Every finding on record at Atchison Senior Village Rehabilitation and Nursing

The facility had a census of 45 residents. Based on observation, interview, and record review, the facility failed to provide Registered Nurse (RN) coverage eight hours a day, seven days a week. Findings included:- The Payroll Based Journal (PBJ-a required detail of staffing information submitted by nursing homes to the Centers of Medicare and Medicaid Services [CMS]) lacked RN eight-hour coverage for September 27, 2025, September 28, 2025, and December 20, 2025. On 02/12/26 at 08:58 AM, Administrative Nurse D verified that the two days in September and one day in December lacked eight consecutive RN hours. The facility's Consistent RN Coverage policy, dated 03/2025, documented it was the policy of the facility to ensure adequate RN coverage. The facility must provide licensed nurse coverage 24 hours a day and an RN on duty for at least eight consecutive hours daily, seven days a week, unless a state-approved waiver applies.

The facility had a census of 45 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to store, distribute, and serve food by professional standards for food service safety in the facility's kitchen. Findings included:- On 02/10/26 at 07:17 AM, observation in the nutrition center two-door refrigerator/freezer had the following: An unlabeled, undated crab salad sandwich wrapped in aluminum foil. An unlabeled, undated plastic bag with 6 cookie dough batters. An 40 ounce (oz) unlabeled, undated, plastic bag of onion rings, approximately a quarter full. An unlabeled, undated, and uncovered cup of ice cream, with the top uncovered and open to the air. The February 2026 refrigerator/ freezer temperature log had missing documentation for morning and evening shifts on February 2, 3, 4, 7, and 8. On 02/10/26 at 07:20 AM, Dietary Staff (DS) BB and Licensed Nurse (LN) G verified the above findings. DS BB stated that dietary staff and activity staff were responsible for labeling and dating food items placed in the nutritional refrigerator/freezer. LN G removed the items and discarded them in a trash can. On 02/10/26 at 07:25 AM, observation in the kitchen revealed the following: The walk-in refrigerator had two, approximately 1/4 full, unlabeled and undated packages of sliced yellow cheese. The two-door refrigerator/freezer and the walk-in refrigerator/freezer temperature logs had missing documentation for the evening shift on 02/08/26 and 02/09/26. On 02/10/26 at 07:30 AM, Certified Dietary Manager (CDM) CC verified the above observations in the kitchen and stated staff should label and date food before placing it in the refrigerator or freezer. CDM CC stated staff should document refrigerator and freezer temperatures twice a day. CDM CC removed the cheese and discarded it in a trash can. On 02/10/26 at 11:30 AM, observation revealed DS BB touched the refrigerator counter and dining tables with ungloved hands and without washing her hands, DS BB picked up R38's roll, with her right hand, placed it in her left hand, and buttered R38's roll. On 02/10/26 at 12:30 PM, CDM CC stated staff should wash their hands and place gloves on when providing help with the resident's food. The facility's Food Procurement and Storage Policy, revised 03/25, documented that education would be provided on proper labeling and dating of each food item. Staff should cover, label, and date refrigerated food items and indicate an expiration date for all items. The policy documented that staff would document the temperatures of external and internal refrigerator gauges.

The facility identified a census of 45 residents. The sample included 12 residents with two medication rooms and three medication carts. Based on observation, record review, and interviews, the facility failed to appropriately store medications and biologicals when staff failed to ensure the tuberculin (a sterile liquid used to diagnose tuberculosis) test serum was dated after opened, and further failed to ensure safe medication administration when staff prepped two residents' medications in medication cups, unlabeled in the medication cart.Findings included: On 02/10/26 at 08:34 AM, a medication room refrigerator contained one vial of tuberculin test serum. The tuberculin serum was opened and undated. On 02/10/26 at 08:37 AM LN H stated all tuberculin test serum that was opened should have a date. She stated the serum was good for 30 days after the vial had been opened. LN H stated the person who opened the serum should have dated the vial. On 02/10/26 at 08:05 AM, Administrative Nurse D stated all nurses should ensure there was no medication outdated or unlabeled. Administrative Nurse D stated it was the assistant director of nursing's responsibility to audit the medication rooms to ensure there were no outdated or undated medications. The facility Medication Labels and Storage policy dated 03/24 documented medications were labeled in accordance with the facility requirements and stated and federal laws. The policy documented only the pharmacy provider modifies or changes prescription labels. - On 02/10/26 at 07:34 AM, during the initial tour of the facility, the medication cart located in the 100 hallways had two medication cups with multiple colors and sizes of medications in clear plastic containers in the top drawer. Licensed Nurse (LN) H identified the cup of medication as R9 and R47 medications. On 02/10/26 at 04:00 PM, Administrative Nurse D verified that medications should not be prepared ahead of time until the resident is ready to take them. The facility's Medication Administration policy, dated 10/2025, documented that only licensed medical and nursing personnel or other lawfully authorized staff members may prepare, administer, and record the administration of medications and/or fluids. Medications may not be set up in advance, and scheduled medications must be administered within the facility's time frame.

The facility identified a census of 45 residents. The sample included 12 residents, with five reviewed for immunization status. Based on record reviews and interviews, the facility failed to administer Resident (R)2's Pneumococcal Conjugate Vaccine (PCV20- vaccination for bacterial pneumonia infections) vaccination that R2 consented to receive.Findings included: - Review of R2's clinical record revealed no documented PCV20, and the last documented influenza vaccine was 10/29/25. R2's consent form for PCV20 was dated 08/30/25.R2's Electronic Medical Record (EMR) lacked documentation R2 received the PCV20.On 02/12/26 at 08:22 AM, Administrative Nurse F stated consent forms for immunizations were signed as refused or consented at admission. She stated it was the floor nurse's responsibility to give the vaccination, if possible. Administrative Nurse F stated R2 signed a consent for PCV20, but the vaccine was not given. She stated it was her responsibility to give the vaccine if the vaccine was not given on admission.On 02/12/26 at 08:05 AM, Administrative Nurse D stated the assistant director of nursing was responsible for immunization auditing. She stated the immunization forms were included in the admission packet, and the floor nurse would ensure a consent was signed or a vaccination was refused. Administrative Nurse D stated the assistant director of nursing was to ensure the vaccine was given.The facility's Immunizations revised 03/25 documented it was the policy of the facility to offer and administer influenza, and pneumococcal, and COVID-19 (highly contagious respiratory virus) immunizations to eligible residents after providing education on the risks and potential side effects of the vaccines and obtaining consent. Eligibility to receive the vaccines may include, but was not limited to current vaccine status, season and time of the year, medical contradictions or resident preferences and choices.

