am not her normal nurse. With her being under quarantine, she was on a different hall. She was asked, Was she in a high-back wheelchair? She stated, Yes. She was asked, Was she weak? She stated, Not that I know of. The nurse said the family wanted her to stay up and eat the 5:00 p.m. meal in her wheelchair because they had one of the workers coming in and feeding her. Her normal nurse is (LPN #3). She works on B Hall every day. She was asked, What interventions have been implemented since that last fall? She stated, They haven't told me what fall interventions have been put into place since that last fall. l. On 6/4/2020 at 1:05 p.m., Social Service Director stated she had been employed at the facility for [AGE] years and had been the Social Service Director for the last [AGE] years. She was asked, Does (Resident #1) sometimes lean forward in her chair? She stated, Yes. She sits up sometimes in the lobby. A lot of times she pulls herself forward trying to pull her brace off or shoe off. I put that in my note because a lot of times we have to get her to lean back and situated. A lot of times I take her outside to try and get her to relax. Before this pandemic she sat at the Nurse's Station to be watched. She was asked, What is being done for residents now that they can't be at the Nurse's Station anymore? She stated, I make a lot of room visits. We have some now that we take out of their rooms and keep them far apart, so they won't be in their rooms all the time. Before (Resident #1) was hospitalized , we were taking her outside. m. On 6/4/2020 at 1:14 p.m., LPN #5, Staff Educator, stated she had been employed at the facility for four years. She was asked, Do you work the floor at times? She stated, Yes. She was asked, Have you worked with (Resident #1)? She stated, I have when I worked up here a couple of nights in the evening time passing medications. She was asked, Tell me about her. She stated, I know she's had [MEDICAL CONDITION], right sided weakness, totally dependent, lift to get in / out of the bed. When she's up in a wheelchair, we always brought her to the Nurse's Station to monitor her. Always made sure the side rails were up and that she was comfortable. She's a total care and we have to help her eat. She was asked, Why was she at the Nurse's Station for monitoring? She stated, Because she likes to bend down and pick things up. Her right foot has a boot and she will mess with the Velcro. She has taken her shoes off. She does like to lean over, so we put her at the Nurse's Station to monitor her. We would watch her to adjust her and make sure she is sitting up in the wheelchair. She was asked, What did the facility do to prevent her from falling once she was in quarantine? She stated, I normally only work in the evening time so she was always in the bed. I know they normally let her lay in the bed and turn her every two hours and monitor her through the shift to make sure she is comfortable. She was asked, Is being in the wheelchair by herself appropriate for her? She stated, I can't answer for the other nurses, but in my opinion, I wouldn't have had her up in the chair like that. I have taken care of her since she's been in here. I am aware of and know her. The other nurses, I can't answer for them. I know her personally and how she does and as far as her leaning goes. She is confused and most of the time when she is up, she is pulling and leaning and doesn't know what is going on. n. On 6/4/2020 at 1:33 p.m., LPN #4 stated she had been at facility for almost three years and worked B Hall. She was asked, Do you normally take care of (Resident #1)? She stated, Yes. I have been on this hall since January (2020). She is non-verbal, she requires a lift. Before she was on isolation, they would get her up in the mornings with the lift. She did not eat really well. Once the COVID started and we had to start feeding her in the room, it went down a little. There is one CNA (#4) that she responds really well to and she does better with her. Most of the time they get that CNA . She was asked, Did staff used to monitor her at the Nurse's Station? She stated, Yes, we would. She was asked, Why? She stated, She would, we were worried she would fall out of it if someone wasn't watching her at all time. The CNAs would do their 2-hour checks. But like with this last fall, the nurse would go in to check on her, but then left and it happened. She was asked, Did she have a habit of leaning while in her chair? She stated, Yes. I have had to get help to reposition her a few times. She has the high-back wheelchair. She was asked, So, if she couldn't be at the Nurse's Station for monitoring, what fall interventions were implemented due to her being in quarantine? She stated, Me, as a nurse for [AGE] years, I would have gotten with the aides to make sure she was checked on frequently. And she was in the bed more. She was asked, Do you feel it was a good idea to leave her in her room unattended? She stated, No. o. The facility Fall Prevention Program provided by the Director of Nursing on 8/12/2020 documented, .Ensure that staff are educated to the definition of a fall, complete a Fall Risk Assessment . When a fall occurs the DON / Designee will review the I&A (Incident and Accident Report), review Post Fall Investigation and evaluate for trends . Update Care Plan . Identify residents who qualify for placement in the 'Falling Star Program' .

Complaint # (AR 907) was substantiated, all or in part, with these finding: Based on observation, record review, and interview, the facility failed to ensure supervision was provided to prevent elopement for 1 (Resident #1) of 4 (Residents #1, #2, #3, #4) case mix residents who were at risk for elopement. The facility failed to follow manufacturer's guidelines for the departure alert system and failed to monitor the activation date of the signaling device to notify the facility when it was close to expiring. The facility failed to ensure all residents who were at risk for elopement had a departure alert bracelet in place and failed to ensure staff was knowledgeable on which residents were at risk for elopement. These failures resulted in Immediate Jeopardy which caused or could have caused serious harm, injury, or death to Resident #1 who exited the building unnoticed by staff due to the departure alert signaling device not working, and who stayed outside for approximately 36 minutes until the Director of Nursing happened to drive by and see her. These failures had the potential to affect 15 other residents in the facility who were at risk for elopement, according to a list provided by the Director of Nursing on [DATE] at 12:34 p.m. The Administrator was informed of the Immediate Jeopardy situation on [DATE] at 4:45 p.m. The findings are: 1. The facility policy titled Elopement provided by the Assistant Director of Nursing (ADON) on [DATE] at 10:42 a.m. documented, .Staff shall investigate and report all cases of missing residents . When a departing-individual returns to the facility, the Director of Nursing Services or Charge Nurse shall . Notify the attending physician . Notify the resident's legal representative of the incident . Complete and file Report of Incident / Accident . 2. Resident #1 had [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] documented the resident was moderately impaired in daily decision-making skills according to a Staff Assessment of Mental Status (SAMS), required a wheelchair for mobility, and exhibited wandering behavior. a. An Elopement Risk assessment dated [DATE] documented, .Less than 5 (equals) Low risk for Elopement (address risk factors) . Between 5 to 10 (equals) High risk for Elopement (Initiate Standard Care Plan) . Total Score . 