Based on record review and interview, the facility failed to ensure a resident remained free of involuntary seclusion by staff and to ensure all other residents were protected from further involuntary seclusion for 1 of 1 (Resident #34) sampled residents who had been involuntary secluded. The Administrator was informed of the Immediate Jeopardy on 01/09/24 at 3:07 PM The failed practice had the potential to affect all 45 residents currently in the facility. The findings are: On 01/08/24 at 3:59 PM, Surveyor notified the family member by phone for a family interview. During the interview the daughter said last week on Wednesday it was reported a staff member locked him (Resident #34) in his room. The staff member was fired, and an investigation is under way. She said she has a meeting with the administrator tomorrow 1/9/24. The facility's policy titled Policy and Procedure Regarding investigation and reporting of alleged violations of federal or state laws involving mistreatment, neglect, abuse, injuries of unknown source and misappropriation of residents property provided by Administrator on 1/08/24 at 11:40 AM., showed the following: It is the policy of this facility {named} to prevent the occurrence of abuse ( verbal, mental, physical, sexual ,involuntary seclusion) . Mental Abuse: isolating a resident from social interaction . INVOLUNTARY SECLUSION is defined as separation of a resident from other residents .confinement to her/his room against the residents will . staff hold a door shut, from the opposite side of the door in order to prevent egress. A Reportable to The Office of Long-Term Care dated 12/29/24 at 3:00 PM documented, .This Staff member reported that (Certified Nursing Assistant) CNA # 2 had pushed resident to his room and held the door closed so the resident could not leave room . Cameras were reviewed by facility Registered Nurse (RN) at approximately l8:14, 6:14 PM, CNA was observed pushing resident into his room. CNA then walked away from the door. CNA was observed pushing the resident into his room and closing the door. CNA stood at the door until 18:16:19 (6:16 PM and 19 seconds). CNA then walked away from the door . At 20:53:20 (8:53 PM and 20 seconds), CNA was observed on camera pushing resident to room again and closing the door on the resident. Based upon posture and hand placement CNA was holding the door shut. CNA moved away from the door at approximately 20:53:46 (8:53 PM and 46 seconds). At approximately 20:53:56 (8:53 PM and 56 seconds), CNA is seen running across the hall to the resident's room. Pushed resident back into room and holds the door closed from 20:54:1 I TO 20:54:39 (8:54 PM and 1 second to 8:54 PM and 39 seconds). The employee was terminated. The Plan of Care dated 12/07/15 documented, .Cognitive Resident has impaired cognitive skills .short term memory problem, decision making problem. Resident #34 had diagnoses of Alzheimer's disease, Dementia, and Encephalopathy. On 1/9/2024 at 9:47 AM, interview with Resident #7. She has been a resident here for 9 years. No issues with staff. She stated, One resident will wander into this resident's room. Resident #7 said, I punch my call light and they come get her. Resident #7 said that she feels the resident wants to stay around and that she feels sorry for her. On 1/9/2024 at 9:30 AM, CNA #3 was asked if she had any knowledge of the alleged abuse of Resident #34, CNA #3 said no. The Surveyor asked what actions, if any, did you take in response to the allegation. CNA #3 stated, Report it to the charge nurse. CNA #3 was asked If she was familiar with the alleged victim and if she has noticed any changes in the alleged victim's behavior as a result of the alleged abuse. If so, describe. CNA #3 stated, I know him but never worked with him. I did hear about [named employee]. I wasn't there but they said she pulled a chair from under him, and he hit the floor. I'm not aware of any harm because I do not work down there. They turned it into the OLTC, and she got fired. No knowledge of any other abuse by this CNA. CNA #3 was asked if she had received training on abuse identification, prevention, and reporting requirements. CNA #3 said, not recently, but had received some training on abuse and aggression, but she did not know when. On 1/9/24 at 10:09 AM, (Licensed Practical Nurse) LPN#3 was asked if she had any knowledge of any alleged abuse If so, describe. LPN #3 stated, Yes, recently he asked the nurse for