The facility identified a census of 41 residents. The sample included three residents reviewed for elopement (when a cognitively impaired resident with little or poor safety awareness exits the facility without staff knowledge). Based on observation, record review, and interview, the facility failed to provide adequate supervision to prevent an elopement for Resident (R) 1, who was cognitively impaired, at high risk for elopement, and had a recent history of exit-seeking. The facility placed a WanderGuard (a bracelet that helps monitor residents who are at risk of wandering) on R1 on 10/04/24 due to R1's exit-seeking behaviors and setting off door alarms. R1 wandered the halls and into other residents' rooms almost daily from 10/06/24 through, and including, 10/11/24. On 10/12/24 R1 ambulated past staff, from the dining room to the great room. Staff observed R1 in the lobby area around the 300 hall after he left the dining room, but did not accompany or redirect him to a safe place. R1 ambulated to the facility's great room, and pushed on the locked door, causing the door to release after 15 seconds. According to staff, the door alarmed, but staff were too far away to hear it. R1 then ambulated unsupervised through the courtyard, opened the gate, and walked around the side of the building on the sidewalk. Staff noted R1 had exited the building unattended when staff observed R1 outside at the front of the facility and at that time staff also acknowledged the sounding door alarm. The lack of supervision and response to a sounding door alarm allowed R1 to exit the facility without staff knowledge or supervision and placed R1 in immediate jeopardy. Findings included: - R1's Electronic Medical Record (EMR), under the Diagnosis tab recorded diagnoses of difficulty in walking, a need for assistance with personal care, dementia (a progressive mental disorder characterized by failing memory and confusion), mild neurocognitive disorder (stage between the expected decline in memory and thinking that happened with age and the more serious decline of dementia) due to known physiological condition with behavioral disturbance, and major depressive disorder (major mood disorder that causes persistent feelings of sadness). The Admission 5-Day Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of one, which indicated severely impaired cognition. R1 required supervision or touching assistance with walking and transfers. R1 required partial to moderate assistance with dressing and toileting. R1 had inattention and disorganized thinking. R1 had physical behavioral symptoms directed toward others and other behavioral symptoms not directed towards others, which occurred one to three days during the look-back period. R1 rejected care one to three days during the look-back period, R1 wandered daily, and significantly intruded on the privacy of activities of others. The Cognitive Care Area Assessment (CAA) dated 10/09/24 documented R1 did not always understand what was being said to him. R1 was disoriented and confused most of the time. R1 wandered aimlessly daily. R1 did exit seek and had a WanderGuard in place for precautionary measures. R1 could be easily triggered for behaviors and had exhibited multiple behaviors since admission related to not cognitively understanding what took place. The Behavioral CAA dated 10/09/24 documented R1 placed himself at greater risk of losing his balance and falling when he lashed out while ambulating. R1 did not sleep well at night and was up most nights. R1 wandered aimlessly and could become behavioral and loud at times disrupting the environment. Staff redirected and attempted to calm R1 to decrease interruptions. Staff continued to intervene and attempted to calm, redirect, resolve, and distract R1 when he had behaviors. R1's Care Plan initiated on 10/04/24 documented R1 could ambulate without assistive devices. Staff were to distract R1 from wandering by offering food, drink, a video of R1 playing in his band, pleasant diversions, structured activities, food, conversations, television, or a book. Staff were directed to document wandering behavior and attempted diversional interventions. R1 was very confused and disoriented and would wander and try doors. R1 was not aware of safety. Staff monitored WanderGuard placement, and staff were to check placement and functioning every shift and as needed. R1's intervention initiated on 10/08/24 documented that R1 wandered daily and was resistant to care and redirection. R1 would hit, slap, yell, cuss, and try the exits. R1 wandered in and out of others' rooms and could be disruptive to the environment with behavioral outbursts. R1's Kardex (a nursing tool that gives a brief overview of the care needs of each resident) informed staff R1 was not aware of his safety, was very confused and disorientated, and would wander and try the doors. It informed staff R1 utilized a WanderGuard and was an elopement risk. R1's Elopement/Wandering Evaluation dated 10/04/24 documented R1's elopement score was 30, which indicated R1 was a high risk of an elopement. R1's Orders dated 10/04/24 ordered staff to monitor the placement and functioning of WanderGuard every shift for monitoring. The Behavior Note dated 10/03/24 at 09:37 PM documented R1 continually wandered the halls since his family left. R1 was very difficult to redirect and at times got very agitated when trying to redirect. The Nursing Note dated 10/04/24 at 07:58 AM documented R1 attempted to exit the door at the end of his hallway and set the door alarm off trying to open the door. R1 was easily redirected back away from the door. The Nursing Note dated 10/04/24 at 08:46 AM documented R1 had a WanderGuard bracelet applied to his right wrist. The Daily Skilled Note dated 10/05/24 at 01:09 PM documented R1 was observed to have wandering behaviors but was easily redirected. The Medication Administration Note dated 10/06/24 at 12:09 AM documented R1 was up and down the halls multiple times, going through drawers, closets, and bins in the hallway. R1 was redirected to the nurses' station and offered snacks, drinks, and distraction with music and television without resolution. R1 received as-needed medication for behaviors. The Daily Skilled Note dated 10/06/24 at 10:26 AM documented R1 was observed to have wandering behaviors. The Nursing Note dated 10/07/24 at 05:38 AM documented R1 was up throughout the night wandering the halls. R1 went in and out of rooms and went through closets at times. R1 was easily redirected. The Behavior Note dated 10/08/24 at 04:07 AM documented R1 wandered the halls all that shift going in and out of other resident rooms. R1 laid down in an empty room and was unable to be redirected back to his room. The Behavior Note dated 10/08/24 at 09:20 PM documented R1 attempted to cut off his WanderGuard. The Daily Skilled Note dated 10/09/24 at 03:50 PM documented R1 rejected care and was wandering. The Behavior Note dated 10/09/24 at 09:47 PM documented R1 continued to wander around the facility and entered other resident rooms. R1 got very agitated and aggressive with staff when staff attempted to redirect R1 out of other resident rooms. R1 was very hard to redirect and attempted to his staff members when staff attempted to redirect R1. The Behavior Note dated 10/11/24 at 10:17 AM documented R1 was undressed from the waist down and staff attempted to assist R1 in putting on clothes, which R1 refused and was hard to redirect. R1 wandered the halls going into other resident rooms. The Daily Skilled Note dated 10/11/24 at 03:22 PM documented R1 wandered around the building and had inappropriate, hard-to-redirect behaviors. R1 would hit staff and was non-compliant when directions were given. The Condition Follow-Up Note dated 10/12/24 at 12:57 PM documented R1 went outside the courtyard door to take a walk at approximately 11:43 AM. The WanderGuard alarm sounded, and staff responded to the alarm in addition to noticing R1 was outside the dining room window. R1 was easily redirected back into the building and assessed. The Facility Investigation dated 10/21/24 documented that at approximately 12:43 PM staff responded to the WanderGuard alarm and noticed R1 was outside the dining room window. R1 went outside the courtyard door to take a walk. Licensed Nurse (LN) H's Notarized Witness Statement dated 10/12/24 documented that Activity Z pointed out the window alerting staff that R1 was outside. LN H went out the dining room door and redirected R1 into the dining room. R1 was easily redirected and sat down to eat at the table. LN H was unable to hear the alarms in the dining room. LN H had last seen R1 seated at the chairs by the little kitchen before LN H started to pass medications and check blood sugars. Certified Medication Aide (CMA) R's Notarized Witness Statement dated 10/12/24 documented R1 was seen at 12:20 PM on a hall, at which time CMA R encouraged R1 to go to the dining room to eat. R1 reportedly turned and faced the dining room. CMA R reported that R1 was seen coming out of the dining room at approximately 12:30 PM. CMA R again told R1 to go eat lunch. CMA R stated she entered the dining room to see what other medication she needed to pass before she sat down to assist residents with eating. CMA R reportedly sat down to assist residents with eating at approximately 12:40 PM. CMA R reported hearing Activity Z state that R1 was outside at 12:43 PM. That is when LN H and CNA N went out the side door of the dining room and walked R1 back into the dining room. On 10/21/24 at 11:45 AM R1 ambulated from the dining room with CMA R walking with R1. R1 appeared clean, well-groomed, and ambulated independently with no assistive devices. CMA R guided R1 to the recliners to sit and watch television. On 10/21/24 at 12:05 PM the door that R1 was suspected of exiting opened into a courtyard on the side of the building. The door had a sidewalk that wrapped from the doorway around to a gate in the fenced-in area of the courtyard. It was approximately 53 feet from the doorway to the gate. The gate was easily opened, even with a lock on the gate, from the inside of the courtyard. The sidewalk continued around the side of the building to wrap to the front side with the sidewalk ending approximately 43 feet from the gate to the courtyard. The sidewalk had slight variations in level but was relatively smooth. The sidewalk that led into the front parking lot had a wheelchair ramp going down to the asphalt and then ended. The sidewalk had an inch to an inch and a half step down to the grass along the sides of the sidewalk. The sidewalk did not start back up until roughly 15 feet away from the wheelchair ramp, which then started at the front door and then wrapped down in front of the dining room windows. On 10/21/24 at 11:55 AM Licensed Nurse (LN) G stated that R1 frequently ambulated down the hall he lived on and triggered the door alarm. LN G stated that staff were good at redirecting R1 when the alarm sounded and having R1 turn away from the door. On 10/21/24 at 12:01 PM, CMA R stated that she had been rounding up residents to eat lunch off a hallway. CMA R stated that R1 ambulated in the hallway and at approximately 12:20 PM CMA R encouraged R1 to go to the dining room for lunch. CMA R stated R1 followed her to the dining room. CMA R revealed that at that time she went to administer medications to residents that were not in the dining room, upon returning to the dining room at approximately 12:30 PM CMA R observed R1 leaving the dining room. Again, CMA R encouraged R1 to go back into the dining room to eat, but R1 continued to ambulate away from the dining room. At approximately 12:43 PM Activity Z asked if that was R1 outside the building. CMA R stated staff responded to R1 out in the parking lot brought R1 back into the building and placed R1 on one-on-one supervision. On 10/21/24 at 02:00 PM, Certified Nurse Aide (CNA) M stated that she was getting residents to the dining room. CNA M revealed that she passed R1 in the hallway and asked if R1 was going to eat lunch. R1 reportedly told CNA M that he was not hungry. CNA M revealed that the dining room was loud, and she could not hear any alarm going off at all. CNA M further stated that it was not until Activity Z stated that R1 was out in the parking lot that staff were aware that R1 had left the building. CNA M stated that R1 usually triggered the door alarms and that staff attempted to redirect him to be able to silence the door alarms. On 10/21/24 at 02:05 PM Administrative Nurse D stated that the alarm was sounding when R1 exited the building. On 10/21/24 at 02:20 PM Administrative Staff A stated that the WanderGuard alarmed on the walkies that were carried by staff and that staff needed to make sure that they had a walkie on. Administrative Staff A also stated that she could not even hear the door alarm from her office, so the facility would need to do something different. On 10/21/24 at 04:09 PM, LN H stated she was in the dining room passing medications when Activity Z said she thought that was R1 outside the building. LN H stated she ran out to him through the door in the dining room and brought him back into the dining room. LN H stated that she could not hear any alarms sounding when she was in the dining room. LN H revealed that when she exited the dining room back towards the nurse's station, she could not hear any alarms going off until she passed the fish tank which was approximately ten feet from the dining room doors. LN H revealed that she was unsure which door R1 had exited but when she went out into the courtyard the gate to the fenced-in area was opened. R1 had his WanderGuard on when he was brought back into the building. On 10/21/24 at 04:54 PM Administrative Nurse D stated that R1 was found on the sidewalk outside the dining room, not the parking lot. On 10/22/24 at 12:01 PM, LN H emailed that Activity Z pointed to the row of windows in the dining room and stated, Isn't that R1 outside? LN H looked up and observed R1 standing next to the window outside. LN H and CNA N ran outside from the dining room door to intercept R1. R1 wore tennis shoes, sweats, and a t-shirt with his WanderGuard visible on his ankle. LN H stated the door alarm was heard after leaving the dining room. The door alarm that was triggered was the great room door. On 10/22/24 at 01:39 PM, Activity Z emailed that while she was in the dining room delivering a plate of food to a resident R1 was seen out the window walking across the parking lot. Activity Z stated she calmly stated R1 was outside. Activity Z stated normally she could hear the door alarm whenever it went off, but on that day she did not. Activity Z stated that after R1 was back in the building staff went to figure out how R1 got out. Activity Z revealed R1 went out the side door by the great room and out the fence. The facility's policy Quality of Care revised October 2024 documented it was the policy of the facility to provide a safe environment, as free of accidents, as possible, for all residents through appropriate assessment, interventions, and adequate supervision to prevent accidents related to unsafe wandering or elopement while maintaining the least restrictive manner for those at risk for elopement. The resident's care plan would be updated to include interventions to address the possible need for an increased level of supervision. On 10/21/24 at 04:58 PM Administrative Staff A received a copy of the Immediate Jeopardy [IJ] Template and informed that the facility's failure to ensure R1 received adequate supervision to prevent an elopement placed R1 in IJ. The facility completed the following corrective actions by 10/16/24: R1 was assessed and placed under one-to-one staff supervision. R1's physician and family were notified. R1's plan of care was updated with interventions to address R1's desire to go outside and experience the weather. The facility implemented daily behavioral audits in the clinical meeting to review and follow up on any new behaviors from the 24-hour report. Staff received education on elopement policies and procedures. All corrective actions were completed prior to the onsite survey therefore the deficient practice was deemed past noncompliance and remained at a scope and severity of J.

The facility identified a census of 32 residents. The sample included 13 residents. Based on record review and interview, the facility failed to provide a Registered Nurse (RN) for at least eight consecutive hours a day seven days a week. This placed the residents at risk of decreased quality of care. Findings included: - The Payroll Based Journaling (PBJ) report provided by the Centers for Medicare & Medicaid Services (CMS) for Fiscal year (FY) 2023 Quarters 3 and 4 indicated 139 days the facility did not have an RN for eight consecutive hours each 24-hour period. A review of timeclock and payroll data revealed the facility had eight consecutive hours of RN coverage all but four days (04/16/23, 05/06/23, 05/07/23, and 05/21/23). On 04/17/24 at 03:06 PM Administrative Staff A stated she could not say what the previous system was to track and ensure there were eight consecutive RN hours seven days a week before 03/01/24. The Nursing Administrative- Nursing Services policy last revised in February 2024 documented it was the policy of this facility to maintain adequate nursing personnel that ensured the care, treatment, and service needs of all residents and complied with minimum staffing levels mandated by federal and state requirements. The facility would ensure the services of an RN for at least eight consecutive hours a day, seven days a week as required by the regulation. The facility failed to provide an RN for at least eight consecutive hours a day seven days a week. This placed the residents at risk of decreased quality of care.

