The Estates At Greeley Llc

During observation on 8/7/24 at 8:13 a.m., R37's fall mat was located on the floor in R37's room and R37 was in the dining room.

During interview and observation on 8/7/24 at 8:14 a.m., licensed practical nurse (LPN)-A verified the mat was on the floor by R37's bed and stated the mat was not a hindrance for R37 and added it was there because R37 tries to get in and out of bed constantly and the mat was kept there to prevent R37 from falling. LPN-A further stated wheelchairs were not locked because it was considered a restraint and stated it did not matter if R37's wheelchair was locked and added R37 was at a very high risk for falling.

During interview on 8/7/24 at 8:21 a.m., registered nurse (RN)-E stated R37 was at risk for falling and stated fall interventions included a soft touch call light and a floor mat while in bed, a toileting schedule and keep R37 in high traffic areas. RN-E further stated locking the wheelchair would be considered a restraint and could cause more of a safety risk because R37 was not able to move and not able to back up.

During interview on 8/7/24 at 9:22 a.m., the director of nursing (DON) stated they always try to follow the care plan and planned to talk with the aides to see why the mat was on the floor and further, housekeeping did not have access to the care plan and stated R37 could unlock the chair and stated it would be important to provide education to housekeeping.

During interview on 8/7/24 between 10:27 a.m., and 10:37 a.m., nursing assistant (NA)-D stated they had a sheet that indicated the cares a resident required and stated she could look at the documentation in the electronic medical record (EMR). NA-D stated R37 could propel her wheelchair and further stated R37 would not be able to think to know how to unlock and lock her wheelchair and stated R37's wheelchair had been locked before such as in the bathroom and when R37 first sits down in the chair and NA-D stated R37 thinks the wheelchair is stuck and does not know how to unlock it. NA-D further stated R37's mat was supposed to be on the floor at all times and verified the mat was on the floor and R37 was in the wheelchair. At 10:37 a.m. , NA-D viewed the [NAME] CNA Report sheet form and verified the form lacked fall prevention interventions including whether the mat was supposed to be off the floor when R37 was in the chair.

During interview on 8/7/24 at 10:43 a.m., the DON was notified R37 was in her room and the mat was located on the floor and staff were going down to R37's room to follow up.

245342

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 245342 B.

Wing 08/07/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Estates at Greeley LLC 313 South Greeley Street Stillwater, MN 55082