7 . b. A Nurse's Note dated [DATE] at 7:00 p.m. documented, .Agitated at intervals, attempting to go outdoors at intervals, requiring frequent redirection . c. A Nurse's Note dated [DATE] at 7:00 p.m. documented, .Resident noted propelling self in w/c (wheelchair) without difficulty . Cont (continues) to go to doors and tries to push door open . d. A Nurse's Note dated [DATE] at 7:00 p.m. documented, .Attempting to leave out exit doors multiple times requiring frequent redirection. Agitated at times. Calming after toileting and redirection . e. A Nurse's Note dated [DATE] at 7:00 p.m. documented, .Multiple attempts to leave out of exit doors this p.m. (evening / night) requiring frequent redirection. Agitated at times. Toileted and meal served. Calmed after receiving meal . f. A Nurse's Note dated [DATE] at 7:00 p.m. documented, .Multiple attempts to leave out (the) doors during beginning of shift requiring frequent redirection. Diversional activities not effective. Calmed in later part of shift after toileting and dressing for bed. No further agitated behavior noted . g. The Care Plan dated [DATE] documented, .Problem . Potential for exit-seeking behavior (Elopement) . Approach .Bracelet and secure environment . Eliminate / minimize opportunities to leave building . h. A Nurse's Note dated [DATE] at 11:00 a.m. documented, .Resident was trying to go out of facility. Family notified . i. A Nurse's Note dated [DATE] at 7:00 p.m. documented, .Resident up to w/c (wheelchair) propelling self about facility. Noted going to exit doors at Station 2 and redirected by staff. Will continue to monitor . j. A Nurse's Note dated [DATE] at 11:00 a.m. documented, .Resident tried to go out the front door unassisted. Would not let me bring her back in. Took resident for a stroll in the parking lot. Resident did not want to come in. Redirection given. Resident sitting up in the front eating snacks at this time. Will continue to monitor . k. A Nurse's Note dated [DATE] at 7:00 p.m. and signed by Licensed Practical Nurse (LPN) #2 documented, .Resident went out of F-Hall door unassisted. Resident allowed me to bring her back in. Resident given water. Redirection given. Resident at Station 1 eating supper. No s/s (signs / symptoms) of distress noted. Will continue to monitor . l. The Treatment Administration Record (TAR) dated [DATE] documented, .Wander Guard Bracelet Frequency . NUR (Nursing) . Every Shift . Check placement . 03:00 (3:00 a.m.) . 11:00 (11:00 a.m.) . 19:00 (7:00 p.m.) . The TAR contained licensed nursing staff signatures documented at 3:00 a.m. and 11:00 a.m. from [DATE] through 11:00 a.m. on [DATE] indicating the resident ' s Wander Guard bracelet was present. m. The TAR dated [DATE] documented, .Wander Guard Battery Frequency . Nur (Nursing) . daily night . Wander Guard battery to be checked nightly on ,[DATE] (11:00 p.m. to 7:00 a.m. shift) . (at) 03:00 (3:00 a.m.) . According to the documentation, licensed nursing staff signatures were present at 3:00 a.m. [DATE] through [DATE] indicating the resident ' s Wander Guard battery was checked and functional. n. On [DATE] at 9:58 a.m., the resident was sitting in a wheelchair by the Nurse's Station. A Wander Guard bracelet was on the resident ' s right ankle. The date on the side of the Wander Guard bracelet was [DATE]. The resident was close to a door and when the door opened, the Wander Guard alarmed. 3. Resident #2 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of [DATE] documented the resident scored 4 (,[DATE] indicates severe impairment) on a Brief Interview for Mental Status (BIMS), required limited assistance from one person for transfers, and did not exhibit wandering as a behavior. a. An Elopement Risk assessment dated [DATE] documented, .Less than 5 (equals) Low risk for Elopement (address risk factors) . Between 5 to 10 (equals) High risk for Elopement (Initiate Standard Care Plan) . Total Score . 5 . b. The Care Plan dated [DATE] documented, .Problem . Potential for exit seeking behavior (Elopement) . Be alert to verbal and non-verbal signs of resident wanting to leave the building . Wander Guard Bracelet in use . Checked Q (every) shift and PRN (as needed), and secure environment . Distraction / redirection for confused residents . c. The TAR dated [DATE] documented, .Wander Guard Bracelet . Frequency . NUR (Nursing) . Every Shift . Check placement . 03:00 (3:00 a.m.) .11:00 (11:00 a.m.) . 19:00 (7:00 p.m.) . Licensed Nursing Staff signatures were present at 3:00 a.m., 11:00 a.m. and 7:00 p.m. from [DATE] through 3:00 a.m. on [DATE] indicating the resident ' s Wander Guard bracelet was present. d. The TAR dated [DATE] documented, .Wander Guard Battery (Check) Frequency . Nur (Nursing) . Daily Night . Wander Guard battery to be checked nightly on ,[DATE] (11:00 p.m. to 7:00 a.m. shift) . 03:00 (3:00 a.m.) . According to the documentation, Licensed Nursing Staff signatures were present at 3:00 a.m. [DATE] through [DATE] indicating the resident ' s Wander Guard battery was checked and functional. e. On [DATE] at 3:27 p.m., Resident #2 was sitting in wheelchair in her room at the side of her bed. A Wander Guard bracelet was on the resident ' s left ankle. The ADON took the Wander Guard tester and held it against the bracelet. The tester display did not turn green, which would indicate the bracelet was functioning properly. The ADON attempted a second time and the tester did not turn green. The date on the side of the Wander Guard bracelet was [DATE]. The ADON assisted the resident in her wheelchair to the exit door at the end of the hallway. The ADON opened the door. The door did not alarm. The ADON assisted the resident back to her room. When exiting the resident's room, the ADON asked a nurse to bring her a new Wander Guard bracelet and a new bracelet was placed on the resident. 4. Resident #3 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of [DATE] documented the resident scored 12 (,[DATE] indicates moderately impaired) on a BIMS, was independent for locomotion off the unit, and did not exhibit wandering behavior. a. An Elopement Risk assessment dated [DATE] documented, .Less than 5 (equals) Low risk for Elopement (address risk factors) . Between 5 to 10 (equals) High risk for Elopement) . Total score . 7 . b. The Care Plan dated [DATE] documented, .Problem . Elopement Risk . Approaches . Involve resident in activities . Make sure resident is accompanied when leaving unit . Wander Guard . Check placement and function Q (every) shift . Wander Guard present to prevent exit from building . c. The TAR dated [DATE] documented, .Wander Guard Battery (check) Frequency . Nur (Nursing) . Daily Night . Wander Guard battery to be checked nightly on ,[DATE] (11:00 p.m. to 7:00 a.m. shift) . 03:00 (3:00 a.m.) . Licensed Nursing Staff signatures were present at 3:00 a.m. from [DATE] through [DATE] indicating the resident ' s battery was checked and functional. d. The TAR dated [DATE] documented, .Wander Guard Bracelet . Frequency . NUR (Nursing) . Every Shift . Check placement . 03:00 3:00 a.m.) . 11:00 (11:00 a.m.) . 19:00 (7:00 p.m.) . Licensed Nursing Staff signatures were present at 3:00 a.m., 11:00 a.m. and 7:00 p.m. from [DATE] through 3:00 a.m. on [DATE] indicating the resident ' s Wander Guard bracelet was present. e. On [DATE] at 3:30 p.m., the resident was sitting on the side of the bed. The ADON entered the resident's room with the Elopement Tester to test functionality of the Wander Guard bracelet. The ADON asked the resident where her bracelet was. The resident stated that she did not have a bracelet. The ADON checked the resident's ankles and wrists, but no bracelet was found. When exiting the resident's room, the ADON asked a Nurse at the Medication Cart to apply a Wander Guard bracelet to the resident. 5. On [DATE] at 10:00 a.m., the Maintenance Director was asked which door the resident eloped from. He stated, I didn't know there was an elopement. He was asked if he had been told to check the functioning of all the doors. He stated, No. He was asked to provide a copy of his documentation that showed where he did his routine door checks for the Departure Alert System. He stated, I don't have a log. I don't routinely check the functioning of the Wander Guard system. a. On [DATE] at 10:43 a.m., the Director of Nursing (DON) was asked where (Resident #1) was found when she eloped. She took the surveyor to the back of the building on the F Hall, next to the Therapy Room. She was asked how the resident got out of the building. She stated, The alarm did not sound. She was asked why it didn't sound. She stated, I checked her bracelet with the tester and the battery in the bracelet was dead. We immediately replaced it. She was asked how long the resident was outside. She stated, About 15 minutes. At this time, we went to watch the video footage of the resident leaving the building. It showed the resident exited the door next to the Therapy Room on [DATE] at 3:19 p.m. in her wheelchair. She propelled herself out of the camera view and was out of view for approximately 15 minutes. She eventually propelled herself back into view of the camera and was found by the Director of Nursing (DON) and Assistant Director of Nursing (ADON) at 