The facility identified a census of 32 residents. The sample included 13 residents. Four Certified Nurse Aides (CNA) and one Certified Medication [NAME] (CMA) were sampled for performance reviews. Based on record review and interview, the facility failed to complete the required nurse aide performance review at least once every 12 months. This placed the residents at risk for inadequate care. Findings included: - CNA N had a hire date of 01/19/17. The facility lacked evidence a performance review was completed in the last 12 months upon request. CNA O had a hired date of 08/27/17. The facility lacked evidence a performance review was completed in the last 12 months upon request. CNA P had a hire date of 04/19/12. The facility lacked evidence a performance review was completed in the last 12 months upon request. CNA Q had a hire date of 11/07/22. The facility lacked evidence a performance review was completed in the last 12 months upon request. CMA N had a hire date of 06/19/22. The facility lacked evidence a performance review was completed in the last 12 months upon request. On 04/17/24 at 12:54 PM, CMA S stated she worked at the facility for over three years and could not recall ever having a performance review completed since she had been hired. CMA S stated staff completed Relias training and education which was done on the computer. On 04/17/24 at 01:08 PM, CNA M stated she did not recall ever having a performance review done since she had been hired. On 04/17/24 at 02:28 PM Administrative Nurse D stated he had not been able to find where prior management staff completed nurse aide performance reviews as required. Administrative Nurse D stated that he, along with other management staff, would be completing performance reviews on nurse aid staff and would have them scheduled annually going forward. The Nursing Staff Competency policy last March 2024 documented each nursing staff member shall complete an annual competency assessment and additional competency assessments as needed based on the resident population's needs in accordance with the facility assessment. The facility would conduct an annual or bi-annual skills fair or equivalent to facilitate the completion of skills and competency evaluation. The facility failed to complete the required nurse aide performance review at least once every 12 months. This placed the residents at risk for inadequate care.

The facility had a census of 32 residents. Based on interview and record review the facility failed to submit complete and accurate staffing information to the federal regulatory agency through Payroll Based Journaling (PBJ) when the facility failed to submit staffing data for all direct care personnel as required one quarter and failed to submit accurate data on others. This placed the residents at risk for impaired care due to unidentified staffing issues. Findings included: - The PBJ report provided by the Centers for Medicare & Medicaid Services (CMS) for Fiscal Year (FY) 2023 Quarter 2 and 2024 Quarter 1 indicated data was suppressed though the facility did not meet the reasons for suppressed data other than inaccurate data or failure to report. The PBJ report indicated 23 days in FY 2023 Quarters 3 and 4 the facility did not have a licensed nurse coverage 24 hours a day. A review of timeclock and payroll data revealed the facility had LN coverage 24 hours a day on the days listed on the PBJ. The PBJ report indicated 139 days in FY 2023 Quarter 3 and 4 the facility did not have a registered nurse (RN) for eight consecutive hours each 24-hour period. A review of timeclock and payroll data revealed the facility had eight consecutive hours of RN coverage on all but four days. On 04/17/24 at 03:06 PM, Administrative Staff A stated the facility had entered the incorrect information into the PBJ. Administrative Staff A stated there was confusion related to the previous staff responsible for reporting and entering the payroll information. Administrative Staff A stated she was now the person who was responsible for ensuring the information was accurately provided to CMS. The facility's Payroll-Based Journal policy dated 03/01/24 documented It was the policy of the facility to submit information every quarter to the Centers for Medicare and Medicaid Services (CMS) as required that detailed the hours the facility staff worked in specific job titles. The facility failed to submit accurate information to CMS PBJ. This placed the residents at risk for impaired care due to unidentified staffing issues.

The facility identified a census of 32 residents. The sample included 13 residents with seven residents reviewed for activities of daily living (ADL) for dependent residents. Based on observation, record review, and interviews, the facility failed to ensure a shower/bath was consistently provided for Resident (R) 30, R22, R18, R7, and R16 who were dependent on staff assistance with ADLs. The facility also failed to ensure R16 was assisted with dressing. This deficient practice had the potential to cause skin breakdown and/or skin complications due to poor personal hygiene and impaired psychosocial well-being. Findings included: - R30's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of need for assistance with personal care, muscle weakness, chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), and Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure). The Significant Change Minimum Data Set (MDS) dated [DATE] documented a staff interview that indicated severely impaired cognition. The MDS documented R30 received oxygen therapy during the observation period. The MDS documented R30 required substantial to maximal assistance with bathing. The Quarterly MDS dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of six which indicated severely impaired cognition. The MDS documented R30 required substantial to maximal assistance with bathing. R30's Falls Care Area Assessment (CAA) dated 11/22/23 documented R30 remained cognitively impaired and was no longer aware of safety. R30's Care Plan dated 03/21/24 documented R30 was dependent on staff assistance for all her bathing needs. A review of R30's EMR under the Documentation Survey Reports tab for bathing reviewed from 03/01/24 to 04/15/24 (46 days) revealed one Shower (SH) on 03/11/24, one Full Bath (FB) on 04/01/24, two Sponge Bath (SB) on 03/05/24 and 03/25/24. Two Resident Refused (RR) on 03/04/24 and 03/06/24. Five Not Applicable (NA) on 03/05/24, 03/14/24, 04/04/24, 04/08/24, and 04/15/24 were recorded. On 04/16/24 at 01:33 PM, R30 sat upright in her Broda chair (specialized wheelchair with the ability to tilt and recline) with her lower extremities elevated. On 04/17/24 at 09:15 AM, Certified Medication Aide (CMA) S stated each resident had a scheduled bath/shower day assigned. CMA S stated R30 had not refused her baths/showers that she was aware of. On 04/17/24 at 10:17 AM Licensed Nurse (LN) G stated staffing was hectic in March 2024. LN G stated some of the residents did not receive their baths. On 04/17/24 at 01:13 PM, Certified Nurse Aide (CNA) M stated the restorative aide and the bathing aide usually did most of the showers. CNA M stated the facility no longer staffed those positions. CNA M stated normally if a shower or bed bath was not done on the day shift, the evening shift would be notified, and perform that duty. On 04/17/24 at 02:33 PM Administrative Nurse D stated the facility was staffed enough to provide bathing as scheduled. The facility's Services to carry out ADLs policy dated 03/01/24 documented it was the policy of the facility that residents were given the appropriate treatment and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident in accordance with a written plan of care. If a resident was unable to carry out activities of daily living, the necessary services to maintain good nutrition, grooming, and personal oral hygiene would be provided by staff as documented on the Care Plan. Residents would be involved in decision-making and given choices related to ADL activities as much as possible and interventions added to the Care Plan for staff assistance. ADL care provided would be documented in the medical record accordingly. The facility failed to provide consistent bathing for R30, who was dependent on staff assistance for bathing. This deficient practice placed R30 at risk for complications related to poor hygiene and impaired dignity. - R22's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of obesity (excessive body fat), muscle weakness, need for assistance for personal care, history of urinary tract infection, and diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 12 which indicated moderately impaired cognition. The MDS documented R22 required supervision to touch assistance with bathing. The Quarterly MDS dated [DATE] documented a BIMS score of 15 which indicated intact cognition. The MDS documented that R22 required substantial to maximal assistance from staff for bathing. R22's Functional Abilities Care Area Assessment (CAA) dated 11/17/23 documented R22 required assistance from the staff for ADLs. R22's Care Plan dated 11/26/23 documented R22 required substantial to extensive assistance with bathing. R22's EMR under the Documentation Survey Reports tab for bathing reviewed from 03/01/24 to 04/15/24 (46 days) revealed two Resident Refused (RR) on 03/19/24 and 03/22/24. Six Not Applicable (NA) on 03/05/24, 03/06/24, 03/12/24, 03/15/24, 04/02/24, and 04/09/24 were recorded. The EMR lacked evidence a bath/shower was provided for R22 for the 46 days reviewed. On 04/16/24 at 10:26 AM R22 sat in her wheelchair in her room next to her husband. R22 stated she would never refuse a bath unless she was ill. R22 stated she always appreciated getting her bath. She stated it made her feel better. On 04/17/24 at 10:17 AM Licensed Nurse (LN) G stated staffing was hectic in March 2024. LN G stated some of the residents did not receive their baths. On 04/17/24 at 01:13 PM, Certified Nurse Aide (CNA) M stated the restorative aide and the bathing aide usually did most of the showers. CNA M stated the facility no longer staffed those positions. CNA M stated normally if a shower or bed bath was not done on the day shift, the evening shift would be notified, and perform that duty. On 04/17/24 at 02:33 PM Administrative Nurse D stated the facility was staffed enough to provide bathing as scheduled. The facility's Services to carry out ADLs policy dated 03/01/24 documented it was the policy of the facility that residents were given the appropriate treatment and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident in accordance with a written plan of care. If a resident was unable to carry out activities of daily living, the necessary services to maintain good nutrition, grooming, and personal oral hygiene would be provided by staff as documented on the Care Plan. Residents would be involved in decision-making and given choices related to ADL activities as much as possible and interventions added to the Care Plan for staff assistance. ADL care provided would be documented in the medical record accordingly. The facility failed to provide consistent bathing for R22, who required extensive assistance from staff for bathing. This deficient practice placed R22 at risk for complications related to poor hygiene and impaired dignity. - R18's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of obesity (excessive body fat), muscle weakness, need for assistance with personal care, and lymphedema (swelling caused by accumulation of lymph). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS documented R18 required substantial to maximal assistance from staff for bathing. R18's Functional Abilities Care Area Assessment (CAA) dated 04/02/24 documented R18 could stand and pivot. R18's Care Plan dated 03/22/24 documented R18 required substantial assistance from staff for bathing. R18's EMR under the Documentation Survey Reports tab for bathing reviewed from 03/01/24 to 04/15/24 (46 days) revealed three Showers (SH) on 04/01/24, 04/04/24, and 04/11/24; two Resident Refused (RR) on 03/06/24 and 03/14/24. Five Not Applicable (NA) on 03/05/24, 03/07/24, 03/26/24, 04/08/24, and 04/15/24 were recorded. On 04/17/24 at 08:05 AM R18 sat in her recliner in her room with her lower extremities elevated. R18 stated she would never refuse a bath. R18 stated she had been informed by staff there was not enough staff to provide her with a bath on occasion. R18 stated she felt dirty when she missed her bath or shower. On 04/17/24 at 10:17 AM Licensed Nurse (LN) G stated staffing was hectic in March 2024. LN G stated some of the residents did not receive their baths. On 04/17/24 at 01:13 PM, Certified Nurse Aide (CNA) M stated the restorative aide and the bathing aide usually did most of the showers. CNA M stated the facility no longer staffed those positions. CNA M stated normally if a shower or bed bath was not done on the day shift, the evening shift would be notified, and perform that duty. On 04/17/24 at 02:33 PM Administrative Nurse D stated the facility was staffed enough to provide bathing as scheduled. The facility's Services to carry out ADLs policy dated 03/01/24 documented it was the policy of the facility that residents were given the appropriate treatment and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident in accordance with a written plan of care. If a resident was unable to carry out activities of daily living, the necessary services to maintain good nutrition, grooming, and personal oral hygiene would be provided by staff as documented on the Care Plan. Residents would be involved in decision-making and given choices related to ADL activities as much as possible and interventions added to the Care Plan for staff assistance. ADL care provided would be documented in the medical record accordingly. The facility failed to provide consistent bathing for R18, who required extensive assistance from staff for bathing. This deficient practice placed R18 at risk for complications related to poor hygiene and impaired dignity. 49634 - R7's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of hypertension (elevated blood pressure), obesity (excessive body fat), congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), candidiasis (a fungal infection caused by a yeast), and muscle weakness. The Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS documented that R7 was dependent on one staff for all bathing. R7's Care Area Assessment (CAA) dated 10/15/23 documented R7 needed substantial assistance from staff to complete her bathing. R7 was not able to reach all areas, so that was completed by staff. She often refused to get in the shower and staff would give her a good bed bath. R7's Care Plan dated 04/08/24 documented R7 needed substantial assistance from staff for all her bathing tasks. R7's EMR under the Documentation Survey Reports tab for bathing documented that she was to have a shower on Tuesdays, Thursdays, and Sundays on the day shift. On 03/02/24 R7's bathing was documented as not applicable (NA). On 03/04/24 the bathing event was documented as NA. R7 received a shower on 03/09/24. The bathing was recorded as refused on 03/11/24. The time from 03/12/24-03/31/24 lacked evidence a shower/bath was provided, offered, or refused. On 04/17/24 at 09:34 AM, R7 reported that in the month of March 2024, she did not receive a bath or shower. R7 stated she usually refused a shower, but she never refused a bed bath. R7 states she was told the facility did not have enough staff to give baths. On 04/17/24 at 10:17 AM Licensed Nurse (LN) G stated staffing was hectic in March 2024. LN G stated R7 usually refused showers but never refused a bed bath. LN G stated if R7 told you she did not receive a bath at all last month, she probably did not. On 04/17/24 at 01:13 PM in an interview, Certified Nurse Aide (CNA) M stated the restorative aide and the bathing aide usually did most of the showers. CNA M stated the facility no longer staffed those positions. CNA M stated that she was unsure if R7 was offered a shower or bed bath in March 2024. CNA M stated normally if a shower or bed bath was not done on the day shift, the evening shift would be notified, and perform that duty. On 04/17/24 at 02:33 PM Administrative Nurse D stated the facility was staffed enough to provide bathing as scheduled. The facility's Services to carry out ADLs policy dated 03/01/24 documented it was the policy of the facility that residents were given the appropriate treatment and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident in accordance with a written plan of care. If a resident was unable to carry out activities of daily living, the necessary services to maintain good nutrition, grooming, and personal oral hygiene would be provided by staff as documented on the Care Plan. Residents would be involved in decision-making and given choices related to ADL activities as much as possible and interventions added to the Care Plan for staff assistance. ADL care provided would be documented in the medical record. The facility failed to provide consistent bathing for R7 who required assistance with bathing. This deficient practice placed R7 at risk for complications related to poor hygiene and impaired dignity. 45668 - The Medical Diagnosis section within R16's Electronic Medical Records (EMR) included diagnoses of an anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), insomnia (difficulty sleeping), and gastro-esophageal reflux disorder (GERD-backflow of stomach contents to the esophagus). R16's Annual Minimum Data Set (MDS) completed 03/04/24 noted a Brief Interview for Mental Status score of 14 indicating intact cognition. The MDS indicated she required substantial to maximal assistance for bathing, dressing, and toileting. The MDS indicated she had moderate difficulty hearing but did not use hearing aids. R16's Communication Care Area Assessment (CAA) completed 03/05/24 indicated she was hard of hearing in both ears and opted to utilize no hearing devices. The CAA noted she had an amplifier, but she chose to utilize this most of the time. The CAA noted the amplifier did assist with her hearing. R16's Functional Abilities CAA completed 03/05/24 indicated she required substantial assistance from staff to complete her activities of daily living (ADLs). The CAA indicated she chose to eat meals in her room. The CAA indicated staff will assist her with her needs and a care plan will be updated to indicate her changing needs. R16's Care Plan initiated 03/07/24 indicated she was at risk for impaired communication related to her hearing deficit. The plan instructed staff to be conscious of her positioning when in groups to promote proper communication. The plan indicated she used a sound amplifier but refused auxiliary aids most of the time. The plan instructed staff to validate communication verbally aloud. The plan directed she required substantial assistance with showering, bed mobility, dressing, and transfers. R16's Documentation Survey Report for bathing from 03/01/24 through 04/17/24 indicated she received bathing on six occasions (03/02/24, 03/09/24, 03/13/23, 03/20/24, 04/03/24, and 04/06/24). The report noted not applicable was noted on four occasions (03/03/24, 03/06/24, 03/31/24, 03/04/24, and 04/07/23). The report indicated she refused on three occasions (03/01/24, 03/23/24, and 03/30/24). On 04/15/24 at 08:50 AM R16 sat in her recliner in her room. R16 stated she needed to put her hearing amplifier headphones on. R16's headphones did not function upon putting them on her head. She stated could barely hear without them. An inspection of the headphones revealed the batteries were dead. R16 was able to communicate but struggled to hear the questions being asked. She stated that staff do not check her headphones very often and she didn't get frequent visits due to most of the residents moving to a different hallway for remodeling. She reported staff don't always come around and check on her as often as they should. R16 stated her bathing days were Wednesday and Saturday. She stated recent assistance for her grooming and bathing had gotten worse. She stated she had missed baths due to no one checking on her. On 04/16/24 07:34 AM R16 sat in her recliner in her room and ate her breakfast. On 04/16/24 at 10:10 AM R16 sat in her recliner in her room. R16 stated she had not seen staff since breakfast. Her breakfast tray remained on her bedside table next to her door. She stated she was still waiting for assistance to get dressed. R16 was still wearing her nighttime pajamas. She stated she did not know why it took this long to get dressed. She stated her amplifier headphone batteries were finally changed out the previous evening. On 04/16/24 at 11:34 AM R16 sat in her recliner. She stated staff finally assisted her with personal hygiene and changing her clothing. R16's green button-up blouse shirt was on inside-out. On 04/17/24 at 12:45 PM, Licensed Nurse (LN) G stated the direct care staff should offer bathing multiple times and document the refusals in the EMR. She stated if a resident refused staff should offer another time or a later date. She stated March was a struggle for bathing due to low staffing. She stated that sometimes showers did not get completed. She stated the direct care staff and nurses should work together to complete bathing. On 04/17/24 at 01:08 PM, Certified Nurse's Aide (CNA) M stated each resident was scheduled for two baths a week. She stated refusals would be reported to the nurse. She stated the nurse would attempt to bathe the resident. She stated refusals would be documented in the EMR and attempted at a later date. On 04/17/24 at 02:34 PM Administrative Nurse D stated staff were expected to provide bathing as scheduled. He stated refusals should be reported to the nurse and attempted at a later time or date. The facility's Services to carry out ADLs policy dated 03/01/24 documented it was the policy of the facility that residents were given the appropriate treatment and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident in accordance with a written plan of care. If a resident was unable to carry out activities of daily living, the necessary services to maintain good nutrition, grooming, and personal oral hygiene would be provided by staff as documented on the Care Plan. Residents would be involved in decision-making and given choices related to ADL activities as much as possible and interventions added to the Care Plan for staff assistance. ADL care provided would be documented in the medical record accordingly. The facility failed to provide consistent assistance for R16 related to bathing and dressing. This deficient practice placed R16 at risk for infections and decreased psychosocial well-being.