assistance he was at the edge of the chair. Before they moved the wheelchair, she (named x-employee) pulled the chair out and he hit the floor. He is Resident #34. They investigated where the CNA held the door, and it was on camera. Assistant Director of Nursing (ADON) does admissions and investigations and she had to talk to her, (named x employee), in the investigation. and (named X-employee) was fired. The Surveyor asked did the alleged perpetrator and/or victim exhibit any behaviors that would provoke one another? LPN #3 said it is all the hollering. It is the way she approached them. LPN #3 was asked if she had received training on abuse identification, prevention, and reporting requirements. LPN #3 stated Yes, most of the time I do it on my [Continuing Education Units] CEUs. Here we get print outs; we haven't had any together trainings since COVID. We used to have them once a month. Nurses will go in with [named employee] and do return demonstration. I do not recall any recent retraining's on aggressive residents. On 1/9/24 at 10:14 AM, CNA #4, was asked if she had any knowledge of Resident #34 being held in his room against his will? CNA stated, No. CNA #4 was asked what action she would you take if a resident reports an allegation of abuse by another resident. CNA #4 stated, I would report it to the charge nurse. CNA #4 was asked what action she would take if a resident reported an allegation of abuse by a staff member to her. CNA#4 stated, I would report it to the charge nurse. CNA #4 was asked if she had received any abuse training. CNA stated, When we get our checks, we get a packet that we read. Before COVID we would have meetings. Different pay periods, we have different packets, such as one on abuse, one on fires, one on storms. CNA #4 was asked if she could recall, when was the last training she had on abuse, and stated I'm not good with dates so I don't remember. On 1/9/24 at 10:24 AM, CNA #5 was asked if she had any knowledge of Resident #34 being held in his room against his will. CNA stated, no. CAN #5 asked what action she would take if a resident reports an allegation of abuse by a staff member to you. CNA #5 stated, I would take the concern up with the charge nurse and we will ' talk to the Administrator. CNA #5 was asked if she had received any abuse training. CNA #5 stated, yes. , CNA #5 was asked if she could remember when she received her last abuse training. CNA#5 stated, I had it when I finished my CNA classes in September 2023. The resident was asked if she had ever been in room and staff would not allow you to leave. Resident stated, no. The resident was asked if she felt comfortable reporting concerns to staff. The resident stated, No, you have to keep your mouth shut. Do you have any concerns about how they would treat you? Resident #28 said, you are asking me some hard questions and I don't know what to say. On 1/9/24 at 8:40 AM, (LPN #1) was asked if she was aware of an incident involving Resident #34. LPN stated I heard one of the CNAs pulled the door shut and held it for about 5 minutes. I heard he was banging on the door to get out. I also heard it was caught on camera and that just wasn't right. LPN #1 was asked who she heard it from, and she stated, I don't really remember; I hate to say the wrong person. LPN #1 was asked if she reported this to anyone. LPN #1 stated, I did not report it because the Administrator was already working on it so I knew she knew. On 1/9/24 at 8:48 AM, Resident # 6 was asked if the staff treated him with dignity, respect, and kindness. Resident stated, I feel an aide [named x-employee] was mean to me because she took my wheelchair and refused to give it back; I feel that was very wrong. The Resident was asked if he reported the incident to anyone and he stated, The Administrator {named}. On 1/9/24 at 9:01 AM, Resident #24, was asked if the staff treated her with dignity, respect, and kindness. Resident stated, Absolutely, I chose to live here. If they were mean, I would leave. On 1/9/24 at 9:15 AM, the CNA #1 was asked if she was aware of an incident that involved Resident #34. The CNA stated, Yes, I have. I heard [named x-employee] took him to his room and held the door. He was banging on the door, then went to the bathroom door and was banging on it. Did you report this to anyone? CNA #1 stated, No they were investigating it already. How often are you trained on abuse and neglect. CNA#1 stated, on hire. On 1/9/24 at 10:15 