3:55 p.m. The DON and ADON were in a car and were driving next door when they saw the resident outside, according to the DON. According to the video, the resident was outside unattended for approximately 36 minutes. b. On [DATE] at 12:00 p.m., the ADON was asked what type of Wander Guard bracelets the facility used. She stated, We use the 90-Day bracelets. When it is activated, it starts counting down, and at the end of that 90 days, it's done. It doesn't work anymore. She was asked if it had a battery inside it that could be changed. She stated, Not that I know of. She was asked if she had ever had one go dead before the 90 days was up. She stated, Not that I'm aware of, and I've been here about [AGE] years. She was asked if the facility had a log that documented when each bracelet was activated so they would know when it is at the end of the 90 days and needs to be replaced. She stated, There is no log. We can start keeping up with one now, but I can't produce a log that shows when a resident's bracelet was activated. She was asked since (Resident #1's) bracelet didn't work on [DATE] which allowed her to exit the building, if it was safe to say the bracelet had expired at some point. She stated, Probably. She was asked if the resident's bracelet was available for inspection. She stated, No. c. On [DATE] at 1:57 p.m., Certified Nursing Assistant (CNA) #1, who had been employed for 3 months, was documenting in the Kiosk. She was asked if she could show the surveyor the CNA Care Plan in the kiosk for (Resident #4) in order to see if the resident was at risk for elopement and wore a Wander Guard bracelet. She stated, I have only been here three months. I only know how to chart what I do for the residents. I do not know anything about the Care Plan. She was asked if she knew which residents were at risk for elopement. She stated, I do not understand what elopement means. She was asked if she could tell the surveyor which residents wore Wander Guard bracelets. She stated, I do not know. I did wonder what the bracelets were for, but no one has told me. d. On [DATE] at 2:00 p.m., CNA #2 was asked if she could show the surveyor the CNA Care Plan in the kiosk for (Resident #4) that would tell her if the resident was at risk for elopement and wore a Wander Guard bracelet. She stated, I know that it's in the kiosk, but I do not know where to find it. The CNA signed into the kiosk but was not able to find the resident's Care Plan. CNA #2 stated, The nurse gives us a Care List at the beginning of the shift that tells us all that information. The CNA had a Care List in her pocket which she shared with the surveyor. Elopement risk was not addressed on the Care List. She was asked how she knew which residents were at risk for elopement. She stated, There is a ' B ' in the Star Sign outside a resident's door. I also know if I see a bracelet on a resident's wrist or ankle. e. On [DATE] at 2:05 p.m., Licensed Practical Nurse (LPN) #1 was asked how CNAs knew which residents were at risk for elopement. She stated, I tell them. If a resident goes out of a door or has a bracelet, I let them know. I give each CNA a Care Sheet at the beginning of the shift. LPN #1 provided a Care Sheet for review. It did not address elopement. She was asked if elopement information could be found on the CNA Care Plan in the kiosk. She stated, Yes, but I do not know where to look on the computer. You will have to ask the Education Nurse. She could tell you. f. On [DATE] at 3:18 p.m., the DON was asked for a copy of the Incident Report for the elopement. She stated, An I/A (Incident / Accident) wasn't done. She was asked if the facility did a Reportable Incident Form. She stated, A Reportable? I can do one, but in all my years of working here, I have never been told that a Reportable has to be done for an elopement. She was asked what interventions were implemented to prevent reoccurrences after the elopement. She stated, We have kept her in line of sight and kept her engaged in activities. She was asked if any interventions were implemented for other residents in the building who were at risk for elopement. She stated, I took the tester and scanned their bracelets to make sure they were working. She was asked how she knew who to check. She stated, I checked the ones I could think of off the top of my head. She was asked if the facility had something like an Elopement Book that had all the residents who were at risk for elopement so the staff could see who was at risk. She stated, No. She was asked how the CNAs knew which residents were at risk. She stated, It is on the CNA Care Plan in the kiosk. g. On [DATE] at 1:50 p.m., the DON was asked what the letter B meant that was outside a resident's door. She stated, B bed. The bed by the door is ' A ' and by the window is ' B ' . h. On [DATE] at 3:49 p.m., LPN #2, who was on duty at the time of the elopement on [DATE], was asked if an Incident Report was completed. She stated, No ma'am. She was asked if the family or physician was notified of the elopement. She stated, No ma'am. They weren't notified by me. I was unaware to call the family. I've been a nurse for like a month. But now I know. I did do a behavior note. She was asked about the date that was printed on the Wander Guard bracelets and what the date meant. She stated, That's the date it's no longer any good. It needs to be replaced. She was asked who was responsible for checking that. She stated, They just put a new in-service out over the weekend. Up until then, the night shift nurse was responsible for checking those. i. On ,[DATE] at 3:58 p.m., LPN #3 was asked how she checked the resident's Wander Guard bracelets. She stated, Sometime during the night if I have the machine, I go around and check them. If it shows green, they're good, and if it shows yellow, that tells me they're going dead. She was asked if she remembered checking (Resident #1's) bracelet the night before she eloped. She stated, I don't remember. I mean, I'm sorry. From week-to-week I can't remember. Sometimes I do miss some. That may be because I don't have the machine, or something has happened where I forget about them. 6. The manufacturer's guidelines for the Wander Guard Signaling Device provided by the Assistant Director of Nursing (ADON) on [DATE] at 12:00 p.m. documented, .Before using the Wander Guard system, read and follow these instructions carefully . Failure to do so could result in injury or death to a person in your care . 90-Day Device . Date Stamped . Shows the 'activate by' date . The stamped date indicates the LAST date the device can be activated to permit approximately 90-Days of use . Note . The date on the back of the device This is the last day the device can be activated to provide approximately 90-Days of useful life . Record the date in the resident's records . Testing your Wander Guard System Correctly . Testing Doors . Test your Wander Guard Systems at least weekly on each shift with all surrounding power devices turned on . Record results in your maintenance records . 7. The Immediate Jeopardy was removed, and the scope / severity lowered to E when the facility implemented the following Plan of Removal on [DATE] at 6:00 p.m.: a.Effective date . [DATE] . Completion date . [DATE] . The above listed residents were checked to ensure that they have orders to check placement every shift and battery checked every day on night shift. Any negative findings were immediately corrected . Completed by DON . b. Effective date . [DATE] . Completion date . [DATE] . All of the above listed residents ' bracelets have been checked to ensure that they were within date and not expired . Any bracelets that were out of date were immediately changed . Completed by (RN Supervisor) . c.Effective date . [DATE] . Completion date . [DATE] . Elopement Risk Assessment is being completed on all residents to ensure that all residents that require a Wander Guard bracelet have one in place . Completed by . (MDS / Care Plan Coordinator) . d.Effective date . [DATE] . Maintenance will check Wander Guard Alert System on all doors weekly and after each elopement attempt . Initial check completed [DATE] . Ongoing process . Completed by . (Maintenance Director) . e.Effective [DATE] . DON / Designee will check 2 random residents 3 times weekly for 8 weeks checking for bracelet placement, proper operation . Any negative findings are to be corrected immediately . All findings will be reported to QAA (Quality Assessment and Assurance) weekly for review . f.Effective [DATE] . Completion date . [DATE] (Cue Shift Representative) added to the Wander Guard order the following questions . Did resident require a new bracelet? .Yes or No . If answer is ' Yes ' , the following questions will follow . Date bracelet placed and date of activation on the device . g.Effective [DATE] . ADON (Assistant Director of Nursing) will have Excel spread sheet with Resident Name, Room Number, Activation Date by Stamped on Wander Guard, Date Put in Use, Nurse Signing Out Wander Guard, Date Listed for 90 Days from Placement for Re-check and / or Replacement . Completion date . Ongoing . h. Effective [DATE] . All staff will be in-serviced on use of Wander Guard System (Bracelets, Activation, Manufacturing Guidelines) . Staff will be in-serviced prior to their next shift . Any staff not present will be in-serviced prior to their providing care on the floor . Completed by . (Medical Records Supervisor) . i. All negative findings will be forwarded to the QA&A (Quality Assessment and Assurance) Committee .

