**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, review of Resident Identifier (RI) #50's medical record and RI #52's medical record, the facility's policy titled Abuse, Neglect, and Exploitation, the Alabama Department of Public Health Online Incident Reporting System and the facility's investigation files, the facility failed to ensure RI #50 and RI #52 were free from abuse perpetrated by a visitor of the facility, who is also the spouse of a resident residing in the facility. On 2/11/2019, without the consent of RI #50, the visitor came up behind RI #50 and placed his hands down the shirt of the resident, while the resident sat in the Dining room. RI #50 stated he/she was scared and shocked by the incident. Due to the facility not implementing interventions to protect and/or prevent further abuse from occurring, on 4/29/2019, without the consent of RI #52, the visitor kissed RI #52 on the forehead and ran his hand down the resident's clothing from the left breast to the resident's pubic area. RI #52 was hitting and screaming at the visitor to stop. A staff member intervened and instructed the visitor he had to leave the facility immediately. RI #52 stated he/she cried as he/she felt violated. These deficient practices placed RI #50 and RI #52, two of 11 sampled residents reviewed for abuse and placed them in immediate jeopardy of serious injury, harm, impairment or death. On 7/26/2019 at 6:50 PM, the facility's Administrator, Director of Nursing (DON), Director of Clinical Services and [NAME] President of Senior Living were given the Immediate Jeopardy (IJ) template and notified of the findings of immediate jeopardy in the area of Freedom from Abuse, Neglect, and Exploitation, F600. Findings include: The facility's policy titled Abuse, Neglect, and Exploitation with an effective date of 11/2016 documented Introduction The resident has the right to be free from verbal, sexual, physical and mental abuse . Residents must not be subject to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the residents, family members or legal guardians, friends, or other individuals . Definitions Abuse Coordinator -Facility representative responsible for coordinating the policies and procedures for abuse, neglect and exploitation and evaluating how policies are operationalized. The facility's Abuse Coordinator is the Director of Nursing. Abuse means the willfull infliction of injury, unreasonable confinements, intimidation, or punishment with resulting physical harm, pain, or mental anguish . Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish . Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm . Sexual abuse includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault. Physical abuse includes, but is not limited to, hitting, slapping, pinching, and kicking . 1) RI #50 was admitted to the facility on [DATE]. RI #50's Annual Minimum Data Set (MDS) with an assessment reference date of 2/7/2019 indicated RI #50 was cognitively intact, with a Brief Interview for Mental Status (BIMS) of 14. According to the Alabama Department of Public Health Online Incident Reporting System on 2/14/2019 at 4:58 PM, the facility reported an allegation of sexual abuse that involved RI #50 and a visitor (another resident's spouse). The report documented the incident occurred on 2/11/2019 at 11:30 AM in which Unit Manager received a call at 3:44pm from resident's representative (RI #50's spouse), stating (RI #50) had contacted him one day this week, he was unsure of the day, and stated to him someone had put their hands down (his/her) shirt. (RI #50's spouse) stated he thought the incident happened on over the weekend but he wasn't sure and he was unsure of the time but it did happen during meal time . The actions taken by the facility were listed as . (RI #50's) sponsor could not return to the facility until we finish the investigation . Investigation begun results to follow. In an interview on 7/23/2019 at 5:11 PM, RI #50 was asked if she remembered the incident that happened in February (2019) when a someone touched him/her. RI #50 replied, yes he/she was in the dining room and a male came up behind him/her and put his hand under his/her shift. RI #50 stated he/she was shocked and when the male spoke, he/she knew it was not his/her spouse. RI #50 stated no one witnessed the incident and he/she returned to his/her room and called his/her spouse. When asked how that incident made RI #50 feel, the resident replied he/she was scared and shocked. 2) RI #52 was admitted to the facility on [DATE] with an admit diagnosis of Spastic Quadriplegic Cerebral Palsy. RI #52's Quarterly MDS with an assessment reference date of 5/2/2019 indicated RI #52 is moderately impaired in cognitive skills for daily decision making, with a BIMS of 11. According to the Alabama Department of Public Health Online Incident Reporting System on 4/29/2019 at 2:54 PM, the facility submitted an allegation of sexual abuse that involved RI #52 and a visitor (another resident's spouse). The report documented the incident occurred on 4/29/2019 at 12:55 PM, in which . (name) is the husband of a resident in the facility. (Name) was visiting his wife in the resident dining room. Staff member heard (RI #52) yell stop. Staff turned around and (visitor) had his hand on (RI #52) near (his/her) private area. the staff member instructed (visitor) he had to leave immediately. (RI #52) stated as (visitor) was leaving the dining room he came to (him/her) and kissed (him/her) head and ran his hand down (his/her) from (his/her) breast to (his/her) vagina . Contained within the facility's investigation file was a handwritten statement from Employee Identifier (EI) #32, a Licensed Practical Nurse (LPN) which documented 4/29/19 While serving plates in the dining room, I heard (RI #52) yelling Stop! When I turned around I saw (RI #-- spouse/visitor) with his (L) (left) arm across (RI #52's) chest, (RI #52) was trying to push him away and continued saying stop, don't do that. I asked (RI #52) what happened and (he/she) stated that (another resident's spouse/visitor) had run his hand from (his/her) (L) breast down to (his/her) private area. The CNA who was at the table stated that what (RI #52) said was true . In an interview on 7/13/2019 at 10:45 AM, RI #52 stated a man groped him/her in the dining room on 4/29/2019. RI #52 explained the male, who was the spouse of another resident, ran his hand down RI #52's breast and in between the resident's legs. When asked how did this make him/her feel, RI #52 replied, just awful that he/she told the male to stop and tried to push the man's arm away. RI #52 stated he/she almost cried when it happened because it made him/her feel violated. RI #52 further explained that it made him/her upset and angry. In an interview on 7/22/2019 at 4:20 PM, EI #2, the DON/Abuse Coordinator acknowledged after the February 2019 incident involving the visitor and RI #50, the visitor was allowed to continue to visit the facility. When asked if anything was done different, EI #2 replied, no the visitor continued to visit his spouse, a resident of the facility, in an open area, usually in the Dining room or lounge. ************************* On 7/28/2019, the facility submitted an acceptable removal plan which documented: On 7/27/19, all residents with behavior careplans were reviewed and updated. On 7/27/19, the company [NAME] President of Senior Living (VP) provided both the facility Executive Director (Administrator) and the facility Clinical Services Administrator (Director of Nursing) with in-service education regarding the facility's policy entitled Abuse, Neglect and Exploitation. On 7/27/19, the RN, NHA, Legal Nurse Consultant provided in-service education on abuse reporting and investigating to facility Executive Director, Director of Nursing and divisional staff. Divisional Staff will then provide in-service education to staff regarding the proper identification, reporting and investigation of abuse. This staff training began on 7/27/19. To ensure the protection of all residents, staff will immediately identify Abuse as the willful inflection of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. This also includes the deprivation by an individual including a caretaker of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental, or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, neglect, and mental abuse, including abuse facilitated or enabled, through the use of technology. Willful, as used by this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. In-service education will be completed by 7/28/19. Any staff members who do not receive in-service education by 7/28/19, will not be allowed to work until they have received in-service education. ************************* After reviewing the facility's information provided in their Removal Plan and verifying the immediate actions had been implemented, the scope/severity level of F600 was lowered to a D level on 7/28/2019, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficiency was cited as a result of the investigation of complaint/report number AL00036361.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, review of Resident Identifier (RI) #204's and RI #205's medical records, the Resident Incident Report, a typed statement and the hospital medical records, the facility failed to develop a care plan to address RI #204's use of a scoot chair and Dycem. On 3/21/2019, while sitting in the scoot chair at the nurses' station, RI #204 fell face forward onto the floor, hitting his/head. Employee Identifier (EI) #7, the Registered Nurse Supervisor who witnessed the fall, stated RI #204 slid from chair with cushion and Dycem still attached to resident's pants. The therapy staff indicated there should be two pieces of Dycem in RI #204's scoot chair. One piece of dycem was to be placed in the chair between the cushion and the chair. Then another piece of Dycem was to be placed on top of the cushion under the resident so the resident's bottom did not slide off the cushion and the cushion did not slide from the chair. EI #7 stated there was only one piece of Dycem and it was placed between the pad and RI #204's bottom. RI #204 was transferred and admitted to a local hospital's Intensive Care Unit for an Acute Subdural Hematoma. The facility further failed to ensure RI #205's care plan specified how RI #205 should be transferred and the level of assistance the resident required. RI #205 was assessed as requiring extensive assistance of two staff members for transfers. On 3/25/2019, EI #5 transferred RI #205 from the chair to the bed by herself using the Standup Lift. During the transfer, the resident became combative and fell to the floor hitting his/her head on the floor. The Licensed Practical Nurse/Restorative Nurse, EI #23, stated she assessed RI #205 prior to the fall and determined the resident was totally dependent on two staff for transfers