AM, the Administrator was asked if she was aware of an incident that involved Resident #34. The Administrator stated, yes. The Administrator was asked if she could tell me what occurred. She stated, Yes, I came in to work and the social worker told me they were watching the videos because it had been reported to her that the [named x employee] had held a door closed so a Resident could not get out of his room. I watched the videos then had the ADON watch them. I called the [named x-employee] in and got her statement. I told her what she had done was involuntary seclusion and that she was terminated and that it would be reported to the Office of Long-term care. We felt we had a finding. The Surveyor asked if she had done an in-service since the incident. The Administrator stated, no. On 1/9/24 at 10:35 AM, the social worker was asked if she was aware of an incident that involved Resident #34. She stated, Yes, [named CNA ' s]came to my office because they were upset over [named x-employee] locking Resident #34 in his room and not letting him out. I heard he was hollering and banging on the door. I told my Administrator. The Social worker was asked how often she was trained on abuse and neglect, and she stated, On hire and during some in-services. The Surveyor asked what was the Administrators response? The social worker stated, she watched the cameras and fired [named x-employee]. On 1/9/24 at 10:45 AM, the Director of Nurses (DON) was asked if she was aware of an incident that involved Resident #34. She stated, Yes, as soon as I arrived at work the Administrator told me. What do you know about the investigation? The DON stated, I know the cameras were watched and she called [named x-employee] in, and they terminated her. They did a reportable. The DON was asked how often staff were trained concerning abuse and neglect. The DON stated, yearly. The DON was asked if she had done an in-service since the incident. The DON stated, no. The following Plan of removal was accepted on 01/10/2024 at 9:10 AM. 1. Corrective Action: Certified Nursing Aide was terminated on 12/29/2023 for involuntary seclusion. 2. Identify: All residents in the facility were checked on 12/29/2023 by designated nurse with no negative findings. 3. Systemic Changes: All staff present were in-serviced on 01/09/2024 by a designated LPN. All incoming staff will be in-serviced by a designated LPN upon arriving at work on involuntary seclusion. 4. Monitor: Cameras will be reviewed 5 times per week by a designated staff to ensure no staff are holding a resident room door shut. Negative findings will be brought to the Administrator immediately. QA will follow up on findings. weekly. 5. Completion Date: 0l/09/2024

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure an effective fall prevention program that included adequate supervision and a system for residents who were at risk for falls was developed and consistently implemented, as evidenced by:failure to ensure anti-rollbacks were consistently monitored to ensure they were in working condition to prevent falls to the extent possible and reduce the potential for further injury from falls that did occur for 1 (Resident #148) of 1 (Resident #148) sampled Resident who sustained a fracture; failed to ensure falls were thoroughly investigated for causative factors and interventions were developed and implemented based on those causative factors to decrease the potential for further falls / injuries for 2 (Residents #18 and #34) of 5 (Residents #18, #23, #34, #40 and #148) sampled residents who had falls in the past 3 months. The failed practices resulted in an Immediate Jeopardy, which caused or could have caused serious harm, injury or death to Resident #148, who experienced falls that resulted in a fracture and Residents #18 and #34, who experienced multiple falls, and had the potential to cause more than minimal harm to 5 residents who experienced falls in the past 3 months. The Administrator was informed of the Immediate Jeopardy on 01/10/2024 at 3:50 PM The findings are: Resident #148 had diagnoses of Osteoarthritis, muscle weakness (generalized), difficulty in walking, unsteadiness on feet and other abnormalities of gait and mobility. A Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/30/23 documented the Resident scored a 00 (00-07 indicates severely impaired) on the Brief Interview for Mental Status (BIMS), used a wheelchair (w/c) for mobility, and required partial / moderate