Complaint # (AR 165) was substantiated, all or in part, with these findings: Based on observation, record review, and interview, the facility failed to ensure the transport van's wheelchair restraints were securely and properly applied per the manufacturer's instructions prior to residents being transported in the facility van to prevent serious potential injury; failed to ensure transport staff called for assistance after a resident fell to the floor in the van during transport to have the resident assessed before moving and to assist the resident off of the van floor prior to continuing the transport to prevent potentially exacerbating any existing injuries; failed to ensure wheelchair restraint manufacturer's instructions were readily available and that all transport staff members were trained on them to ensure resident safety; and failed to ensure the incident in which a resident fell to the floor of the van during transport was evaluated for causative factors to facilitate the ability to determine if the incident was due to staff or equipment failure and facilitate the ability to implement corrective actions to prevent potential recurrence for 1 (Resident #1) of 4 (Residents #1, #2, #3 and #5) case mix residents who required a wheelchair during transport in the facility van. The failed practices resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury or death to Resident #1, who was positioned incorrectly in a wheelchair on the van, fell from her wheelchair during transport and was transported back to the facility on the van floor, and had the potential to cause more than minimal harm to 25 residents who were transported via wheelchair in the facility van from 8/30/18 through 10/25/18, as documented on a list provided by the Administrator on 10/25/18 at 6:50 p.m. The Administrator was informed of the Immediate Jeopardy on 10/25/18 at 5:50 p.m. The findings are: Resident #1 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an Assessment Reference Date of 10/2/18 documented the resident scored 13 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status, was totally dependent for transfer per 2 people, was not steady, only able to stabilize with staff assistance for surface to surface transfer, used a wheelchair, had no falls since admission, and received [MEDICAL TREATMENT] treatment while a resident. a. A physician's orders [REDACTED].Resident to receive [MEDICAL TREATMENT] on Tuesday, Thursday, and Saturday (at) 1605 (4:05 p.m.) . b. A Care Plan dated 7/3/18 documented, .Disease Process / [MEDICAL CONDITION] with left sided [MEDICAL CONDITION] and requires staff assist when having ADLs (activities of daily living) . Resident requires transfers via mech (mechanical) lift with (times) 2 (person) assist (assistance) as well as toileting bed (mobility) and bathing .Potential for complications related to [MEDICAL TREATMENT] for [DIAGNOSES REDACTED]. Make transportation arrangements for [MEDICAL TREATMENT] .To receive [MEDICAL TREATMENT] on Tuesday, Thursday and Saturday at 1605 (4:05 p.m.) . c. A Care Plan with a revised date of 8/30/18 at 2044 (8:44 p.m.) documented, .R (resident) slid out of w/c (wheelchair) as a result of CNA (Certified Nursing Assistant) driver slowing down on brakes. R (Resident) sitting on floor of van in front of her w/c (wheelchair). R (Resident) stated she was not in pain (and) that she did not hit her head. CNA agreed. R (Resident) able to move extrem (extremities) . When R (Resident) was sliding, CNA assisted R (Resident) to sitting position. Therapy assessing w/c (wheelchair) positioning . d. A facility form titled 72 Hour Acute Charting dated 8/31/18 at 20:44 (8:44 p.m.) documented, .Informed by CNA (Certified Nursing Assistant) via telephone while on the way back from [MEDICAL TREATMENT] center, that R (Resident) slid out of wheelchair as a result of CNA driver slowing down on the brakes. I went outside to transport van and I saw R sitting on the floor of the van in front of her wheelchair. R stated that she was not in pain. R stated that she did not hit her head. Both CNAs agreed and stated R did not hit her head. R able to move extremities without pain noted. O (No) visible injuries . e. A facility Fall Screen dated 9/5/18 documented, .Resident has an underlying health issue that can cause falls . slid out of w/c (wheelchair) in the van .Recommendations . assess w/c (wheelchair) . f. The manufacturer's instructions for the van's wheelchair restraints, received from the DON on 10/25/18 at 12:55 p.m., documented, .A. Secure Wheelchair .1. Place wheelchair facing forward in securement area . apply wheel locks or turn power off . 2. Attach tie-downs into floor anchorages and ensure they are locked in . 3. Attach the four tie-down hooks to solid frame members or weldments, near seat level . Ensure tie-downs are fixed at approximately 45 degrees, and are within angles shown in (fig 2) . Do not attach hooks to wheels, plastic, or removable parts of wheelchair . 4. Ensure all tie-downs are locked and properly tensioned . If necessary, rock wheelchair back and forth or manually tension retractor knobs (if present) to take up additional webbing slack . B. Secure Passenger . 1. Attach Lap Belts . use integrated stiffeners to feed belts through openings between seat backs and bottoms, and / or armrests to ensure proper belt fit around occupant . a. On the aisle side, attach belt with female buckle to rear tie-down pin connector . ensuring buckle rests on passenger's hip . b. On the window side, attach belt with male tongue to rear tie-down pin connector and insert into female buckle . 2. Attach Shoulder Belt . Extend shoulder belt over passenger's shoulder and across upper torso and fasten pin connector onto lap belt . 3. Ensure belts are adjusted as firmly as possible, but consistent with user comfort . g. On 10/25/18 at 1:26 p.m., CNA #1 and CNA #2 transferred the resident from bed into a locked wheelchair at the end of the bed. At 1:35 p.m., CNA #3 and CNA #4 entered the room, attached the lift pad to the lift, and repositioned resident in the wheelchair. The resident was covered with a blanket. At 2:02 p.m., CNA #3 and CNA #4 placed the resident onto the facility van. The resident was placed backwards onto the ramp of the lift that had been lowered. The brakes of the wheelchair were locked. The lift of the van was raised, and the resident was rolled from the ramp of the lift into the van facing forward. The wheelchair was locked. The two tie downs behind the wheelchair attached to the anchorages were crossed and hooked to the frame of the wheelchair under the seat. The front tie down straps were hooked to the frame of the wheelchair. The shoulder harness strap was placed over the resident's left shoulder, placed under the left arm rest of the wheelchair across the resident's abdomen, under the right arm rest of the wheelchair, and secured into the floor ratchet / anchorage behind the right wheel of the wheelchair. A lap belt was not observed. There was no lap belt present. CNA #3 stated they were ready to leave. CNA #3, CNA #4 and the Director of Nursing (DON) who had entered the van, were asked where the lap belt was, and if the shoulder harness was positioned correctly to secure the resident. CNA #3 and CNA #4 stated they had never used, or had been trained to use a lap belt. This was how they were trained to use the shoulder harness, and this is how they