with a Hoyer lift. RI #205 was transferred to the local hospital for further evaluation; the resident sustained a Closed Head Injury and a Traumatic Hematoma to the forehead. These deficient practices placed RI #204 and RI #205, two of eight sampled residents reviewed for accidents and placed them in immediate jeopardy of serious injury, harm, impairment or death. On 7/26/2019 at 6:50 PM, the facility's Administrator, Director of Nursing Service, Director of Clinical Services and [NAME] President of Senior Living were given the Immediate Jeopardy (IJ) template and notified of the findings of immediate jeopardy in the area of Comprehensive Resident Centered Care Plans, F656. Findings include: 1) RI #204 was admitted to the facility on [DATE] with an admit diagnosis of Dementia without behavioral disturbance. RI #204's Resident Incident Report prepared by Employee Identifier (EI) #7, a Registered Nurse (RN) indicated on 3/21/2019 at 9:14 PM while at the nurses' station Resident leaned forward out of scoot chair, slid from chair with cushion and dycem still attached to resident pants. Landed face first on floor. Assessed for injury . Large hematoma approx (approximately) size of baseball above left eye. Two skin tears above left eye with large amount of bleeding noted . RI #204's care plan titled Potential for falls related to dementia with a problem onset date of 5/25/2018, did not include an approach for the use of a scoot chair with Dycem. RI #204's care plan titled Resident needs assist with ADL's (activities of daily living) related to history of CVA (Cerebrovascular Accident) and dementia with a problem onset date of 5/25/2018, did not include an approach for the use of a scoot chair with Dycem. In an interview on 7/22/2019 at 9:57 AM, Employee Identifier (EI) #16, the Minimum Data Set (MDS) Coordinator was asked was RI #204 care planned for a scoot chair and Dycem. EI #16 replied, it was not on RI #204's fall or ADL care plan. When asked why she was not, EI #16 she was not sure. When asked should the resident have been care planned for the scoot chair and Dycem, EI #16 stated if it was listed as an intervention it should have been care planned. EI #16 was asked what was the negative outcome of not care planning RI #204's use of a scoot chair and Dycem. EI #16 replied, the Dycem or scoot chair would not be in place, which could cause the resident to possible slide and fall. During an interview with EI #33, the Occupational Therapy Assistant (OTA) on 7/22/2019 at 10:17 AM, she was asked when was the scoot chair and Dycem ordered for RI #204. EI #33 replied, she didn't know but when RI #204 was seen for a quarterly screen on 11/8/2018, the resident was already in the scoot chair. A typed statement signed by EI #33, an Occupational Therapy Assistant (OTA), dated 7/22/2018 (2019) documented Nursing issued scoot chair for (RI #204), date (he/she) was issued scoot chair is unknown by therapy staff, it is also unknown at this time that dycem and cushion was in place. Patient was seen for a quarterly screen on 11/8/18 and was evaluated with no concerns documented regarding patient's positioning in scoot chair. Patient was discharged from therapy services 12/4/18 with FMP (Functional Maintenance Plan) noting scoot chair as appropriate positioning. Patient evaluated by OT 3/19/19 with dysem (dycem), cushion, and leg rests with standard foot plates on scoot chair documented in evaluation with no concerns. On 7/23/2019 at 8:40 AM, an interview was conducted with EI #2, the Director of Nursing. EI #2 was asked,were the interventions of the scoot chair and Dycem care planned for RI #204. EI #2 replied, no. RI #204's local hospital's History and Physical dated 3/22/2019, documented . Chief Complaint Pt (patient) resided at The Village at [NAME] Springs. Pt was sitting in a chair and fell forward and hit face. Lac (laceration) noted to left forehead. Takes aspirin. Hx (history) dementia History of Present Illness . The patient presented with fall. The onset was yesterday evening. The character of symptoms is pain with forehead laceration. The degree at onset was moderate . Pt . with hx (history) of dementia and TIA (Transient Ischemic Attack) who presented to the ED (Emergency Department) from nursing home c/o (complaint of) fall onset the evening of 3/21/2019. Per EMS (Emergency Medical Service) report, pt fell from a rolling chair and hit (his/her) face. (He/She) now presents with a L (left) side head injury with laceration. Unknown LOC (level of conscious). Pt.'s wound was bandaged en route to ED and sutured in the ED due to continuous bleeding. EMS notes BP (blood pressure) 200/100 en route. (He/She) takes 81 mg (milligram) ASA (aspirin) daily . In ED, . CT (Computed Tomography) Head: Impression: There is a small left subdural hematoma. There is no mass effect or midline shift. There are small hemorrhagic contusions in the left frontal lobe. This is a critical result . Neurosurgery was consulted by ED physician. No intervention recommended at this time - neurosurgery will consult in the AM (morning) . Assessment/Plan 1. Acute subdural hematoma s/p (status post) fall . 2. Head laceration - appx (approximately) 4 sutures to left forehead . RI #204 was admitted to the Intensive Care Unit. RI #204's Neurosurgery Consult Note dated 3/22/2019, documented . CT shows small acute left frontoparietal SDH (subdural hematoma) without mass effect. stable this am (morning . The SDH is small and stable. No surgical intervention needed. No follow-up needed . The Discharge Summary revealed RI #204 was discharged home on 3/29/2019 with hospice care arranged. 