assistance with personal hygiene and with sit to stand, had two falls since admit / prior assessment with no injury and one fall since admit / prior assessment with a major injury. A Care Plan (CP) with a review date of 12/05/23 documented the resident was at risk for fall related injury evidenced by a previous fall. Resident #148 fell on [DATE] and sustained a left (L) hip fracture (fx). The CP was not updated to reflect interventions for monitoring / caring for a resident with a sustained fx from a fall. Resident #148 ' s Incident and Accident (I&As) Reports were reviewed and the following information was noted: On 10/07/23 at 5:10 PM, [Resident #148] was found on the floor in front of wheelchair. Intervention: OT (Occupational Therapy) will work on core strengthening. Cause of fall: may have been sitting on the edge of wheelchair. On 10/10/23 at 12:50 PM, [Resident #148] was found on floor sitting on buttocks with back against wheelchair. Intervention: OT will work on transfers. Cause of fall: blank. On 11/05/23 at 4:00 PM, [Resident #148] was found sitting upright in front of her wheelchair with a small laceration to left side of forehead. Intervention: PT [Physical Therapy] will eval. (evaluate) and treat. Cause of fall: Resident transfers self to/from bed. Obtain UA (urinalysis). Fall occurred on 11/05/23, referred to therapy on 11/06/23. PT to eval on 11/07/23. 11/8/23 orders to obtain a UA & (and) C&S (culture and sensitivity) on 11/10/23. PT orders were recommended for PT treatment 2-4 (two to four) X ' s (times) a week for up to 8 weeks. On 11/16/23 at 15:35 (3:35) PM, witnessed by hall nurse attempting to transfer from wheelchair to straight back chair. The brakes of the wheelchair were not locked, and it rolled out from under her, and she fell on the floor. Intervention: PT will work on wheelchair safety. On 11/26/23 at 1:50 AM, found sitting on the floor by the wheelchair. Intervention: Because PT and OT benefits were exhausted. Restorative will work on transfers. Cause of fall: Transferring without assistance. On 11/29/23 at 2054 [8:54] P.M., found lying on the floor. The wheelchair brakes were unlocked. Intervention: ordered x-ray of hip. (Resulted in a fracture.) Installed antiroll backs on wheelchair. Cause of fall: resident transfers self to wheelchair and the brakes are never locked. PT started treatment on 12/13/23. On 1/3/24 at 12:48 PM, found on the floor. Intervention: PT will educate on transfer safety. Cause of fall: blank. On 1/9/24 at 2:00 PM, the Director of Rehab (DOR) was asked if she felt the repetitious interventions had been effective and she stated, no. She was asked if a Resident #148 with a BIM of 00 had the ability to be educated per therapy treatment and she stated, She can respond immediately sometimes but can ' t retain 30 minutes later. On 01/09/24 at 3:29 PM Resident #148 was propelling self-down the hall. The bar to the antiroll backs on the right side was upside down causing the antiroll backs to improperly function. Licensed Practical Nurse (LPN) #1 reached down to straighten up the bar and it fell out when she pulled on it. LPN #1 and the Housekeeping Supervisor attempted to reinsert the bar but couldn't. On 1/10/24 at 9:25 AM, Certified Nursing Assistant (CNA) #2 was asked if she was familiar with the device (anti roll backs) on the wheelchair. She stated, It ' s an anti-rollback. CAN #2 was asked what the purpose of anti-roll backs were for and stated, So it doesn ' t roll back when the resident gets in or out of it. She was asked if she ever checked them for proper functioning and stated, Every day, before putting them in the wheelchair. She was asked to explain the functioning verses non-functioning and stated, If it isn't working properly, a person can fall and break something. She was asked if she had ever had an in-service on anti-roll backs and she stated, yes. On 1/10/24 at 9:35 AM, CNA #6 was asked if she was familiar with the device (anti roll backs) on the wheelchair and she stated, No, maybe can' t roll the chair backwards. CNA #6 was asked what is the purpose of an anti-roll back, and she stated, I've never had one. She was asked if she ever checked them for proper functioning and she stated, no. CAN #6 was asked to explain the functioning verses non-functioning and she stated, The resident can fall out and possibly be injured. She was asked if she'd ever had an in-service on anti-roll backs and she stated, I can't remember. On 