usually transport the resident to [MEDICAL TREATMENT]. The two surveyors present on the van expressed concern of a lap belt not being used, and the shoulder harness not being placed correctly to secure the resident. The Administrator, now on the van, and the DON reviewed the manufacturer's guidelines and stated the pictures do not illustrate a lap belt, only a shoulder harness. The resident's legs remained elevated. The resident was transported to [MEDICAL TREATMENT]. Per the manufacturer's instructions at paragraph f., above, a lap belt should have been applied. h. On 10/25/18 at 12:15 p.m., the surveyors used a mileage calculator to determine the distance to the facility, from the location where the van incident occurred on 8/31/18. The distance was approximately 6 miles. i. As of 10/25/18, the most recent documentation of training on resident van transports or van restraints was a Summary of Meeting Minutes, provided by the DON on 10/25/18, which documented, Lift Van Safety Meeting and Demo (Demonstration) was conducted on 8/24/18. j. On 10/25/18 at 2:58 p.m., CNA #5 stated, I have been trained to drive the van by (CNA #4). All the Big Heads were there at the time of the training, but (CNA #4) did the training. The CNA was asked who the, Big Heads were and stated, The Administrator and the DON. We observed (CNA #4) secure the wheelchair in the van, but we did not actually tie someone down. The training was a few months ago during the summer. I was driving the van on the day of the incident with (Resident #1). The resident was in her wheelchair when we picked her up from [MEDICAL TREATMENT]. The resident's legs are always elevated when she is on the van. We put the resident onto the van. The resident was facing towards the front. We strapped the resident in. We used the lift mechanism to put the resident onto the van. We secured all four legs of the wheelchair down. We placed the back straps on the cross bar of the wheelchair under the seat. On the front of the wheelchair, we placed the straps on the frame of the wheelchair. The straps were on something below the wheelchair. We then got her seatbelt. It came across and was put under the armrest of the wheelchair. I placed the belt over her left shoulder, and then put it under the left arm rest of the wheelchair. I then put it under the right armrest of the wheelchair and hooked it near the back wheel. I drove the van. The resident slipped from her wheelchair right where we entered I-530 (Interstate 530). (CNA #6), the other CNA, then told me that the resident had slid out of her chair. I had (CNA #6) ask her if she was hurting, and then put in a phone call to the facility immediately. It was just the two of us. We could not pick her (the resident) up. The resident was sitting in front of her wheelchair on the floor. The resident came completely out of the wheelchair. The resident had come out underneath the strap. There is supposed to be a strap across her lap. I was trained to use just the one belt, and it went around the waist. I spoke to (Licensed Practical Nurse (LPN) #1) at the facility. I was trained to tighten the straps by pulling on the release button to make sure that there is no slack in the straps. It took 4 of us to get the resident up from the floor of the van. We put a gait belt around the resident, and we also got a lift pad. It took several people to lift her back up into her chair. It was (CNA #6) that called the facility. We were told to come back to the facility. (LPN #1) wanted to make sure that the resident was fine. We were told to come back to the facility. Since the incident, I was counseled by the Administrator on the proper use of the van. I have driven the van since the incident. It's been about two weeks ago when I last drove the van. The CNA was asked if any training had been provided on what the transport staff were to do if there was an incident on the van during resident transports and stated, It is possible that I was trained on what to do if there is an accident on the van; I do not remember. Generally, there are two people on the van when we are transporting residents. k. On 10/25/18 at 3:19 p.m., CNA #6 stated, I was on the van on the evening that (Resident #1) had the incident and fell from her wheelchair. I have not been trained on tying the resident on the van. The night of the incident, I attached the back wheel straps and the shoulder strap. I went under the left arm of the wheelchair and the right arm of the wheelchair with the shoulder strap, and tied it to the floor. When we arrived at the [MEDICAL TREATMENT] center, the resident was in her wheelchair. We used the lift pad under her and positioned her correctly in the wheelchair. The resident always rides with her feet elevated. The shoulder strap went across her upper section, underneath her boobs, not on the shoulder. That was my 3rd or 4th time of helping on the van. I was trained to put the strap under the arms of the wheelchair and back through the other arm rest so that I am also strapping down the wheelchair. I have never been given a copy of any paper work on how the straps should be. We were coming onto the on-ramp of the freeway by the mall when the resident fell . There is a lot of construction there. (CNA #5) slowed down and the resident began sliding. I tried to grab her around the shoulders, and she continued to slide. We called the supervisor at the facility, and she told us to come back to the facility. Several people helped to get her (the resident) out of the van. The resident slid to the floor and was sitting in front of the wheelchair. The legs of the wheelchair went down, and she sat on the floor. I was sitting right next to the resident on the floor. I asked the resident if she was hurt. She told me, 'No, but it is uncomfortable down here'. l. On 10/25/18 at 3:32 p.m., LPN #1 stated, I was here on the night when (Resident #1) fell on the van. I was passing medication. (CNA #6), one of the CNAs on the van, called me between 8:30 (p.m.) and 9:00 p.m. to let me know about the incident. I asked what had happened. She said (CNA #5), the driver, slowed down coming off the freeway. The resident slid down out of her wheelchair onto the floor. I asked if she was strapped down and (CNA #6) said, 'Yes'. I went outside to assess the resident when she arrived at the facility. The resident was on the floor of the van. Several of us went out to get the resident up into her wheelchair. The resident told me that she was not hurt. I called her family. The family questioned about how she was strapped. I called the DON after the resident returned to facility. She was going to let the Administrator know. I have never had specific training on what to do if there is an accident on the van. I followed protocol and did an Incident Report. Since the incident, I have not had any training on what to do if there is an accident on the van. The resident was fine during the remainder of the shift. The resident was sitting right in front of her wheelchair when she arrived at the facility. Based off of my own personal judgement, I felt it was okay to let her return to the facility. I did call the Doctor. I was more worried about if she was okay. I do not know the protocol of what to do if there is an accident on the van. m. On 10/25/18 at 3:43 p.m., the Maintenance Man stated, I have just what they printed out and gave to me for securing a resident on the van, and the training that (CNA #4) did with me. The Maintenance Supervisor did train us when I first came here, but he is no longer here. They only ever showed me the shoulder harness and how to put it under the arms of the wheelchair. I was never told about a lap belt. I was trained on securing the wheels with the ratchets. I have never read the manufacturer's guidelines (instructions). The main thing we do on the van is mess with the lifts. I have not done any training with staff about the van. (CNA #4) has done all of the training. n. On 10/25/18 at 3:49 p.m., the DON stated, I was trained in 2011 on how to secure a resident in the van during transport. I was also trained on using the lift, raising the resident up on the lift, hooking straps to the bottom of the wheelchair, and hooking the strap across the resident. I watched a video, and someone from (Transportation Company) came to train us. We do hands-on return demonstration for training. We do not use the video. (CNA #4) and the maintenance man do the training. They both do the return demonstration. I