2) RI #205 was admitted to the facility on [DATE] with an admit diagnosis of Dementia without Behavioral Disturbance. RI #205's Quarterly Minimum Data Set (MDS) with an assessment reference date of 3/7/2019 indicated the resident was severely impaired in cognitive skills for daily decision making, with a Brief Interview for Mental Status (BIMS) of two. RI #205 was assessed as being totally dependent on staff for transfers, requiring two plus persons physical assist. RI #205's Resident Incident Report prepared by Employee Identifier (EI) #19, a Licensed Practical Nurse (LPN) indicated on 3/25/2019 at 8:30 PM, . Resident was sitting on the edge of the bed, CNA (Certified Nursing Assistant) was undressing (him/her) to get (him/her) ready for bed. Resident was combative was grabbing onto her. CNA bent down and resident fell forward onto the floor. ROOT CAUSE: Resident requires 2 person assist with ADL (Activities of Daily Living) care . The report indicated the physician and resident representative were notified, neurological checks were initiated, an ice pack was applied to RI #205's head and the resident was transferred to a local hospital for evaluation. The report further indicated the facility staff involved was EI #5, a CNA. In a telephone interview on 7/15/2019 at 11:35 AM, EI #5, a CNA who no longer works at the facility, was asked why on 3/25/2019, did she not have assistance when she transferred RI #205 back to bed, EI #5 stated she wasn't taught to have two people and that she had watched other staff do it by themselves as well. According to EI #5, the white book at the nurses' station that contained residents' care plans did not indicate that RI #205 required two persons assist with a lift. RI #205's care plan titled (RI #205) has potential for falls related to muscle weakness and dementia with a problem onset date of 7/25/2016 did not include an approach of how the resident should be transferred or the level of assistance required, prior to 3/25/2019. On 3/25/2019, the care plan was updated to include . Resident is to be a 2 person assist when placing in bed . On 3/26/2019, the care plan was updated to include . Resident is to be a mechanical lift with all transfers . In a follow-up telephone interview on 7/22/2019 at 12:01 PM, EI #5 stated when RI #205 fell on 3/25/2019, that she had only transferred the resident to the bed to a sitting position on the side of the bed. When asked if she was dressing the resident, EI #5 said no. When asked if she was changing the resident's pants, EI #5 said no, that she could not change the resident's pants until the resident was lying down on the bed. EI #5 was asked how could having a second person to assist with the transfer prevent the fall. EI #5 replied, one person could have been on each side of the resident, that as she went to pick the resident's legs up, the other person could have been behind or beside her. In an interview on 7/23/2019 at 5:12 PM, EI #16, the Minimum Data Set (MDS) Coordinator was asked what details should be included in a resident's care plan for the staff assisting with transfers. EI #16 replied, how the resident should be transferred and the number of staff it takes to transfer the resident. When asked why this information is important to include on the care plan, EI #16 replied, it lets the staff know how the resident should be transferred. When asked what could happen if the care plan did not give specific instructions on how the resident should be transferred, EI #16 answered, it would be confusing to the staff on how the resident should be transferred. EI #16 was asked prior to 3/25/2019, what instructions were provided on the resident's care plan. EI #16 stated, assist with transfer and ambulation as needed. When asked where on the care plan did it instruct the staff to use the Standup lift, EI #16 replied, it did not. When asked why it didn't, EI #16 replied she didn't know. In a follow-up interview on 7/24/2019 at 10:21 AM, EI #16, the MDS Coordinator stated RI #205 was assessed as being dependent on two persons for transfers; however, the care plan only indicated the resident was to be assisted with transfers as needed. On 7/24/2019 at 10:45 AM, an interview was conducted with EI #23, the LPN Restorative who assessed RI #205's functional status during the 3/7/2019 Quarterly MDS. EI #24 acknowledged that RI #205 was assessed as being totally dependent on two staff for transfers with a Hoyer lift. EI #24 stated she did not know why the staff would use a Standup lift with RI #205. When asked why RI #205's care plan was not updated to reflect the resident's assessed needs to be a two person assist with a Hoyer lift, EI #23 replied, she did not update the care plan. When asked why RI #205's care plan was not updated after the assessment was done on 3/7/2019 that indicated the resident was assessed to be a Hoyer lift transfer with two staff assistance, EI #23 replied, she didn't know and there was no excuse for it not being updated. In an interview on 7/25/2019 at 10:54 AM, EI #2, the Director of Nursing (DON) was asked why RI #205's care plan was not updated to reflect the resident required two person assistance for transfers. EI #2 replied, she didn't know but it should have been. RI #205's Emergency Documentation from the local hospital