The facility had a census of 32 residents. The sample included 13 residents with five residents reviewed for accidents and/or hazards. Based on observation, record review, and interview the facility failed to secure hazardous materials out of reach of five cognitively impaired, independently mobile residents. The facility also failed to ensure Resident (R)25's fall interventions were implemented per her plan of care at mealtime. This deficient practice placed the affected residents at risk for preventable injuries and accidents. Findings Included: - On 04/18/2024 at 07:11 AM a walkthrough of the facility was completed. An inspection of the facility's 100 and 200 unsecured laundry rooms revealed accessible containers of sanitary bleach wipes. The wipes contained a Keep out of reach from children warning. An inspection of the 300 hallway's unsecured laundry room revealed sanitary bleach wipes and a bottle of tuberculocidal (bacterial infection of the lungs) disinfectant spray. The wipes contained a Keep out of reach from children warning. On 04/17/24 at 12:45 PM, Licensed Nurse (LN) G stated hazardous chemicals were supposed to be locked out of the resident's reach. She stated the residents should not be in the laundry rooms and said she was not sure why the rooms did not lock. On 04/17/24 at 01:08 PM Certified Nurse's Aide (CNA) M stated cleaning products should always be in a locked area or cabinet away from the residents. On 04/17/24 at 02:34 PM Administrative Nurse D stated staff were expected to ensure hazardous cleaning products remained locked away from the residents. The facility's provided Hazardous Chemical Storage policy revised 03/2024 indicated all potentially hazardous materials will be stored in secured areas out of reach from the resident population. The policy indicated products in use will be monitored. The policy indicates all housekeeping products will be stored in a clean and safe manner. The facility failed to secure hazardous materials out of reach of five cognitively impaired, independently mobile residents. This deficient practice placed affected residents at risk for preventable injuries and accidents. - The Medical Diagnosis section within R25's Electronic Medical Records (EMR) included diagnoses of repeated falls, muscle weakness, insomnia (difficulty sleeping), dementia (a progressive mental disorder characterized by failing memory, and confusion), and congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid). R25's Annual Minimum Data Set (MDS) completed 02/24/24 noted a Brief Interview for Mental Status score of zero indicating severe cognitive impairment. The MDS indicated she required maximal assistance with transfers, bed mobility, bathing, personal hygiene, dressing, and mobility. The MDS indicated she used a manual wheelchair. The MDS indicated she had two non-injury falls since admission. R25's Care Plan initiated on 12/01/23 indicated she had a deficit related to her functional activities of daily living (ADLs). The plan indicated she had severe cognitive impairment and was dependent on staff assistance for transfers, dressing, bathing, toileting, and personal hygiene. The plan indicated she was dependent on staff for mobility but could propel herself. The plan noted R25 had a history of attempting to pick up non-existent objects off the floor due to her severe cognitive impairment. The plan indicated she had a history of sliding out of her wheelchair due to her cognitive impairment. R25's plan instructed staff to bring her to the dining room only once her meal was ready and staff were to sit with her. On 04/16/24 at 08:35 AM R25 was in the dining room alone at a table. R25 pushed her wheelchair away from the table and attempted to stand several times before staff intervened. On 04/16/24 at 11:54 AM R25 was brought to the dining room. R25's food plate was not ready to be served. R25 sat alone at the center dining room table. R25 pushed herself away from the table. R25 placed her feet in between her wheelchair's foot pedals. From 11:54 AM to 12:07 PM, R25 attempted to stand up from her wheelchair multiple times without staff in the immediate area to intervene. On 04/17/24 at 12:54 PM, Licensed Nurse (LN) G stated that R25 was at high risk for falls due to her severe cognitive impairment. She stated staff should be with R25 during mealtimes to prevent her from falling. She stated staff should take R25 to her meals only when the meal was ready. On 04/17/24 at 01:08 PM Certified Nurse's Aide (CNA) M stated staff were not supposed to take R25 to the dining room until her meal was ready. She stated R25 wanders and had previous falls due to her confusion. On 04/17/24 at 02:34 PM Administrative Nurse D stated staff were expected to bring R25 to the dining room when her meals were ready and stay with her. The facilities provided a Fall Management System policy revised on 03/01/24 that indicated the facility will provide an environment that remains free from accident hazards. The policy indicated the residents would be assessed for potential risk and provided care planned interventions. The facility failed to ensure a safe environment related to R25's care-planned fall interventions when staff brought her to the dining area before her meal was served. This deficient practice placed R25 at risk for preventable falls and related injuries.