1/10/24 at 9:40 AM, Maintenance pulled the wheelchair backwards and stated, It's still not working. Resident #18 has diagnoses of Vascular Dementia without Behavioral Disturbances, Altered Mental Status and Sciatica Right Side The Quarterly MDS with an ARD of 11/09/23 of Resident #18 documented the Resident had a BIMS of 7 (00-07 indicates severely impaired). A Care Plan with a review date of 11/14/23 documented problem of falls with the following approaches: Provide w/c for mobility, Provide Restorative Therapy to prevent decline, 09/03/23-PT will eval and tx, 09/25/23-OT to eval and tx, 10/08/23-PT will work on strengthening, 10/28/23-Vitamin D level drawn, 11/04/23- PT/OT to eval and tx as indicated, 11/06/23-Obtain UA [urinalysis] to r/o [rule out] UTI [Urinary Tract Infection], 11/21/23- OT to work on transfer safety, 11/25/23-OT to work on using urinal; Problem- Safety 11/10/23- Approaches: CNA information sheet will reflect that resident transfers self. On 01/08/24 at 10:45 AM, Resident #18 was in bed and both of his arms were purple and he complained of back pain. There was a dressing to the left arm. The Resident stated, I fell. The following Incident and Accident (I & A)'s reports regarding falls were documented for Resident #18: 09/3/23 at 0100 [1:00] AM, Resident (Res) turned on emergency call and CNA found res (Resident) sitting up against the wall, soaked in urine and bleeding on the (left) (L) side of face. Res stated legs gave out on him. Immediate Action: R [Resident] was cleaned up, [adhesive strips] applied to area cut above (L) eyebrow. Fall investigation completed and PT notified at 09/25/23 at 10 AM. Interventions: P/T will eval & [and] treat. 09/25/23 at 5:45 AM, Incident: Res attempted self-transfer and stood up to see who was at door and legs gave out. Immediate Action: No due to no injury Interventions: Fall investigation completed and PT notified 09/25/23 at 10 AM and res reminded to hit CL [call light] for assistance getting oob [out of bed] and walking. O/T will eval & treat. 10/08/23 at 1:40 PM, Incident: Another Res yelled that res was trying to turn w/c around and he got tangled in it and fell on (L) arm. Sustained an abrasion to (L)arm and skin tear to (L) arm. Immediate Action: w/c, xerofoam, drsg [dressing].(exactly how I&A documented). Interventions: Fall Investigation completed, and PT notified 10/08/23 at 1:40 PM. P/T will work on strengthening. 10/28/23 at 8 PM, Incident: LPN [Licensed Practical Nurse] noted dried blood on bed linen. Res assessed and skin tear to [right] elbow. Res informed LPN he fell earlier in bathroom. Injury documented laceration. Immediate Action: Tx [treatment] applied per protocol and ROM [range of motion] to extremities Interventions: No noted. 11/04/23 at 23:15 (11:15) PM, Incident: Resident fell exiting bathroom Immediate Action: N/A (Injury section blank) Interventions: Fall Investigation completed and PT notified 11/6/23 at 10 AM. P/T & O/T will eval and treat. 11/06/23 at 5:25 AM, Incident: staff called to Resident room and Resident stated he fell and hit (L) arm on doorway. Denied hitting head. Injury documented other and diagram shows skin tear, bruise to (L) arm and skin tear to (L) hand. Immediate Action: First aid but no documentation as to what it was. Interventions: Fall Investigation completed, and PT notified 11/06/23 at 10 AM. U/A [urinalysis] & [and] C/S [culture and sensitivity]. 11/21/23 at 20:15 [8:15] PM, Incident: Resident observed sitting in floor in hallway behind w/c by nurse. Injury section blank but diagram shows skin tear to right arm. Immediate Action: nothing documented, and first aid box not checked. Interventions: Investigation F/U (follow up) has no date when completed but noted O/T will work on transfer safety. 11/25/23 at 7:15 AM, Incident: CNA yelled for LPN noting resident on floor, lying behind w/c, adult brief partially down and urine on floor. Bleeding noted (L) arm. Injury-laceration. Immediate Action: Tx per protocol. Interventions: Fall Investigation completed, and PT notified 11/27/23 at 1:46 PM. O/T will work on using urinal. 12/05/23 at 4:35 AM, Incident: staff member knocked on resident door, called resident ' s name and resident rolled out of bed and hit back of head on dresser. Injury noted redness and small bruise to back of head. Immediate Action: N/A (Non-Available) Interventions: Fall Investigation completed, and PT notified 12/5/23 at 10 AM. O/T to work on bed mobility. 