documented on 3/25/2019 . Per EMS (Emergency Medical Service) report pt (patient) was sitting on the edge of the bed and fell forward at The Village at [NAME] Springs, hitting the floor. Hematoma to R (right) forehead noted . Pt disorientedx4 (person, place, time, location). Daughter reports this is pt's baseline . The patient presents with head injury. The onset was just prior to arrival . The patient . with a hx (history) of Alzheimer's Dementia, TIA (Transient Ischemic Attack), and HTN (Hypertension) who presents to the ED (Emergency Department) via EMS with a head injury . (He/She) is not on blood thinners. Patient cannot give adequate hx due to Dementia . The Computed Tomography (CT) done on 3/25/2019 revealed Severe intracranial atrophy and severe supratentorial small vessel white matter disease without evidence of acute cortical infarct, intracranial hemorrhage, or mass lesion. RI #205 was discharged from the local hospital on 3/26/2019 and transferred back to the facility with a discharge diagnoses of Closed Head Injury, Dementia, Fall, and Traumatic hematoma of the forehead. ************************* On 7/28/2019, the facility submitted an acceptable removal plan which documented . Beginning 7/27/19 all residents with falls in the last 30 days had fall care plans updated to include all risk factors and individualized interventions put in place and sent to Daily Care Guide. Beginning 7/28/19 all residents with fall care plans had fall care plan reviewed and updated to include all risk factors and individualized interventions put in place and sent to Daily Care Guide. Beginning 7/28/19 licensed staff and CNA's were in-serviced on fall care plans, Daily Care Guides, and identifying risk factors and following interventions listed on Daily Care Guides. Daily Care Guides will be printed daily to include new interventions, and changes made to resident care-plans. MDS staff will list resolved interventions on Daily Care Guides to ensure proper and timely communication for direct care staff. Interdisciplinary Team (IDT) will print daily care guides at the time the care-plan is updated, and make Daily Care Guides available to all nursing staff (RN/LPN/C.N.A). ************************* After reviewing the facility's information provided in their Removal Plan and verifying the immediate actions had been implemented, the scope/severity level of F656 was lowered to a D level on 7/28/2019, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficiency was cited as a result of the investigation of complaint/report number AL00036361.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and review of Resident Identifier (RI) #204's medical record, RI #205's medical record, the Resident Incident Report, a typed statement, the hospital medical records and the facility's policy titled Mechanical Lift, the facility failed to ensure the Dycem was correctly placed in RI #204's scoot chair. On 3/21/2019, while sitting in the scoot chair at the nurses' station, RI #204 fell face forward onto the floor, hitting his/head. Employee Identifier (EI) #7, the Registered Nurse Supervisor who witnessed the fall, stated RI #204 slid from chair with cushion and Dycem still attached to resident's pants. The therapy staff indicated there should be two pieces of Dycem in RI #204's scoot chair. One piece of dycem was to be placed in the chair between the cushion and the chair. Then another piece of Dycem was to be placed on top of the cushion under the resident so the resident's bottom did not slide off the cushion and the cushion did not slide from the chair. EI #7 stated there was only one piece of Dycem and it was placed between the pad and RI #204's bottom. RI #204 was transferred and admitted to a local hospital's Intensive Care Unit for an Acute Subdural Hematoma. The facility further failed to ensure EI #5, a Certified Nursing Assistant (CNA) transferred RI #205, as determined by the resident's comprehensive assessment. RI #205 was assessed as requiring extensive assistance of two staff members for transfers. On 3/25/2019, EI #5 transferred RI #205 from the chair to the bed by herself using the Standup Lift. During the transfer, the resident became combative and fell to the floor hitting his/her head on the floor. The Licensed Practical Nurse/Restorative Nurse, EI #23, stated she assessed RI #205 prior to the fall and determined the resident was totally dependent on two staff for transfers with a Hoyer lift. RI #205 was transferred to the local hospital for further evaluation; the resident sustained a Closed Head Injury and a Traumatic Hematoma to the forehead. These deficient practices placed RI #204 and RI #205, two of eight sampled residents reviewed for falls and placed them in immediate jeopardy of serious injury, harm, impairment or death. On 7/26/2019 at 6:50 PM, the facility's Administrator, Director of Nursing Service, Director of Clinical Services and [NAME] President of Senior Living were given the Immediate Jeopardy (IJ) template and notified of the findings of immediate jeopardy in the area of Quality of Care, F 689. Findings include: 1) RI #204 was admitted to the facility on [DATE] with an admit diagnosis of Dementia without behavioral disturbance. RI #204's Quarterly MDS with an assessment reference date of 2/4/2019, indicated the resident was moderately impaired in cognitive skills for daily decision making, with long and short term memory problems. RI #204's Resident Incident Report prepared by EI #7, a Registered Nurse (RN) indicated on 3/21/2019 at 9:14 PM while at the nurses' station Resident leaned forward out of scoot chair, slid from chair with cushion and dycem still attached to resident pants. Landed face first on floor. Assessed for injury. Neuro checks initiated. MD (Medical Doctor) notified with new orders to send to ER (Emergency Room). Non-verbal. Alert. ROOT CAUSE - leaned forward in chair. Intervention - PT/OT (Physical Therapy/Occupational Therapy) consulted for new chair. Large hematoma approx (approximately) size of baseball above left eye. Two skin tears above left eye with large amount of bleeding noted . RI #205's Departmental Notes written by EI #7, a RN, and dated 3/21/2019 10:26 PM, documented At approx. 