The facility identified a census of 32 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to ensure guidelines for enhanced barrier precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms which employ targeted gown and glove use during high contact care) were followed when the facility failed to have personal protective equipment (PPE) readily available for staff use, stored outside the room. The facility failed to ensure staff sanitized resident equipment when it fell on the floor. This placed the residents at risk of infection development. Findings included: - Upon inspection of the facility during the initial tour on 04/15/24 around 07:15 AM observation revealed that the facility did not have PPE readily available for staff usage if needed stored outside the room. The facility had PPE stored in the resident's room and not in a covered cart or storage area. On 04/17/24 at 08:48 AM Licensed Nurse (LN) G was outside of Resident (R) 2's room with her medication cart. LN G grabbed R2's continuous glucose monitor (CGM- a glucose monitoring system that tests glucose levels without finger pricking) and it dropped on the floor. LN G picked the machine up off the floor but failed to properly sanitize the machine or her hands before use on R2. On 04/17/24 at 12:27 PM LN G stated she had not realized until after being observed earlier that morning that she had forgotten to sanitize R2's blood sugar machine after it had fallen on the floor. LN G stated usually she would usually have sanitized the machine afterward or after use. On 04/17/24 at 02:28 PM Administrative Nurse D stated that residents that were on EBP now have PPE available for them. Administrative Nurse D stated PPE was available inside the resident's room in a drawer. Administrative Nurse D stated there were also carts out in the halls that should have PPE stocked in them all the time. Administrative Nurse D stated that he expected staff to clean/sanitize equipment after each use especially if the equipment had fallen onto the floor. On 04/17/24 at 02:55 PM Administrative Staff A stated the facility would ensure that PPE was always available for staff to use on any resident on EBP. The Infection Control Policy/Procedure: Cleaning and Disinfecting of Shared Equipment last revised in May 2007 documented that supplies and equipment would be cleaned immediately after use. Disinfection should be completed by cleansing the equipment with approved cleansing wipes. Allow the item to dry before use on another resident per the wet time specifications. The Infection Prevention and Control Program (IPCP) Standard and Transmission-Based Precautions policy revised in March 2024 documented EBP used in conjunction with standard precautions and expanded the use of PPE with a gown and gloves during high-contact resident care activities. The facility failed to ensure the required EBP guidelines were followed when the facility failed to have PPE readily available for staff use outside the residents' rooms. The facility failed to ensure staff sanitized resident equipment when it fell on the floor. This placed the residents at risk of infection development.

The facility identified a census of 32 residents. The sample included 13 residents with eight residents reviewed for resident rights. Based on observation, interview, and record review, the facility failed to ensure Resident (R)7 was treated with respect and dignity during incontinence care. This deficient practice placed the resident at risk for negative psychosocial outcomes and decreased autonomy and dignity. Findings included: - R7's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of hypertension (elevated blood pressure), obesity (excessive body fat), congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), candidiasis (a fungal infection caused by a yeast), and muscle weakness. The Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS documented R7 was dependent on staff for toileting and was frequently incontinent. R7's Care Area Assessment (CAA) dated 10/15/23 documented R7 was incontinent of bladder and wore a brief. R7 received diuretic (medication used to promote the formation and excretion of urine) medications as ordered, which increased her need to be toileted or have her brief changed. R7's Care Plan dated 04/08/24 documented she used disposable briefs. The plan directed staff to provide R7 with good peri-care and brief changes as needed. On 04/17/24 at 09:34 AM R7 reported an incident with Certified Nurse Aide (CNA) N. R7 said CNA N told the resident she was not allowed to wear her incontinence brief throughout the night. R7 stated this made her very uncomfortable and embarrassed at night when she did not get to wear a brief to bed. On 04/17/24 at 10:17 AM Licensed Nurse (LN) G stated R7 told her that CNA N did not allow her to wear a brief at night. LN G stated she forgot to report this information to anyone. LN G stated if R7 wanted to wear a brief at night, she should be allowed. LN G stated she would let CNA N know R7 had the right to wear a brief at night. On 04/17/24 at 01:13 PM in an interview, CNA M stated she felt R7's brief was left off because CNA N wanted to leave R7's skin to be open to air. CNA M stated if a resident wanted to wear a brief to bed, the resident should be allowed to do so. CNA M stated staff should respect the residents' rights. On 04/17/24 at 02:33 Administrative Nurse D stated he was unaware staff required R7 to sleep without a brief. Administrative Nurse D stated R7 should wear a brief to bed if that is what she wanted. The facility's Resident Rights policy revised on 10/2015 documented it is the policy of the facility that all residents be treated with kindness, dignity, and respect. The facility failed to ensure R7 was treated with respect and dignity and failed to ensure staff respected the resident's choices. This deficient practice placed R7 at risk for negative psychosocial outcomes and decreased autonomy and dignity.

The facility identified a census of 32 residents. The sample included 13 residents with eight residents reviewed for resident rights. Based on observation, interview and record review, the facility failed to ensure Resident (R)22 was allowed to exercise her right for self-determination without intimidation. This deficient practice placed the resident at risk for negative psychosocial outcomes related to decreased autonomy and impaired rights. Findings Included: - On 04/17/24 at 11:00 AM R22 stated she felt pressured by the facility to switch pharmacy services during the facility's ownership changeover. She stated R21 (her spouse) and she were told by the facility their medications may be difficult to obtain by their previous pharmacy once the facility switched to the new one. She stated she was afraid of not receiving her medications due to her existing medical problems. R22 stated after she changed pharmacy, she had to wait two days for clotrimazole (medication used to treat a fungal infection) cream to be delivered by the new pharmacy. R22 stated she and R21 would not have changed pharmacies if the facility had not told them the medications would be difficult to obtain from the local pharmacy, where they had been receiving their medications from before the change of ownership. A review of the facility's new Admission Agreement indicated if the resident preferred a different vender than the facility's contracted vendor, this must be communicated to the facility administrator at the time of admission or at a care plan meeting. The agreement indicated the facility must be given a 30-day notice to ensure services can be arranged. The agreement indicated both services and charges from non-contracted providers would need to be managed by the resident or their representative. On 04/17/24 at 02:34 PM Administrative Nurse D stated a letter was sent out to all the residents two weeks in advance with the provided pharmacy information. He stated he met with the resident council and received no concerns at that time. He stated no one in the facility was forced to switch pharmacies or pressured into changing. He stated R22's medications should have not been delayed because the new pharmacy delivered medications seven days a week instead of five. The facility's Resident Rights policy revised 03/2024 indicated the facility will inform each resident in a manner that is both clear and understandable. The facility failed to ensure support R22's right to self-determine healthcare providers and services including pharmacy services. This deficient practice placed R22 at risk for negative psychosocial outcomes related to decreased autonomy and impaired rights.

The facility identified a census of 32 residents. The sample included 13 residents with seven reviewed for maintaining activities of daily living. Based on observation, record review, and interviews, the facility failed to assist Resident (R)16 with maintaining her amplified hearing device. This deficient practice placed R16 at risk for a decline in communication and psychosocial well-being. Findings Included: - The Medical Diagnosis section within R16's Electronic Medical Records (EMR) included diagnoses of an anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), insomnia (difficulty sleeping), and gastro-esophageal reflux disorder (GERD-backflow of stomach contents to the esophagus). R16's Annual Minimum Data Set (MDS) completed 03/04/24 noted a Brief Interview for Mental Status score of 14 indicating intact cognition. The MDS indicated she required substantial to maximal assistance for bathing, dressing, and toileting. The MDS indicated she had moderate difficulty hearing but did not use hearing aids. R16's Communication Care Area Assessment (CAA) completed 03/05/24 indicated she was hard of hearing in both ears and opted to utilize no hearing devices. The CAA noted she had an amplifier, but she chose to utilize this most of the time. The CAA noted the amplifier did assist with her hearing. R16's Functional Abilities CAA completed 03/05/24 indicated she required substantial assistance from staff to complete her activities of daily living (ADLs). The CAA indicated she chose to eat meals in her room. The CAA indicated staff will assist her with her needs and a care plan will be updated to indicate her changing needs. R16's Care Plan initiated 03/07/24 indicated she was at risk for impaired communication related to her hearing deficit. The plan instructed staff to be conscious of her positioning when in groups to promote proper communication. The plan indicated she used a sound amplifier but refused auxiliary aids most of the time. The plan instructed staff to validate communication verbally aloud. The plan directed she required substantial assistance with showering, bed mobility, dressing, and transfers. On 04/15/24 at 08:50 AM R16 sat in her recliner in her room. R16 stated she needed to put her hearing amplifier headphones on. R16's headphones did not function upon putting them on her head. She stated she could barely hear without them. An inspection of the headphones revealed the batteries were dead. R16 was able to communicate but struggled to hear the questions being asked. She stated that staff do not check her headphones very often and she did not get frequent visits due to most of the residents moving to a different hallway for remodeling. She reported staff did not always come around and check on her as often as they should. She stated she was not sure when her headphones worked last. On 04/15/24 at 02:30 PM, R16's amplifier headphones were still not functioning. On 04/16/24 at 10:10 AM R16 sat in her recliner in her room. R16 stated she had not seen staff since breakfast. She stated her amplifier headphone batteries were finally changed out the previous evening. She stated it was so much easier to communicate with her headphones. On 04/17/24 at 12:45 PM, Licensed Nurse (LN) G stated R16 was very hard of hearing. LN G stated R16 had amplifier headphones but often did not use them. She was not sure if the staff was supposed to make sure the headphones were functioning. LN G stated staff usually just talked loudly to R16 while standing in front of her. She stated R16 uses the headphones while at activities. On 04/17/24 at 01:08 PM, Certified Nurse's Aide (CNA) M stated R16 could hear if standing directly in front of her and talking in a loud voice. She was not sure how often or if staff checked R16 headphones daily for function. On 04/17/24 at 02:34 PM Administrative Nurse D stated he changed out R16's headphone batteries the previous evening. He stated staff were expected to check on the functioning of the headphones each shift to ensure she could use them if she wanted. The facility's Services to carry out ADLs policy dated 03/01/24 documented it was the policy of the facility that residents were given the appropriate treatment and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident in accordance with a written plan of care. If a resident was unable to carry out activities of daily living, the necessary services to maintain good nutrition, grooming, and personal oral hygiene would be provided by staff as documented on the Care Plan. Residents would be involved in decision-making and given choices related to ADL activities as much as possible and interventions added to the Care Plan for staff assistance. ADL care provided would be documented in the medical record accordingly. The facility failed to assist R16 with charging or changing the batteries on her amplified hearing device. This deficient practice placed R16 at risk for a decline in communication and psychosocial well-being.