12/29/23 at 4:55 AM, Incident: CNA called nurse to room and stated pt. [patient] on floor. Pt. on buttocks and with skin tear to (L) elbow as injury. Immediate Action: No first aid needed for form. Interventions: Fall Investigation completed, and PT notified 12/29/23 and Melatonin 3 mg [milligrams]1 tab [tablet] PO [by mouth] q [every] HS [bedtime]. 01/02/24 at 11:45 AM, Incident: Resident stood out of w/c and fell on buttock. Hit back of door. Injury: section blank but diagram documents old skin tears to right arm. Immediate Action: First aid but not documented what it was. Interventions: Fall Investigation completed, and PT notified 01/03/24 at 10:30 am and P/T will eval and treat. 1/10/24 at 9:50 AM, LPN #3 was asked, How do you know what residents risk factors are for having an accident? LPN #3 said when they come in, they do a head-to-toe assessment. I know from dealing with residents every day what their risk factors are. If they have one coming in from another facility, they make it known to us what those are. She was asked, A resident with risk factors for falls, how often are they assessed and where is it documented? LPN #3 stated Every day they are assessed. I just put mine on shift report if anything changes. If there are no changes, I don't put it anywhere, just follow up as needed. She was asked, how do you know what interventions or assistance is needed to prevent falls? and she stated, We have a CNA book that has what the resident can do regarding ADLs. I refer to the resident ' s care plan and we have shift report regarding any change and sometimes it's just verbally told to me by the nurse. She was asked, if a resident has a fall and you witness this, what do you do? LPN #3 stated, I assess the resident before I move them and if assistance is needed I will help to get them either to the bed or restroom or wherever they need to go. She was asked, what do you do if a resident refuses the intervention in place? and she stated, I would tell the doctor and make a note on the Progress Note or shift report. She was asked, how did you identify that the interventions were suitable for this resident? She stated, By working with them every day, and there to assess them every day. Just knowing their diagnosis and what they are capable of doing. On 1/10/24 at 9:41 AM, CNA #3 was asked, How do you know what care a resident need? and she stated, If something is going on with resident, the CNA will tell me or the nurse. She was asked, How do you know if a resident has had a fall or other incident? and she stated, If it happens on another shift, the nurse will tell me when I come in. She was asked, How do you know what interventions are in place for a resident that may have fallen? and she stated, It will be in their charts, in their care plan. If they fall on us, the paper will say what your interventions will be, so we have to write something. She was asked, If a resident has a fall or other injury and you witness this, what do you do? and she stated, Come and report it to the charge nurse and then we fill out the witness statement and give it to the charge nurse. She was asked, What do you do if a resident refuses the intervention in place? and she stated, I would go and let the charge nurse know. Resident #34 had diagnoses of Alzheimer's Disease, and Dementia. A 5-Day MDS with an ARD of 12/06/23 documented Resident #34 had a BIMS of 01 (00-07 indicates severely impaired), used a walker and w/c for mobility, dependent for toileting, and required substantial / maximal assist for sit to stand. A Progress Note Report for Sat [Saturday], Sep [September] 30, 2023 Thru [through] Wed [Wednesday], Dec [December] 06 2023 documented, . 12/06/2023 1200 Nursing Staff admission admitted to facility from hospital with left femur fracture . Fall on 12/1/23 no injury . Fall on 12/02/23 no injury. Fall on 12/06/23 with minor injury-red area to top of head. Another fall on 12/06/23 with minor injury-abrasion . transferred to ER [Emergency Room] due to pain in my left hip. X RAYS were negative . A Medicare Nurse's Notes dated 11/20/23 documented, Admit to [Named Facility] from [Local Hospital] . PT /OT to eval. DX [Diagnosis]: (L) [Left] femur fx [fracture] . Other dx (diagnosis): Alzheimer's dementia . An Activities of Daily Living (ADL) sheet for Resident #34, dated 12/6/23, documented the resident was independent for bed mobility, but required supervision for transfers and toilet use. A Care Plan with no