9:14pm looked up from nurse's station and saw resident leaning forward out of scoot chair. Resident slid from chair with cushion and dycem still attached to resident pants. Resident landed face first on floor. Log rolled resident onto (his/her) back to assess fro injury. Large hematoma noted above left eye with large amount of bleeding noted coming from two skin tears also above left eye . PT/OT consulted for possible change of chair from scoot chair to geri-chair if appropriate. A typed statement signed by EI #33, an Occupational Therapy Assistant (OTA), dated 7/22/2018 (2019) documented Nursing issued scoot chair for (RI #204), date (he/she) was issued scoot chair is unknown by therapy staff, it is also unknown at this time that dycem and cushion was in place. Patient was seen for a quarterly screen on 11/8/18 and was evaluated with no concerns documented regarding patient's positioning in scoot chair. Patient was discharged from therapy services 12/4/18 with FMP (Functional Maintenance Plan) noting scoot chair as appropriate positioning. Patient evaluated by OT 3/19/19 with dysem (dycem), cushion, and leg rests with standard foot plates on scoot chair documented in evaluation with no concerns. RI #204's care plan titled Potential for falls related to dementia with a problem onset date of 5/25/2018, did not include an approach for the use of a scoot chair. RI #204's care plan titled Resident needs assist with ADL's (activities of daily living) related to history of CVA (Cerebrovascular Accident) and dementia with a problem onset date of 5/25/2018, did not include an approach for the use of a scoot chair. In an interview on 7/16/2019 at 9:30 AM, EI #14, a Physical Therapy Assistant was asked, what was the appropriate way to use dycem. EI #14 replied, to place the dycem between the resident and the sitting surface and if the sitting surface was a cushion, then place the dycem between the cushion and the sitting surface as well as between the resident and the cushion. When asked why would a resident fall out of a scoot chair that had dycem in place, EI #14 replied, the dycem may need to be replaced. During a telephone interview on 7/16/2019 at 9:53 AM, EI #15, an Occupational Therapist was asked, what was the appropriate way to use dycem. EI #15 replied, place dycem under any movable surface and under the patient. When asked why would a resident fall out of a scoot chair that had dycem in place, EI #15 replied, the dycem may not have been positioned appropriately or it needed to be replaced. In a follow-up telephone interview on 7/17/2019 at 11:36 AM, EI #15, the OT stated during the re-evaluation of RI #204 on 3/19/2019, there was two pieces of dycem in the resident's scoot chair. One piece of dycem was under the cushion and another piece of dycem was under the patient. In an interview on 7/20/2019 at 1:43 PM, EI #7, a Registered Nurse (RN) Supervisor acknowledged that she was at the nurses' station charting when RI #204 fell on 3/21/2019. When asked if RI #204 was exhibiting any behaviors prior to the fall, EI #7 said no. When asked what happened, EI #7 replied that she saw RI #204 fall forward from the scoot chair, all in one continuous motion. In a follow-up interview on 7/24/2019 at 11:13 AM, EI #7, a RN Supervisor was asked how was the dycem placed in RI #204's scoot chair prior to the resident falling on 3/21/2019. EI #7 replied, she didn't remember. After the resident fell, EI #7 stated, the dycem was attached to the resident and the cushion. During an interview on 7/24/2019 at 11:19 AM, EI #6, the RN Unit Manager was asked, who was responsible for placing dycem in a resident's chair. EI #6 replied, it can be the nurses or the Certified Nursing Assistants; whoever places the resident in the chair is responsible for making sure the dycem in the chair. When asked who trained the staff on the proper way to place dycem in RI #204's scoot chair, EI #6 stated, the CNAs should learn this in CNA class, that anyone could show the CNAs how to put dycem in the chair. On 7/25/2019 at 10:35 AM, an interview was conducted with EI #2, the Director of Nursing. EI #2 was asked, during the investigation of RI #204's fall on 3/21/2019, did she determine if the dycem in RI #204's scoot chair was properly placed. EI #2 replied, there was nothing in the investigation to reflect that. EI #2 further stated, the dycem was attached to the resident, so it had to have been in the chair because there was no other ay to place it in the scoot chair. When asked if there was supposed to be two pieces of dycem in RI #204's scoot chair, EI #2 replied, it doesn't necessarily have to be. During an interview on 7/15/2019 at 11:17 AM, EI #7, a RN Supervisor was asked how