was notified on the night that (Resident #1) had the incident on the van. I was told that she had slid out of the wheelchair on her way back from [MEDICAL TREATMENT], and she did not have any injuries. I am not positive who called me. I told them to call the Doctor and the family. I told them to follow the instructions from the Doctor. I was notified after the incident was over. Staff are instructed to stop the van and to call immediately for instruction if there is an accident on the van. We have never had this happen before. I would not necessarily instruct the van drivers to return back to the facility. I would have someone go to assess them. I was aware after the incident that the nurse told them to drive back to the facility. I talked to the nurse and told her, that in the future, the resident needs to be assessed before they are moved. I do not have that in writing. I have not done any retraining with any other nurses on what to do. I have done retraining with (CNA #5) since the incident. I have not done any further retraining. As far as I knew from when I was trained, I thought the resident was secured correctly on the van today. I know now how to secure the resident from looking at the guidelines and pictures. I was never aware that (CNA #4) was not aware to secure the resident across the shoulder. We have only ever had one strap. We have never had a lap strap. I found out today about the lap strap. I did not know before today. o. On 10/25/18 at 4:30 p.m., CNA #4 stated, I was trained in (MONTH) 2011 how to secure a resident on the van. The van was new to us at that time. We watched the video that came with the van. We have not had any retraining since then. We have not had any retraining since the last incident. The CNA was asked if she trained transport staff on the van restraints and stated, Yes ma'am, I train the staff on the use of the restraint system. I show them how to start the van, open the door, how to open the lift, how to let the lift down, and how to let the lift up. I show them how to restrain the wheelchair. I do a return demonstration with them. I pull the seat belt over the resident, under the arm rest, across the stomach under the other arm rest and secure it to the lock in the back of the wheelchair onto the tie down. It hooks in the tie down. I have not had any training on the lap belt. The first thing to do if there is an accident on the van is to call the facility. If anything bad, call 911. But if anything happens, call the facility. I was not here on the night of the incident. I work 7:30 (a.m.) to 4:00 (p.m.) Monday thru Friday. p. On 10/25/18 at 4:44 p.m., CNA #3 stated, I have been assisting as a van driver for two years. I do drive the van. I was off duty when the incident happened with (Resident #1). (CNA #4) trained me on how to secure the residents on the van. I received training last year, and we had an in-service a couple of months ago. The in-service a couple of months ago was from (CNA #4) and the maintenance man. (Resident #1's) legs always remain elevated when she is on the van. I was trained to pull over and call the facility if there is an accident on the van. They will get someone out there. I have not received any training on how to secure a resident on the van since the incident. I was trained to secure the resident with the shoulder strap going under the arms of the wheelchair, and then to secure the strap behind the wheelchair. I have never received any documentation or pictures. I have never watched a video. I was trained on the shoulder harness. I was not trained on the lap belt. I have not seen a lap belt on the van. q. The immediate jeopardy was removed, and the scope and severity reduced to E on 10/25/18 at 8:33 p.m. when the facility implemented the following Plan of Removal: 1.) On 10/25/18, (Resident #1) will be transported back to the facility via ambulance which is being arranged by the DON. 2.) Effective immediately, the Maintenance Supervisor will train himself using the manufacturer's guideline manual, and will retrain the designated van drivers on following the manufacturer's guideline to secure wheelchairs on the facility van to ensure residents are properly secured. 3.) The Maintenance Supervisor will obtain further training on van safety at (technical assistance and training provider) on the first available class. 4.) When transporting residents on the facility van, the DON / Designee will monitor thru observation until compliance achieved to ensure residents' wheelchairs was (are) properly secured using the manufacturer's guidelines. 5.) While being transported, if the resident has an incident with no obvious injury or complaint of pain, call the facility nurse for further guidance. If the resident complains of pain with no deformity, go to the closest emergency room for evaluation. If there is an injury with obvious deformity, call 911. 6.) Any negative findings will be corrected immediately prior to transporting the resident. 7.) All negative findings will be reported to the Administrator / designee for further recommendations and corrective action. 8.) There were 16 residents who had the potential to be affected.

Complaint # (AR 483) was substantiated (all or in part) with these findings. Based on observation, record review and interview, the facility failed to ensure the mechanical lifts were used as planned to ensure safe transfer and to reduce the risk of injury for 1 (Resident #5) of 2 (Residents #1 and #5) case mix residents who were assessed to require a mechanical lift for transfer. The facility failed to ensure residents were accurately assessed regarding use of gait belt versus mechanical lift and that staff did not attempt to transfer non weight bearing resident with use of a gait belt to reduce the potential for injury for 1 (Resident #3) of 2 (Residents #2 and #3) case residents who were assessed for gait belt transfer. These failed practices resulted in Immediate Jeopardy which caused or could have caused serious harm, injury, or death to Resident #5 who had bilateral lower leg fractures after incorrect transfer and Resident #3 who was improperly transferred with a gait belt. The failed practices had the potential to cause more than minimal harm to 25 residents who were assessed for mechanical lift transfers and 6 residents who were assessed for two person gait belt assist transfers according to a list provided by the Director of Nursing (DON) on 8/6/15. The Administrator was informed of the Immediate Jeopardy on 8/5/15 at 5:05 p.m. The findings are: 1. Resident #5 had [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/1/15 documented the resident scored 11 (8 - 12 indicates moderate impairment) on a Brief Interview for Mental Status (BIMS), was totally dependent on 2 staff assistance for transfers, required one person assist for bathing, was not steady for surface to surface transfer, and had no falls. The Care Area assessment dated [DATE] documented, .Falls. (at) risk for falls. (Resident #5) needs total assistance x (times) 2 persons for transfers via mech (mechanical) lift. Non-ambulatory. a. A physician's orders [REDACTED]. b. The Fall Risk assessment dated [DATE] documented the resident scored 13. A score above 10 equaled high risk. c. The Care Plan dated 7/6/15 documented, Problem:.HX (history) of falls with fx of vertebra and ribs.total assist with transfers.Falls:.has hx of falls with fx (fracture) vertebra and ribs. Dx (diagnosis) Osteoporosis.Approaches: She is not able to stand or transfer alone, total assist of two using the lift.Report falls to physician and responsible party.7/23/15 fall (with) major injury.X-ray bil (bilateral) hip bil femur (and) bil tib & fib (tibia and fibula) stat d/t (due to) fall. (Resident) (complaint of) severe pain.Send (Resident) to ER (emergency room ) for eval (evaluation) r/t (related to) fall. d. Nurse Notes dated 7/23/15 at 8:00 a.m. documented, Reported by CNA (certified nursing assistant) (CNA #1) (Resident).stumbled into the lower position. CNA #1 stated that her (and) CNA #2 got (Resident #5) off of the shower chair (and) CNA #2 reported that when she stumbled to the floor. (Resident) is also a via Hoyer lift 2 person assist. CNA #1 and CNA #2 reported that when she stumbled her legs buckled (and) they hurried up (and) took her to the bed via gait belt. I then went to resident room (and) observed the two lower extremities (and) knees because CNA #1 stated that resident was now complaining of knees