review date documented falls with a problem date of 12/07/23 as evidenced by reason for prior hospital stay and recent falls at facility. The approaches where a. observe for side effects of any drugs that can cause, but there were no side effects listed; b. Provide environmental adaptations, but none were listed and c. Safety measures to reduce fall risk, but none were listed. The resident fell once on 12/1 and twice on 12/6 and neither fall was care planned. The following Incident / Accident Reports are regarding Resident #34's falls: 12/1/23 at 8:40 AM, Resident sitting upright on side of bed on floor. Type of Injury: None apparent. Investigation Follow-Up dated 12/1/23 documented Recommendations / New Interventions P/T [Physical therapy] to work on strengthening. Fall Investigation dated 12/1/23 documented Physical Therapy notified of fall 12/4/23 and cause of fall was[resident] got up [without] assistance. 12/6/23 at 5:30 AM, [resident] Rt [right] side was between chair back [and] arm (chair back broken) Rt side neck against chair leg [and] throat against bottom rail of chair . Type of Injury Abrasion. Investigation Follow-Up dated 12/6/23 documented Recommendations / New Interventions Remove chair or have fixed son stated he would bring out new chair. Fall Investigation documented Physical Therapy notified of fall 12/7/23 and cause of fall was the chair back broke. 12/6/23 at 1515 [3:15] PM, resident tried to transfer himself. Landed on the left side. Abrasion on (L) temple Guarding (L) hip. Complaining of pain. Unable to do ROM [range of motion]. Type of Injury-blank. Resident was sent to hospital by EMS [Emergency Medical Services]. Investigation Follow-Up dated 12/6/23 documented Recommendations / New Interventions P/T will work on transfers. Fall Investigation dated 12/6/23 documented Physical Therapy notified of fall 12/8/23 and cause of fall was transferring without assistance. 12/7/23 at 1932 [7:32] PM, Resident was observed by CNA [Certified Nursing Assistant] [Name] to be on the floor in his room in front of his recliner on his bottom. W/c was in the doorway . w/c brakes were not locked . Type of Injury nonapparent. Investigation follow-up dated 12/7/23 documented recommendations / New Interventions: Rocking recliner taken out of room. Fall Investigation dated 12/7/23 documented Physical Therapy notified of fall 12/11/23. 12/8/23 at 8:40 AM, Staff heard resident yell Help Noticed door closed d/t [due to] isolation precautions. Opened door observed [named Resident] lying on his back in front of his recliner. Recliner legs were reclined. C/O [complain of] pain (L) hip which is normal complaint prior this fall. Type of Injury-blank. Investigation Follow-Up dated 12/8/23 documented Recommendations / New Interventions Recliner replaced w/a [with a] love seat. Fall Investigation dated 12/8/23 documented Physical Therapy notified of fall 12/11/23 and no cause of fall listed. 12/28/23 at 2:30 PM, Pat [patient] had feet on other resident ' s bed. CNA was told resident would need pulled up before could be moved. She stated, It will be fine. and pulled wheelchair before pt was properly in wheelchair. Resident landed on butt. Type of Injury None apparent. Investigation Follow-Up documented Date of Incident 12/28/23 and Recommendations / New Interventions CNA terminated. Fall Investigation dated 12/28/23 documented Physical Therapy notified of fall 1/2/24 and cause of fall as improper transfer. On 1/10/24 at 10:00 AM, the Director of Nursing (DON) was interviewed and asked to explain the procedure for the Incidences and Accidents. She stated, Whoever sees it tells the nurse, obtains a witness statement. The nurse will do an I & A report, investigation follow-up and notify the MD [Medical Doctor] and family. Complete a body audit and assess the resident. Text the DON. She was asked if an intervention is in place and another fall occurs, what is the next step and she confirmed that you find a different intervention, specific for the situation. She confirmed an in-service on falls and interventions was performed May 2023 per her logs. She was asked if putting repetitive interventions in place was their policy and procedure and have, they been effective and she stated, Probably not. Resident could sustain an injury. On 1/10/24 at 10:05 AM, the Administrator stated, We use therapy a lot and we refer for different strengthening's. She was asked, You refer to Physical therapy, Occupational therapy and restorative for strengthening and alternate between OT & PT. Did that prevent the falls before an injury occurred? She stated, No, but we depend on therapy a lot for different kinds of strengthening. The Immediate Jeopardy was removed on 01/11/24 at 11:13 AM, when the following Plan of Removal was implemented by the facility 1. Corrective Actions: Residents #148's anti-rollbacks are in working order and her Florinef was added on 1/10/2024. Resident #34 was placed on a toileting program on 1/10/2024. Resident #18's Buspar was decreased 1/10/2024. All anti-rollbacks were checked on 1/11/2024 and repaired by maintenance if needed. 