was RI #204 and the dycem placed in the resident's scoot chair. EI #7 replied, it was the scoot chair, the pad, the dycem and then RI #204's bottom. In an interview on 7/17/2019 at 11:45 AM, EI #33, the OTA was asked how should dycem be properly placed in RI #204's scoot chair. EI #33 replied, a piece of dycem is placed in the chair between the cushion and the chair. Then another piece of dycem is placed on top of the cushion under the resident so the resident's bottom does not slide off the cushion and the cushion does not slide from the chair. RI #204's local hospital's History and Physical dated 3/22/2019, documented . Chief Complaint Pt (patient) resided at The Village at [NAME] Springs. Pt was sitting in a chair and fell forward and hit face. Lac (laceration) noted to left forehead. Takes aspirin. Hx (history) dementia History of Present Illness . The patient presented with fall. The onset was yesterday evening. The character of symptoms is pain with forehead laceration. The degree at onset was moderate . Pt . with hx (history) of dementia and TIA (Transient Ischemic Attack) who presented to the ED (Emergency Department) from nursing home c/o (complaint of) fall onset the evening of 3/21/2019. Per EMS (Emergency Medical Service) report, pt fell from a rolling chair and hit (his/her) face. (He/She) now presents with a L (left) side head injury with laceration. Unknown LOC (level of conscious). Pt.'s wound was bandaged en route to ED and sutured in the ED due to continuous bleeding. EMS notes BP (blood pressure) 200/100 en route. (He/She) takes 81 mg (milligram) ASA (aspirin) daily . In ED, . CT (Computed Tomography) Head: Impression: There is a small left subdural hematoma. There is no mass effect or midline shift. There are small hemorrhagic contusions in the left frontal lobe. This is a critical result . Neurosurgery was consulted by ED physician. No intervention recommended at this time - neurosurgery will consult in the AM (morning) . Assessment/Plan 1. Acute subdural hematoma s/p (status post) fall . 2. Head laceration - appx (approximately) 4 sutures to left forehead . RI #204 was admitted to the Intensive Care Unit. RI #204's Neurosurgery Consult Note dated 3/22/2019, documented . CT shows small acute left frontoparietal SDH (subdural hematoma) without mass effect. stable this am (morning . The SDH is small and stable. No surgical intervention needed. No follow-up needed . The Discharge Summary revealed RI #204 was discharged home on 3/29/2019 with hospice care arranged. 2) RI #205 was admitted to the facility on [DATE] with an admit diagnosis of Dementia without Behavioral Disturbance. RI #205's Quarterly Minimum Data Set (MDS) with an assessment reference date of 3/7/2019 indicated the resident was severely impaired in cognitive skills for daily decision making, with a Brief Interview for Mental Status (BIMS) of two. RI #205 was assessed as being totally dependent on staff for transfers, requiring two plus persons physical assist. RI #205's Resident Incident Report prepared by Employee Identifier (EI) #19, a Licensed Practical Nurse (LPN) indicated on 3/25/2019 at 8:30 PM, . Resident was sitting on the edge of the bed, CNA (Certified Nursing Assistant) was undressing (him/her) to get (him/her) ready for bed. Resident was combative was grabbing onto her. CNA bent down and resident fell forward onto the floor. ROOT CAUSE: Resident requires 2 person assist with ADL (Activities of Daily Living) care . The report indicated the physician and resident representative were notified, neurological checks were initiated, an ice pack was applied to RI #205's head and the resident was transferred to a local hospital for evaluation. The report further indicated the facility staff involved was EI #5, a CNA. In a telephone interview on 7/15/2019 at 11:35 AM, EI #5, a CNA who no longer works at the facility, stated on 3/25/2019, she had just used the stand up lift to place RI #205 back in the bed. As EI #5 lowered RI #205 to a sitting position, EI #5 moved the lift back and RI #205 became combative by pushing against EI #5 and holding onto the CNA's shirt. EI #5 stated the resident then fell forward onto the floor and hit his/her head. EI #5 stated that it happened so quick that she had no time to catch the resident. When asked why did she not have assistance when she transferred RI #205 back to bed, EI #5 stated she wasn't taught to have two people and that she had watched other staff do it by themselves as well. According to EI #5, the white book at the nurses' station that contained residents' care plans did not indicate that RI #205 required two persons assist with a lift. RI #205's care plan titled (RI #205) has potential for falls related to muscle weakness and dementia with a problem onset date of 7/25/2016 did not include an approach of how the resident should be transferred or the level of assistance required, prior to 3/25/2019. On 3/25/2019, the care plan was updated to include . Resident is to be a 2 person assist when placing in bed . On 3/26/2019, the care plan was updated to include . Resident is to be a mechanical lift with all transfers . In a follow-up telephone interview on 7/22/2019 at 12:01 PM, EI #5 stated when RI #205 fell on 3/25/2019, that she had only transferred the resident to the bed to a sitting position on the side of the bed. When asked if she was dressing the resident, EI #5 said no. When asked if she was changing the resident's pants, EI #5 said