The facility reported a census of 32 residents. The sample included 13 residents with two reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) care. Based on record review, interviews, and observations, the facility failed to ensure Resident (R)25's pressure-reducing device was in her recliner as care planned. This deficient practice placed the resident at risk for complications related to skin breakdown and pressure ulcers. Findings Included: - The Medical Diagnosis section within R25's Electronic Medical Records (EMR) included diagnoses of repeated falls, muscle weakness, insomnia (difficulty sleeping), dementia (a progressive mental disorder characterized by failing memory, and confusion), and congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid). R25's Annual Minimum Data Set (MDS) completed 02/24/24 noted a Brief Interview for Mental Status score of zero indicating severe cognitive impairment. The MDS indicated she required maximal assistance with transfers, bed mobility, bathing, personal hygiene, dressing, and mobility. The MDS indicated she used a manual wheelchair. The MDS indicated she was at risk for pressure ulcers but had no unhealed wounds. The MDS indicated she had pressure-reducing devices for her wheelchair and bed. R25's Pressure Ulcer Care Area Assessment (CAA) completed 03/03/24 indicated she was at risk for pressure injuries and required regular repositioning/turning and seat cushion to reduce or relieve pressure. R25's Care Plan initiated on 12/01/23 indicated she had a deficit related to her functional activities of daily living (ADLs). The plan indicated she had severe cognitive impairment and was dependent on staff assistance for transfers, dressing, bathing, toileting, and personal hygiene. The plan indicated she was dependent on staff for mobility but could propel herself. The plan noted R25 had a history of attempting to pick up non-existent objects off the floor due to her severe cognitive impairment. R25's plan instructed staff to bring her to the dining room only once her meal was ready and sit with her. The plan indicated she had a history of sliding out of her wheelchair due to her cognitive impairment. The plan indicated she was at risk for pressure injuries related to poor skin integrity and her medical diagnoses. The plan indicated she utilized a pressure-relieving cushion for her wheelchair and recliner. On 04/16/24 at 08:17 AM R25 sat in a recliner in front of the television in the day room. R25's pressure-reducing cushion remained in her wheelchair. R25 had no pressure relieving device on the recliner. On 04/17/24 at 10:20 AM R25 slept in the day room recliner in front of the television in the day room. Her pressure-reducing cushion remained in her wheelchair. R25 had no pressure relieving device on the recliner. On 04/17/24 at 12:54 PM, Licensed Nurse (LN) G stated that R25 was at high risk for skin breakdown and pressure ulcers due to her immobility. She stated therapy had been making improvements during transfers, but staff still should be inspecting her for skin breakdown and applying barrier cream during peri-cares. She stated staff should ensure R25's pressure cushion was in place when she sat in the recliner. On 04/17/24 at 01:08 PM Certified Nurse Aide (CNA) M stated R25 had a cushion for her wheelchair and staff should move it to the recliner during transfers. She stated R25 was a high fall risk and required staff assistance for all transfers. She stated staff might not be moving the cushion over during transfers to the recliners. On 04/17/24 at 02:34 PM Administrative Nurse D stated staff were expected to follow the care plan interventions for each resident. He stated staff should ensure the pressure-reducing devices were in place for each resident. He stated staff was expected to move R25's cushion during her transfer between chairs. The facilities provided Skin and Wound Monitoring policy revised 03/2024 indicated the facility will implement and ensure practices that prevent and promote healing related to injuries. The policy indicated the facility would educate staff and ensure implemented interventions were followed to prevent avoidable impairments and wounds. The facility failed to utilize R25's pressure-reducing device in her recliner as care planned. This deficient practice placed R25 at risk for preventable pressure injuries.

The facility identified a census of 32 residents. The sample included 13 residents with one resident reviewed for respiratory care. Based on observation, record review, and interviews, the facility failed to ensure the nebulizer (a device that changes liquid medication into a mist easily inhaled into the lungs) mask was stored in a sanitary manner to decrease exposure and contamination for Resident (R) 30. This placed R30 at increased risk for respiratory infection and complications. Findings included: - R30's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of need for assistance with personal care, muscle weakness, chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), and Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure). The Significant Change Minimum Data Set (MDS) dated [DATE] documented a staff interview that indicated severely impaired cognition. The MDS documented R30 received oxygen therapy during the observation period. The Quarterly MDS dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of six which indicated severely impaired cognition. R30's Falls Care Area Assessment (CAA) dated 11/22/23 documented R30 remained cognitively impaired and was no longer aware of safety. R30's Care Plan dated 03/21/24 documented staff would monitor R30 for difficulty with breathing on exertion. R30's EMR under the Orders tab revealed the following physician orders: Albuterol sulfate inhalation (medication used to open the airway) nebulization solution (2.5 milligrams (mg)/3 milliners (ml) 0.083% (albuterol sulfate) one vial inhaled orally via nebulizer every four hours as needed for COPD or shortness of air dated 04/01/24. On 04/15/24 at 10:32 AM R30 lay on her right side in the bed. R30's undated and unbagged nebulizer mask lay directly on the nebulizer machine. On 04/16/24 at 08:01 AM R30 lay on her left side awake in the bed. R30's undated and unbagged nebulizer mask was laid directly on the dresser. On 04/17/24 at 09:15 AM, Certified Medication Aide (CMA) S stated R30's nebulizer mask should be stored in a plastic bag when not in use. On 04/17/24 at 11:06 AM, Licensed Nurse (LN) G stated nebulizer masks were changed out weekly. LN G stated R30's nebulizer mask should be dated and stored in a plastic bag when not in use. On 04/17/24 at 02:29 PM, Administrative Nurse D stated nebulizer masks should be dated and stored in a plastic bag. Administrative Nurse D stated he had replaced all the respiratory equipment and ensured there was a plastic bag for items to be stored in when not in use. The facility did not provide a policy related to sanitary storage of respiratory equipment. The facility failed to ensure R30's nebulizer mask was stored in a sanitary manner to decrease exposure and contamination. This placed R30 at increased risk for respiratory infection and complications.

The facility identified a census of 32 residents. Based on observation, record review, and interview, the facility failed to ensure nursing staff demonstrated the appropriate competencies and skill sets to provide nursing services to care for resident's needs when staff lacked knowledge related to dosing and administering diclofenac gel (a topical ointment used to relieve arthritis pain) for Resident (R) 17. This deficient practice placed R17 at risk of adverse side effects. Findings included: - On 04/16/24 at 09:38 AM Certified Medication Aide (CMA) R prepared and dispensed medications for R17. CMA R performed hand hygiene and applied clean gloves. CMA R then opened the tube of diclofenac gel and squeezed an unmeasured amount onto her glove. CMA R did not review R17's diclofenac gel order for a dosage amount before she applied the medication. On 04/16/24 at 09:40 AM CMA R stated she was not aware that the diclofenac even had a dosage amount. CMA R stated she had always been told to just squeeze out an amount either on the finger of a glove or to squeeze some into a medication cup. CMA R stated she had not known the order stated a dosage amount and that the box for the medication had a plastic measuring chart used to measure the medication amount to dispense from the tube until she was informed by the surveyor. On 04/17/24 at 02:28 PM Administrative Nurse D stated that CMA R and other nursing staff had been educated on the proper dosage and administration for diclofenac. Administrative Nurse D stated that all residents who had an order for diclofenac had the physician-ordered dosage amount on their orders. The Nursing Staff Competency policy last revised in March 2024 documented it was the policy of this facility to have sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Competency in skills and techniques necessary to care for resident's needs included medication management. Staff would demonstrate competency by demonstrating the ability to use tools, devices, or equipment that were subject to training and used to care for residents. Staff would demonstrate the ability to perform activities that were in the scope of practice that an individual was licensed or certified to perform. All nursing staff must meet the specific competency requirements as part of their license and certification requirements defined under State law or regulations. The facility failed to ensure staff demonstrated the appropriate competencies and skill sets to provide nursing services to care for residents' needs when staff lacked knowledge on how to administer diclofenac gel for R17. This deficient practice placed residents at risk of adverse side effects.

The facility identified a census of 32 residents. There were 13 residents in the sample. Based on observation, record review, and interview, the facility failed to ensure Resident (R)4's medications were available for administration without missed doses during the facility's change-over to a new pharmacy provider. This deficient practice placed R4 at risk of unnecessary complications and an ineffective medication regimen. Findings included: - R4's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of depressive disorder (a mood disorder that causes a persistent depression feeling of sadness and loss of interest), dementia (a progressive mental disorder characterized by failing memory, confusion), anxiety (an emotion characterized by feelings of tension, worried thoughts, and physical change), weakness, hypertension (HTN-elevated blood pressure), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), and bipolar disorder (major mental illness that caused people to have episodes of severe high and low moods). The Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of five which indicated severely impaired cognition. The MDS documented R4 received antidepressants (medication used to treat depression) during the observation period. R4's Psychotropic Drug Use Care Area Assessment (CAA) dated 11/05/23 documented R4 continued to receive scheduled antidepressant medication for depression and anxiety. R4 was monitored every shift for side effects of her medication. R4 received a medication review monthly. R4's Care Plan dated 01/04/23 documented R4 received an antidepressant and will be free from adverse effects related to antidepressant therapy. The plan directed staff to administer medications as ordered. R4's Care Plan dated 01/05/24 documented a cardiac impairment related to hypertension. The plan directed staff to give antihypertensive medication as ordered and monitor side effects. R4's EMR under the Orders tab dated 04/01/24 documented the following orders: Sertraline (medication for depression) HCl tablet give 50 milligrams (mg) by mouth at bedtime for bipolar disorder. Atorvastatin (medication used to lower cholesterol) 10 mg at bedtime. Trazadone (antidepressant) give 25 mg at bedtime for insomnia related to anxiety and major depression. Depakote (anticonvulsant also used to treat bipolar disorder) tablet delayed release 250 mg give each morning and bedtime for bipolar disorder. Metformin HCL (medication used to control blood glucose levels) tablet give 500 milligrams every morning and every evening related to diabetes mellitus. A review of R4's Medications Administration Record (MAR) in the EMR revealed on 03/20/24 that the atorvastatin, Trazodone, Depakote, Sertraline, and Metformin were not given. A review of R4's MAR on 03/30/24 revealed the Sertraline was not given. R4's Medication Administration Note dated 03/20/24 documented a hold on all medication until the medications were available. On 04/16/24 at 03:30 PM, Consultant GG stated R4's medications were routinely delivered in February 2024 to the facility. Consultant GG stated R4's maintenance medications would have run out on 03/20/24. Consultant GG stated he was no longer the provider for R4's medications on 03/20/24 and the medications should have come from somewhere else. On 04/17/24 at 07:27 AM Certified Medication Aide (CMA) R stated R4's medication was not available while she was passing medication on 03/20/24. CMA R stated when the medications were delivered from the new pharmacy, the medication was not sorted. She stated the pharmacy delivery person just spread the medications out all over the nurse's station. She stated there was confusion with the medications because the new pharmacy was logging into the old EMR program. CMA R stated the previous nursing procedure would have been to let the nurse know, and she would get the medications from the emergency kit. CMA R stated the facility was supposed to get a delivery twice a day from the new pharmacy but thus far, it had not happened. On 04/17/24 at 12:27 PM, Licensed Nurse (LN) G stated if R4 did not get her medication the nurse should have called the pharmacy to ensure the medication would be on the next pharmacy delivery. LN G stated the nurse on duty should have also looked in the emergency medication kit and called the physician. LN G stated most of the time, the CMAs take care of the medications. On 04/17/24 at 02:33 PM Administrative Nurse D stated he did not realize R4 had gone without medication. He stated staff were trained on the new pharmacy protocol and said the pharmacy would deliver twice daily. Administrative Nurse D stated the nurse on duty should get what medications she could out of the emergency medication kit and then call the physician if there were remaining medications unavailable. The facility provided a policy for Services of a Licensed Pharmacist but did not provide a policy related to pharmacy services as requested. The facility failed to ensure R4's medications were available for administration without missed doses during the facility's change-over to a new pharmacy provider. This deficient practice placed R4 at risk of unnecessary complications and an ineffective medication regimen.