2. Identify: All residents who have had multiple falls over the past 30 days have been identified and interventions reviewed. All residents with anti-rollbacks have been identified by Maintenance. 3. Systemic Changes: Administrator, Director of Nursing and nurses were trained on 1/10/12024 on not having similar interventions that are not effective by designated LPN. All nurses were trained on effective fall interventions upon arrival to work. All CNA's were trained on how anti rollbacks work and to notify Maintenance of any not working correctly. Maintenance was in-serviced on 1/10/2024 by a designated nurse on checking anti-rollbacks. The Administrator was in-serviced on 1/11/2024 on anti-rollbacks and fall interventions by an RN who is a member of the governing body. 4. Monitor: All falls will be reviewed daily x [times] 5 by Director of Nursing and Administrator to ensure interventions chosen are not similar and effective and will correct negative findings immediately. Anti-rollbacks will be checked daily x 5 to ensure they are working properly and will correct negative findings immediately. Findings will be discussed weekly at QA [Quality Assurance] meeting for effectiveness. 5. Completion Date: 1/11/2024 On 01/11/2024 at 9:39 AM, the Maintenance was asked, Have you been checking and fixing anti-rollbacks this morning? Maintenance replied, Yes I have. The Surveyor asked, You have had to fix anti-rollbacks this morning and if so, how many have you fixed? He stated, Yes, the anti-rollbacks were not tight enough. I have had to fix 4 this morning, the 4th one is in activities and will be fixed after activities. He was asked, Have you had any training on anti-rollbacks? and he stated, I had training when I started on anti-rollbacks. Surveyor asked, Have you had to train any other staff on anti-rollbacks? and he stated, No I have not. On 01/11/2024 at 2:02 PM, LPN #3 was asked, When was the last time you were trained on anti-rollbacks and how they work and how to monitor if they are functioning properly? LPN #3 stated, I have been trained on that. I do not remember the last time. On 1/11/24 at 2:02 PM, CNA #3 was asked when she was last trained on antiroll backs and she stated, Today. They are to keep them from falling. You can't roll them if the resident is not sitting in the chair. On 1/11/24 at 2:07 P.M. LPN #4 was asked if she had been trained on anti-rollbacks, and she stated no. She was asked if she knew what they were for and if she would have any idea if they were functioning properly and she stated, no. At 2:15 PM, LPN #4 came to the room and stated, I didn ' t understand what you were asking. I do know what the antiroll back is, and I was in-serviced today. It ' s the metal bar to prevent falls. A Falls and Fall Risk, Managing form, provided by the Administrator on 1/12/24 at 12:27 P.M. documented, . Policy Statement Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling . 5. If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable . On 1/11/24 at 2:42 PM, the Administrator provided a copy of a form titled Complete In-Service Training Report with Personnel Attending, dated 1/10/24, and the subjects listed were I/A not having similar interventions that are not effective as previous I/A ' s, CNA to anti rollbacks work & notify Maintenance if any not working properly. Resident #2 placed on a toileting plan. Resident #3 Buspar was decreased, Resident #1 Florinef was added. It contained signatures with various titles, RNs, LPN, CNAs, and Maintenance. There was also a page of CNAs who were in-serviced by telephone. There was another form on In-Service Training Report and the subject was Antiroll backs- What it is, reason we use them which included . CNA names listed on it. The Administrator said these were completed after they reported to work at 2 PM.