no, that she could not change the resident's pants until the resident was lying down on the bed. EI #5 was asked how could having a second person to assist with the transfer prevent the fall. EI #5 replied, one person could have been on each side of the resident, that as she went to pick the resident's legs up, the other person could have been behind or beside her. In a telephone interview on 7/23/2019 at 8:33 AM, EI #19, a LPN was asked how many staff are required to transfer a resident with a Standup lift. EI #19 replied, that she believed it was two but couldn't be completely sure. The facility's policy titled Mechanical Lift with an effective date of March 2018, documented PURPOSE: A mechanical lift should be used to help lift residents who may be too heavy to lift, or who cannot assist with a transfer. STANDARD: Two nursing staff should be used for the mechanic (mechanical) lift . On 7/24/2019 at 10:45 AM, an interview was conducted with EI #23, the LPN Restorative who assessed RI #205's functional status during the 3/7/2019 Quarterly MDS. EI #24 acknowledged that RI #205 was assessed as being totally dependent on two staff for transfers with a Hoyer lift. EI #24 stated she did not know why the staff would use a Standup lift with RI #205. EI #23 explained that to be able to use the Standup lift, the resident must be able to follow directions and since RI #205 was demented and sometimes could not comprehend directions, the Standup lift was not the best option. Review of RI #205's hospital records with an admission date of 3/25/19 revealed Emergency Documentation with Radiology Orders for CT Head or Brain with a reason documented as Head Injury and a Discharge Diagnosis of Closed Head Injury and Traumatic Hematoma of Forehead. According to a document titled Mechanical Lifts, Bed Bolsters, T&P (Turn and Position), and Heel Floating Objectives Skills Fair April 2018, there are two types of mechanical lifts, the Hoyer lift and the Standup Lift. The documented further listed . Standup Lift Resident has to be able to follow directions . RI #205's Emergency Documentation from the local hospital documented on 3/25/2019 . Per EMS (Emergency Medical Service) report pt (patient) was sitting on the edge of the bed and fell forward at The Village at [NAME] Springs, hitting the floor. Hematoma to R (right) forehead noted . Pt disorientedx4 (person, place, time, location). Daughter reports this is pt's baseline . The patient presents with head injury. The onset was just prior to arrival . The patient . with a hx (history) of Alzheimer's Dementia, TIA (Transient Ischemic Attack), and HTN (Hypertension) who presents to the ED (Emergency Department) via EMS with a head injury . (He/She) is not on blood thinners. Patient cannot give adequate hx due to Dementia . The Computed Tomography (CT) done on 3/25/2019 revealed Severe intracranial atrophy and severe supratentorial small vessel white matter disease without evidence of acute cortical infarct, intracranial hemorrhage, or mass lesion. RI #205 was discharged from the local hospital on 3/26/2019 and transferred back to the facility with a discharge diagnoses of Closed Head Injury, Dementia, Fall, and Traumatic hematoma of the forehead. ************************* On 7/28/2019, the facility submitted an acceptable removal plan which documented . All other residents with fall risks factors have the potential to be affected. On 07/27/19 facility staff reviewed residents who had a fall in the last thirty (30) days to identify fall risk factors. Facility staff reviewed the resident's Fall Risk Care Plans, updated as indicated, listed fall risk indicators and updated Daily Care Guides. Beginning 07/27/19, nursing staff (RN/LPN/C.N.A) was in-serviced on mechanical lift use with 2-person assist. In-service education will be completed by 07/28/19. Any staff members who do not receive in-service education by 07/28/19 will not be allowed to work until they have received in-service education. On 07/27/19 nursing staff began to provide in-service education on identifying fall risk factors, and following both resident care-plans and Daily Care Guides. In-service education will be completed by 07/28/19. Any staff members who do not receive in-service education by 07/28/19, will not be allowed to work until they have received in-service education. On 07/27/19 nursing staff began to provide in-service education on mechanical lift use with 2-person assist, to include the [NAME]-3000 stand-up lift. In-service education will be completed by 07/28/19. Any staff members who do not receive in-service education by 07/28/19, will not be allowed to work until they have received in-service education. On 07/27/19 licensed staff began to receive in-service education concerning fall-risk care-plans, fall-risk indicators, and updating Daily Care Guides for both residents being admitted and readmitted to the facility. In-service education will be completed by 07/28/19. Any staff members who do not receive in-service education by 07/28/19, will not be allowed to work until they have received in-service education. ************************* After reviewing the facility's information provided in their Removal Plan and verifying the immediate actions had been implemented, the scope/severity level of F689 was lowered to a D level on 7/28/2019, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficiency was cited as a result of the investigation of complaint/report number AL00036361.