The facility had a census of 32 residents. The sample included 13 residents with five reviewed for unnecessary medications. Based on observation, record review, and interview the facility failed to ensure the multiple unsuccessful attempts for nonpharmacological symptom management were documented including risk versus benefits for the continued use of an antipsychotic (class of medications used to treat a mental disorder characterized by gross impairment in reality testing) for Resident (R) 29, who had a diagnosis of dementia (a progressive mental disorder characterized by failing memory, confusion) and received Risperdal (antipsychotic). This placed the resident at risk for unnecessary psychotropic (alters perception, mood, consciousness, cognition, or behavior) medications and related complications. Findings included: - R29's Electronic Medical Record (EMR) documented the resident had diagnoses of subarachnoid hemorrhage (bleeding in the space just outside the brain), dementia, and hypertension (HTN-elevated blood pressure). The Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of five which indicated severely impaired cognition. The MDS documented that R29 was dependent on staff assistance for activities of daily living (ADLs). The MDS documented R29 received antipsychotic medication during the observation period. The MDS documented a GDR had not been attempted. R29's Psychotropic Drug Use Care Area Assessment (CAA) dated 11/12/23 documented R29 continued her antipsychotic medication for restlessness, agitation, and paranoid personality disorder. R29's Care Plan dated 03/14/23 documented R29 used psychotropic medications and directed staff to administer medication as ordered. The care plan documented the facility should consult with the pharmacy and physician to consider a dosage reduction when clinically appropriate, or at least quarterly. The Physician's Order dated 4/01/24 stated to give Risperdal (antipsychotic medication) 1.5 milligrams (mg) by mouth every morning and at bedtime related to restlessness, agitation, and paranoid disorder. R29's Pharmacy Consult dated 10/30/23, asked for an identified documented clinical rationale for the administration of the Risperdal based on the physician's assessment of R29's condition. R29's EMR lacked any documentation or evidence of nondrug behavioral interventions that were tried and failed before starting the antipsychotic medication. On 04/16/24 at 04:19 PM R29 laid in the recliner in the commons room with her feet elevated. R29 watched television with peers. On 04/17/24 at 12:27 PM, Licensed Nurse (LN) G stated she was unsure what R29's Risperdal was used for. On 01/22/24 at 11:32 AM Administrative Nurse D indicated there should have been a risk versus benefits completed as well as documentation of non-pharmacological interventions for R29's antipsychotic drug use. The facility's Psychotropic Medication Use policy, revised 03/2024 documented it is the policy of this facility to ensure that residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record. Psychotropic medications shall not be administered for discipline or convenience. Residents who use psychotropic drugs will receive a possible GDR and behavior interventions unless clinically contraindicated. The facility failed to ensure documented multiple unsuccessful attempts for nonpharmacological symptom management before the use of Risperdal for R29. This placed the resident at risk for unnecessary psychotropic medications and related complications.

The facility identified a census of 32 residents. The sample included 13 residents with two residents reviewed for hospice services. Based on observation, record review, and interviews, the facility failed to ensure a communication process was implemented, which included how the communication would be documented between the facility and the hospice provider, for Resident (R) 2 and R30. This deficient practice created a risk for missed or delayed services and impaired physical, and psychosocial care for R2 and R30. Findings included: - R2's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), multiple sclerosis (MS- progressive disease of the nerve fibers of the brain and spinal cord), and congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid). The Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of nine which indicated moderately impaired cognition. The MDS documented R2 received hospice services. R2's Functional Abilities Care Area Assessment (CAA) dated 04/10/24 documented staff would continue to assist R2 with her activities of daily living. R2's Care Plan dated 03/29/24 documented the hospice provider would provide a bed with a low air loss mattress and a Broda chair (specialized wheelchair with the ability to tilt and recline). The plan of care documented the hospice nurse would visit approximately two times weekly; a hospice aide would visit approximately one time a week, a social service would visit approximately one time monthly, and the chaplain would visit as needed. The plan of care documented the facility and hospice provider would work to provide maximum comfort for R2. The plan of care documented the facility and hospice provider would work cooperatively to ensure R2's spiritual, emotional, intellectual, physical, and social needs were met. R2's EMR under the Orders tab revealed the following physician orders: Admit to hospice services dated 03/30/24. A review of the book provided by hospice for communication and collaboration of care lacked physician order with a pertinent diagnosis, hospice care plan, list of medication covered by the hospice provider, and frequency of visits from the hospice staff to provide care. On 04/15/24 at 02:45 PM, R2 sat upright in a Broda chair in her room with her pressure-relieving boots on her lower extremities. On 04/17/24 at 09:15 AM, Certified Medication Aide (CMA) S stated the nurse would let the staff know which residents received hospice services. CMA S stated R2 was currently on hospice services. CMA S stated she was not sure if hospice information of what was provided by hospice was listed on the care plan. On 04/17/24 at 11:06 AM, Licensed Nurse (LN) G confirmed the communication book provided by hospice lacked a care plan, admission paperwork with an admitting order from the physician. LN G stated she visited with hospice when they had come to the facility to provide care for R2 but was not sure if they documented their visit anywhere. LN G stated hospice was no longer able to chart on the facility's EMR for R2. On 04/17/24 at 02:29 PM, Administrative Nurse D stated the hospice providers were not able to document their visits in the facility's EMR system. Administrative Nurse D stated he was working with R2's hospice provider to collaborate on care for R2. Administrative Nurse D stated hospice should provide a care plan and admitting documentation for R2. The facility's End of Life Care; Hospice and/or Palliative Care policy dated 03/01/24 documented it was the policy of the facility to provide dignified and compassionate end-of-life care for terminally ill or dying residents. Through continuing interdisciplinary assessment, individualized plans would be developed and implemented to address the prevention and relief of symptoms and the resident's physical, intellectual, emotional, social, spiritual, and practical needs. Support and reassurance for family and friends close to the resident would be an integral part of the plan. The facility failed to ensure collaboration between the facility and the hospice provider for R2. This deficient practice placed R2 at risk for delayed services which could affect her mental, and psychosocial well-being. - R30's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of need for assistance with personal care, muscle weakness, chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), and Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure). The Significant Change Minimum Data Set (MDS) dated [DATE] documented a staff interview that indicated severely impaired cognition. The MDS documented R30 received oxygen therapy during the observation period. The MDS documented R30 received hospice services. The Quarterly MDS dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of six which indicated severely impaired cognition. The MDS documented R30 received hospice services. R30's Falls Care Area Assessment (CAA) dated 11/22/23 documented R30 remained cognitively impaired and was no longer aware of safety. R30's Care Plan dated 03/21/24 documented the hospice provider had provided a hospital bed a special mattress overlay, an overbed table, a nebulizer (a device that changes liquid medication into a mist easily inhaled into the lungs), a suction machine, oxygen concentrator, oxygen portable tanks, wheelchair cushion, incontinent supplies, and a Broda chair (specialized wheelchair with the ability to tilt and recline). The plan of care documented hospice nurse would visit one to five times weekly, a hospice aide would visit and bath R30 one time a week, a social worker would visit one to four times monthly, and approximately one time monthly, the hospice volunteer would visit one to four times weekly, and the chaplain would visit one to four times monthly. The plan of care documented the facility and hospice provider would work to provide maximum comfort for R30. The plan of care documented the facility and hospice provider would work cooperatively to ensure R30's spiritual, emotional, intellectual, physical, and social needs were met. R30's EMR under the Orders tab revealed the following physician orders: R30 was admitted to hospice on 11/14/23 for Alzheimer's disease and COPD dated 04/01/24. A review of the book provided by hospice for communication and collaboration of care lacked any documentation of hospice visits and care provided by hospice since February 2024. On 04/16/24 at 01:33 PM, R30 sat upright in her Broda chair with her lower extremities elevated. R30's hair appeared oily. On 04/17/24 at 09:15 AM, Certified Medication Aide (CMA) S stated the nurse would let the staff know which residents received hospice services. CMA S stated R30 was currently on hospice services. CMA S stated she was not sure if hospice information of what was provided by hospice was listed on the care plan. On 04/17/24 at 11:06 AM, Licensed Nurse (LN) G confirmed the communication book provided by the hospice lacked evidence of documentation of any hospice visits since February of 2024. LN G stated she visited with hospice when they had come to the facility to provide care for R30 but was not sure if they documented their visit anywhere. LN G stated hospice was no longer able to chart on the facility's EMR. On 04/17/24 at 02:29 PM, Administrative Nurse D stated the hospice providers were not able to document their visits in the facility's EMR system. Administrative Nurse D stated hospice should provide documentation of the care during their visits with R30. The facility's End of Life Care; Hospice and/or Palliative Care policy dated 03/01/24 documented it was the policy of the facility to provide dignified and compassionate end-of-life care for terminally ill or dying residents. Through continuing interdisciplinary assessment, individualized plans would be developed and implemented to address the prevention and relief of symptoms and the resident's physical, intellectual, emotional, social, spiritual, and practical needs. Support and reassurance for family and friends close to the resident would be an integral part of the plan. The facility failed to ensure collaboration between the facility and the hospice provider for R30. This deficient practice placed R30 at risk for delayed services which could affect her mental, and psychosocial well-being.