hurting. There was slight swelling at that time. 0830 (8:30 a.m.) (Resident) was medicated with PRN (as needed) Tylenol 650 mg (milligrams). (At) 12 noon CNA #1 called me back to the room to look at her legs again. They were black (and) blue. (Resident) medicated with Tramadol 50 mg. X-ray came to X-ray legs. Now awaiting X-ray results per MD (Medical Doctor) order. Nurse's Note dated 7/23/15 documented, Late entry 1200 (12:00 p.m.) Approx (approximately) 12 N (12:00 p.m.) (Licensed Practical Nurse (LPN) #2) notified this nurse to come assess (Resident) r/t (related to) incident that happened. This nurse assessed (Resident) to find that BLE (bilateral lower extremities) were black/blue from the knee down and (Resident) (complained of) pain to (left) leg upon assessment. Notified DON (Director of Nursing) (and) Administrator of what I knew r/t incident and asked DON to come assess (Resident). DON informed this nurse to inform LPN charge nurse to get v/s (vital signs), medicate for pain and call MD for further orders and that she would be in to assess her. LPN notified of the above. e. A 72 Hour Acute Charting form dated 7/23/15 at 12:00 p.m. documented, (CNA #1) reported that she (and) another CNA transfer (resident) without Mech lift to (and) from shower chair. (Resident) lost her balance falling to the floor. CNA amb (ambulated) (resident) to bed. (Resident) has bil (lower) extrs (extremities) purple (and) red. (Resident) (complaint of) severe pain to left (lower) ext. (decreased) sensation in ft (foot). (Resident) assessed by DON (Resident's physician) called N.O. (new order) give to do X-ray. f. Nurse's Note dated 7/23/15 at 2:23 p.m. documented, Late entry - New order was received by (resident's physician). X-ray bil hip, bil femur (and) bil tib fib stat d/t (due to) fall (and) (Resident) (complaint of) severe pain. Nurse's Note dated 7/23/15 (not timed) documented, Tramadol 50 mg given out the ER box at 1430 (2:30 p.m.) for pain.1600 (4:00 p.m.).Order received from (resident's physician) to send to (hospital) ER for eval.1630 (4:30 p.m.) Resident transported via amb (ambulance) via stretcher to hospital. g. A Radiology report dated 7/23/15 and faxed to the facility on [DATE] at 4:37 p.m. documented, There is mild osteoporosis. There are acute mildly angulated fractures proximal tibia and fibula. There are modest degenerative changes (to) knee. h. The Emergency Department note dated 7/23/15 at 5:18 p.m. documented, Pt (patient) sent from NH (nursing home) after being dropped during transfer and has a broken knee. Pt not sure which knee is broken, but family states maybe both. Pt denies pain currently. Pt only fell on legs, pt did not hit head.bruised LE (lower extremities) from knees down with some weeping of blood.Final Diagnosis: [REDACTED]. i. Staff interviews/statements regarding the incident: 1) A statement signed by CNA #2 (no date/time) documented, I, (CNA #2), came to (Resident #5) room to assist (CNA #1) with getting (Resident #5) off the shower chair to the bed. While pulling up her brief (Resident #5) legs began to buckle up under her and we assisted (Resident #5) with the gait belt back to the bed from shower chair. 2) A statement signed by CNA #1 (no date/time) documented, (Resident #5) was in shower chair. (CNA #2) was assisting me to get her out of chair put gait belt on her raised her up to pull up brief her legs buckled up under her and we hurried up and put her in bed her feet was shuffling. An attached statement signed by CNA #1 and dated 8/4/15 documented, At breakfast time I reported to nurse that (Resident #5) legs buckled under her when we was trying to stand her up with the gait belt and pull her brief up from the shower chair while we were trying to pull brief up her knees buckled down under her she said ooh my legs hurt we tried to get her on bed quickly her feet was shuffling when we were trying to turn her (pivot) to bed. We got her in bed. I went directly to nurse she was passing meds I called her to side she was fixing to give (another resident) med told her what happened with (Resident #5) told nurse (Resident #5) said her legs was really hurting and that her legs was turning color she said she haven't stood on her legs in a long time. That's why they hurting nurse said that's part of her disease I told nurse several times after that that she said her legs were still hurting the nurse in training with her brought some Tylenol I told her to look at her legs they turning color she said that's part of her disease I went back later told nurse again she said they still hurting she said she had some medicine and that they'll look at her legs in a few. I went and finished doing friend care and went back to desk (LPN #2) was up there I told nurse again about her legs turning color she said O.K. We gonna let (LPN #2) go look at them and they went and checked on her. I helped with lunch was feeding (another resident) Nurse in training said you and (CNA #2) have to write witness statement of what happened. 3) On 8/5/15 at 2:55 p.m., LPN #1 was asked about the incident with Resident #5. LPN #1 stated, It was a little after 8:00 (a.m.), there were no changes to her legs after the CNA said her knees buckled. About an hour later, I checked on the resident. There were no changes. About lunch time, her legs looked different. I got help, the DON. That's when we called the doctor and got an X-ray order. 4) On 8/5/15 at 3:00 p.m., LPN #2 was asked about the incident with Resident #5. She accompanied the surveyor to the room previously occupied by the resident. There was a shower in the bathroom in the resident room. LPN #2 stated, They (the CNAs) used the shower chair with wheels for her shower. About 12:00 noon, (LPN #1) got me. I assessed the resident and called the doctor and got the order for X-rays. I talked to (CNA #1) about the mechanical lift. When asked if the aides knew to use the mechanical lift, LPN #2 stated, Yes. The lift pad was in her wheelchair (in the room). She (the aide) was aware. j. On 8/4/15 at 2:53 p.m. the DON provided a facility form titled 'Documentation of Employee Conference' dated 7/23/15 at 1:30 p.m. documented, (CNA #2).(Resident #5) sustained bil tib/fibula Fx from CNA not using mechanical lift (and) attempting a 2 person transfer thus resident had a fall (and) sustained injuries.Employee resigned 7/31/15. On 8/4/15 at 2:54 p.m. the DON provided a facility form titled 'Documentation of Employee Conference' dated 7/23/15 at 1:30 p.m. documented, (CNA #1).(Resident #5) sustained bil tib/fibula Fx from CNA not using mechanical lift (and) attempting a 2 person transfer thus resident had a fall (and) sustained injuries. A section to document employee's statement documented, I didn't mean to hurt her.said she didn't think.Employee resigned 7/28/15. k. A facility training form dated 7/23/15 (no time) documented, It is the CNAs responsibility to read the CNA plan of care for each resident on your assignment. You are responsible for the safety of each resident in your care. Do not transfer someone who is a mechanical lift without two persons. The CNA Plan of Care is Not the ADL flowsheet. The sign-in sheet documented 42 CNA signatures. The same facility training was documented on 7/23/15 for the nursing department. The sign-in sheet documented 2 RN (Registered Nurse) signatures and 15 LPN signatures. A facility form titled 'New assignment sheets (with) assist for transfers' dated 8/4/15 documented every resident's name and next to each name was the resident's transfer assist needs/requirements. A facility training form dated 8/4/15 documented, Attention: Licensed Nurses and CNAs.It is imperative.you read each.plan of care and know how to safely take care of them (residents). If another CNA or nurse asks for assistance you must make sure that you know what the (resident's) needs are and we must keep them safe.Never do any action that is unsafe and do not take shortcuts.The more you know about each of our (residents) the better care you can deliver.If any resident has a change in their condition you must report it immediately to your charge nurse. The sign-in sheet documented 26 CNA signatures, 2 RN signatures and 11 LPN signatures. l. On 8/5/15 at 9:10 a.m., the DON provided a list of residents with method of transfer that was printed on 7/24/15 at 12:45 p.m. It was attached to a hand written note dated 7/24/15. The note documented, 1 mesh (at) St (station) 2 clean linen, 0 in laundry, 1 mesh to dirty linen, 1 mesh (at) St 2 in box.ordered 2 shower chairs.15 full body slings in fac (facility), 5 mesh sling in fac, ordered 2 mesh (and) 4 solid slings.as of 8/4/15 have 19 full body slings 7 mesh slings. m. On 8/5/15 at 3:05 p.m., the DON was asked about LPN #1 observing the resident at 8:00 a.m. The DON stated, She should have assessed and called the doctor when it happened. She didn't understand it was a fall not a stumble. 2. Resident #3 had [DIAGNOSES REDACTED]. The Quarterly MDS with and ARD of 5/18/15 documented the resident scored 13 (13 - 15 indicates cognitively intact) on a BIMS, required extensive assistance of two persons for transfer and had one fall with no injury since the prior assessment. a. A physician's orders [REDACTED]. b. The Care Plan dated 5/20/15 documented, .Problem: Effects of recent CVA (Cerebrovascular Accident). Has muscle weakness and atrophy, abn (abnormal) gait. Lack of coord (coordination).Note: The assistance may vary day to day and shift to shift depending on how she feels if given the opportunity by staff.Approaches:.Provide only the amount of assistance/supervision that is needed.weight bearing.Falls: Problem date: 08/19/2014.not able to stand on her own at this time and has been noted to attempt to stand.Hx of recent fall without injury.two to aid in transfers. c. A Fall Risk Assessment form dated 6/25/15 documented the resident scored 13. A score above 10 equaled high risk. d. A Care Plan Face Sheet in the CNA care plan book with an Initial Completion Date of 6/20/14 and a Review Date of 7/21/15 documented, Transfers:.# (number) assist 2.CVA (left) side weakness, wt (weight) bearing partial, equipment: belt, fall risk. e. On 8/5/15 at 11:45 a.m., CNA #3 and CNA #4 applied a gait belt around the resident's waist. The wheelchair brakes were not locked. The CNAs pulled the resident up after a count of 3 and dragged her to the bed. The resident did not stand and pivot. Her knees were slightly bent and her toes dragged across the floor. CNA #3 pushed the wheelchair away from the bed with her foot during the transfer and it rolled away easily. f. On 8/5/15 at 3:46 p.m., the DON was informed of the incorrect gait belt transfer for Resident #3. The DON stated, They need to ensure the resident stands on one good foot before transfer. Need to lock wheelchair brakes. 3. On 8/5/15 at 3:03 p.m., the DON was asked if the residents had been assessed for method of transfer after the incident with Resident #5. The DON stated, We looked at everybody for transfer and appropriate equipment. Had mesh slings available for showers. When asked about the new assignment sheets with assist transfers, the DON stated, Yesterday (8/4/15) about 10:00 a.m., (Ombudsman) came to facility and went over the plan of action. First visited with (Ombudsman) on the 27th about the incident on the 23rd. Each aide that comes into work gets their section of the sheet for transfers and we'll add vital signs, etc. Another in-service was held 8/4 with (Ombudsman) meeting to read the resident's plan of care every day every shift. When asked who did the aide training, the DON stated, Physical Therapy Assistant (PTA) and (LPN #3). On 8/5/15 at 3:35 p.m., the PTA demonstrated how she taught the aides to transfer with a gait belt. She stated she instructed them no chicken wing, lock wheelchair and if cannot bear weight to use mechanical lift. 4. On 8/5/15 at 4:45 p.m., CNA #5, who had been employed approximately 6 months, was asked if she had been trained in the use of a mechanical lift and gait belt. She stated, Yes. When asked why you would use a mechanical lift instead of a gait belt, she stated, Those who can't do for themselves. When asked what about somebody who can't stand up, CNA #5 stated, Use a gait belt and 2 assist. On 8/5/15 at 4:52 p.m., the PTA was asked if she taught CNAs why the use of a mechanical lift versus a gait belt. She stated, Yes. I tell them about cognition and debility. 5. The Use of Gait Belt policy provided by the PTA on 8/5/15 at 3:35 p.m. documented, Gait belts are to be used at all times while assisting a resident in getting in/out of bed, on/off commode or walking in room or on the floor.WHY: Gait belts prevent injury of both the resident and the caregiver and promote safety in the facility. A checklist of skills was attached that included review of the policy, application of the belt and precautions for use, sit to stand and pivot transfers, two man transfer, ambulation, techniques to prevent falls, floor to stand transfer. 6. On 8/5/15 at 3:44 p.m., in-service training related to transfers was reviewed. A form dated 2/11/15 documented, Please be extremely careful with our frail elderly residents. They are fragile! Keep their safety a priority! Always use a gait belt and make sure you know if the resident is a one or two person transfer and if they require mechanical lift for transfers always use two staff persons. When you transfer a resident make sure their feet are on the floor. When you get them to a standing position they must be able to pivot (turn their feet) in order to get from one surface to another. If you have to twist their body and they are unable to turn their feet this would be an unsafe transfer and has the potential to cause injury to a resident. CNA #1, #3 and #4 had signed the sign-in form for the training. CNA #2 had a Gait Belt Policy and Training Record (check off) in her file dated 3/2/15. CNA #3 did not have a gait belt transfer check off in her file on 8/5/15. 7. The Immediate Jeopardy was removed with the following Plan of Removal received from the Administrator on 8/5/15 at 8:52 p.m.: Accident happened on 7/23/15 where a resident that was assessed as needing a mechanical lift for safety during transfers, was not transferred using a mechanical lift but was transferred by two CNAs using a gait belt instead causing the resident to fall and receive injury to both legs. On 7/24/15 we reviewed all of the residents that used a lift to ensure that we had enough equipment such as regular slings and mesh slings for bathing. On 7/24/15 more mesh slings were ordered. On 7/24/15 we began pricing additional Hoyer type lifts so the staff would not feel as rushed when transferring residents by mechanical lifts or would not be waiting on others to finish using the lift before they can use it. On 7/24/15 the Administrator, along with the Weekend RN (Registered Nurse) met with all of the Day Shift and the Evening Shift to go over the accident, reading the CNA Plan of Care for each resident prior to providing care, what can happen to our residents if we do not think before we attempt to provide care. This was carried out throughout the weekend by the Weekend RN. On 7/31/15 started in-servicing the CNAs on the proper use of the Hoyer Lift On 8/4/15 the DON created a form that is to be placed on top of the CNA plan of care so that we know by documentation that they have read the Plan of Care. On 8/4/15 the CNA assignment sheets only had the resident name and room number on them but we added a 1, 2 or lift behind each resident's name so that the safe transfer information would be right at the CNA fingertips. On 8/5/15 more slings were ordered for use with the Mechanical lifts. On 8/5/15 there was a resident transfer that was not done properly as observed by the State Surveyor. (Resident #3 was changed to mechanical lift on a list received from the DON dated 8/6/15). On 8/5/15 the DON and the Physical Therapist reassessed the resident that was improperly transferred earlier in the day with no negative findings. On 8/5/15 all residents are being reassessed for proper transfer methods to ensure their safety is being met. This is being done by the DON, ADON (Assistant Director of Nursing), Physical Therapist, and Administrative Nurses. On 8/5/15 CNA and LPN staff are being called to come to the facility for immediate training for proper use of a gait belt during any transfers and what can happen to any resident if we do not do this correctly. No CNA will work again until they have received this training and done return demonstration and can prove that they know how to do transfers of residents with a gait belt correctly. This training started with the Physical Therapist and Director of Nursing training all the administrative nurses, the social director (CNA) and transportation CNA. Every CNA will be monitored by DON and/or Designee 4 or more times during the next 8 weeks to ensure they are conducting proper transfers using gait belts.