The facility had a census of 50 residents. The sample included 19 residents. Based upon observation, record review and interviews the facility failed to reposition 2 (#35, #18) of 2 residents at risk for pressure sore development. Findings included: - Resident #35's quarterly Minimum Data Set (MDS) 3.0 dated 10/10/13 identified the resident had severely impaired cognition, were totally dependent upon staff for bed mobility, locomotion on/off the unit, dressing, eating, personal hygiene and toilet use. The MDS coded the resident was at risk for the development of pressure ulcers and was not on a turning/repositioning program. The resident's Cognitive Loss/Dementia Care Area Assessment (CAA) dated 7/17/13 documented the resident was totally dependent upon staff for activities of daily living. The resident's Pressure Ulcer CAA dated 7/17/13 documented the resident had the potential for alteration in his/her skin integrity. The resident was incontinent of bowel and bladder. The resident's care plan dated 10/7/13 included staff repositioned the resident every 1 to 2 hours during the day and at night during rounds. On 1/2/14 the resident sat in the television room in a recliner at 9:30 AM, 9:45 A.M., 10:00 A.M., 10:15 A.M., 10:30 A.M., 10:45 A.M., 11:00 A.M., 11:15 A.M., 11:30 A.M. and 11:45 A.M. (duration of 2 hours and 15 minutes) with no change in position. On 1/6/14 the resident sat in the television room in a recliner at 9:28 A.M., 9:39 A.M. 9:50 A.M., 10:00 A.M., 10:10 A.M., 10:15 A.M., 10:30 A.M., 10:45 A.M., 11:00 A.M., 11:15 A.M., 11:30 A.M. and 11:45 A.M. (duration of 2 hours and 17 minutes) with no change in position. On 1/6/14 the resident laid in bed on his/her back at 1:00 P.M., 1:15 P.M., 1:30 P.M., 1:45 P.M., 2:00 P.M., 2:15 P.M., 2:30 P.M., 2:45 P.M., 3:15 P.M., 3:30 P.M., 3:45 P.M. ( a duration of 2 hours and 45 minutes) with no change in position. On 1/7/14 at 4:50 P.M. direct care staff Q stated staff repositioned the resident at least every 2 hours. On 1/8/14 at 2:23 P.M. licensed nurse J stated staff repositioned the resident at least every 2 hours. On 1/8/14 at approximately 3:00 P.M. administrative nursing staff D stated staff determined the need of the resident's repositioning every hour or two based on the resident's abilities that day. The facility failed to reposition this severely impaired dependent resident at risk for the development of pressure ulcers every 1 to 2 hours as planned. - Resident #18's annual Minimum Data Set ((MDS) dated [DATE] identified the resident had severely impaired cognition, no behaviors, was totally dependent upon staff for bed mobility, transfers, locomotion on/off the unit, dressing, eating, toilet use, personal hygiene and the resident did not walk in the room/corridor. The MDS coded the resident used a wheelchair, was always incontinent of urine, was at risk for the development of pressure ulcers and was not on a turning/repositioning program. The resident's care plan dated 10/22/13 included the resident could not turn on his/her own, and was totally dependent upon staff for repositioning. The resident's bed had a low air loss mattress, staff turned/repositioned the resident every 1 to 2 hours and as needed, and used pillows as needed for support. On 1/6/14 at 1:00 P.M. the resident laid in bed. Observation revealed a pillow behind the resident's right back but the resident was positioned more on his/her back than side. The resident continued in that position at 1:15 P.M. 1:30 P.M., 1:45 P.M., 2:00 P.M., 2:15 P.M., 2:30 P.M., 2:45 P.M., 3:15 P.M., 3:30 P.M., 3:45 P.M. (a duration of 2 hours and 45 minutes) with no change in position. On 1/8/14 the resident sat in the television room in a recliner at 9:19 A.M., 9:30 A.M., 9:45 A.M., 9:50 A.M., 10:00 A.M., 10:10 A.M., 10:20 A.M., 10:30 A.M., 10:40 A.M., 10:45 A.M., 11:00 A.M., 11:15 A.M., 11:30 A.M., 11:45 A.M. (a duration of 2 hours and 25 minutes) with no change in position. On 1/7/14 at 3:37 P;.M. direct care staff R stated staff repositioned the resident at least every 2 hours. On 1/8/14 at 2:20 PM licensed nurse J stated the resident was totally dependent upon staff for repositioning/turning. Licensed nurse J stated the resident's bed had a low air low mattress; therefore staff may not reposition the resident every 2 hours. On 1/8/14 at 3:16 P.M. administrative nursing staff D stated staff repositioned/turned the resident at least every 2 hours. The facility failed to reposition this severely impaired dependent resident at risk for the development of pressure ulcers every 1 to 2 hours as planned.

The facility identified a census of 50 residents. The sample was 3 residents. Based on observation, record review, and interview, the facility failed to implement effective interventions for 3 (#3, #16, and #47) residents that resulted in injuries. Findings included: - Resident #3's quarterly Minimum Data Set (MDS) 3.0 dated 12/9/13 identified the resident had moderately impaired cognition, short and long term memory impairment, and physical behavioral symptoms 1 to 3 days of the 7 day look back period. The MDS identified the resident was totally dependent upon staff for bed mobility and personal hygiene, required extensive staff assistance with transfers, dressing, eating, and toilet use. The MDS identified the resident was not steady, and was only able to stabilize with staff assistance when moving on/off the toilet, surface to surface transfer and when moved from seated to standing position, the activity of walking and turning around and facing the opposite directions while walking did not occur. The MDS identified the resident was frequently incontinent of urine, and had 2 or more non-injury falls since admission or the prior assessment. The resident's Cognitive Loss/Dementia Care Area Assessment (CAA) dated 9/11/13 documented the resident needed assistance with all of his/her activities of daily living (ADL's), the resident did not remember to call for staff assistance, and staff frequently checked on the resident. The resident's ADL Functional/Rehabilitation Potential CAA dated 9/11/13 documented the resident had ADL deficit, advanced dementia, did not make his/her needs known, was incontinent of bowel and bladder, required assistance of 1 to 2 staff, the resident did not walk, and did not follow simple direct questions. The CAA included the resident did not use his/her call light so staff frequently checked on him/her. The resident's Fall CAA dated 9/11/13 documented the resident was at risk for falls, fell in the last 6 months and had a fall on 9/10/13. The CAA included 2 staff transferred the resident to ensure his/her safety, used a wheelchair for all locomotion, the resident did not ambulate and staff propelled him/her to all areas. The resident had a [DIAGNOSES REDACTED]. The resident's care plan included the following interventions effective 7/9/13: The resident's was at an increased fall risk because he/she dropped items. Staff picked up the dropped items and ensured the items were within the resident's reach. The resident forgot to use his/her call light, staff checked on him/her frequently when in his/her room. The resident's required 1 or 2 staff assistance with transfer up from his/her recliner. The resident did not ambulate, used wheelchair for all locomotion, and the staff propelled the resident's wheelchair. A nurse's note dated 9/10/2013 and timed 2:59 P.M. included at 11:55 A.M. the resident attempted to stand up and slid out of his/her wheelchair. Interventions included staff would not leave the resident unattended in the dining room. A nurse's note dated 9/23/2013 timed 10:46 P.M. documented at 10:05 P.M. staff observed the resident on the floor with his/her head up against the bed rails, the resident stated he/she rolled out of bed and hit his/her head on the bed rails. The resident had a hematoma (collection of blood outside of the blood vessels) on his/her right hand and a skin tear below the knee on his/her left leg. Interventions included removal of the side rails and the placement of a mobility bar. A nurse's note dated 10/13/2013 and timed 3:19 A.M. documented the resident sat on the floor with his/her legs stretched in front of him/her, the resident sat on blankets and a pillow and the resident stated he/she slipped from the side of the bed. Interventions included staff checked on the resident frequently; and checked his/her bedding frequently. A nurse's note dated 10/18/2013 and timed 3:10 P.M. documented staff observed the resident on the floor at 11:45 P.M. A nurse's note dated 11/18/2013 and timed 6:34 P.M. documented at 4:30 P.M. a staff stated the resident slid out of his/her wheelchair. The note included the resident sat upright on the pedals of his/her wheelchair. Interventions included staff placed a different cushion in the resident's wheelchair. A nurse's note dated 11/19/2013 and timed 6:28 P.M. documented the raised area on the resident's left arm continued, and a faded bruise noted in front of the area. Staff was unsure if the above occurred when the resident slipped from the wheelchair on 11/18/13. A nurse's note dated 11/24/2013 and timed 1:40 A.M. documented the resident's roommate called out, staff entered the room and observed the resident sitting upright on the floor near the center of his/her bed. The resident stated he/she tried to get up to go to the bathroom, but had "fell out of bed." Blankets were observed on floor next to the bed. The interventions included toileting the resident and frequent checks. A nurse's note dated 11/25/13 and timed 10:28 P.M. documented at 10:00 P.M. staff observed the resident on the floor. The note included the resident slid from his/her wheelchair to the floor. Interventions included staff would know the resident's whereabouts at all times, the resident was quite anxious at times and staff frequently checked on the resident. The resident had new tennis shoes with non skid soles when in his/her room. Staff transferred the resident to his/her recliner and did not leave the resident unattended in the wheelchair in his/her room. A nurse's note dated 1/1/2014 and timed 2:49 A.M. documented the resident laid on a blanket on the floor bedside his/her bed at 1:45 A.M. The note included the resident had a quarter sized abrasion on the upper left side of his/her forehead, and staff performed neurological checks because the resident hit his/her head. A nurse's note dated 1/1/2014 and timed 4:47 A.M. documented the resident's child came to the facility to check on the resident, the hematoma on the resident's forehead had increased, the resident's child wanted the resident transferred to a local hospital and an ambulance transferred the resident to the hospital. The resident's discharge orders and instructions/transfer form from the local hospital dated 1/1/14 timed 4:30 P.M. documented the resident's primary [DIAGNOSES REDACTED]. A nurse's note dated 1/1/2014 and timed 10:14 P.M. documented the resident returned to the facility. The resident wore a soft collar, the resident's left eye was swollen shut, the resident's right eye was swollen, and the resident had a bruise on his/her forehead above his/her left eye. The note included the resident's children requested the resident wore a personal body alarm (PBA) when in bed. A nurse's note dated 1/3/2014 and timed 2:52 A.M. documented the resident's PBA sounded, and staff found the resident siting on the side of his/her bed. The local hospital emergency department history and physical with an encounter date of 1/1/14 documented per emergency medical staff, upon rounds staff found the resident on the floor beside his/her bed. The resident had a hematoma and swelling to and above his/her left eye. The resident's facial bones CT (computed tomography-type of X-ray) without contrast dated 1/1/14 included the resident had extensive soft tissue edema overlying his/her left front scalp and orbit (eye). The resident's CT of his/her Cervical Spine dated 1/1/14 included the resident fell , he/she had a large bruise above his/her left eye and a laceration (cut in the skin) of the forehead. The impression of the CT was a corner fracture seen at the C2 anterior inferior vertebral body (broken bone in the neck). Consider cervical spine MRI to evaluate for soft tissue injury. The resident's CT of the Head without contrast dated 1/1/14 included the resident fell and sustained a massive left frontal scalp hematoma. A local hospital's patient visit information dated 1/2/14 and timed 4:06 P.M. included the resident was seen for contusion (blood leaked into tissue under the skin) of his/her left hip. On 1/2/14 at 1:30 P.M. observation revealed the resident laid in bed. Further observation revealed a large purple colored hematoma above his/her left forehead with an abrasion in the center of the hematoma, purple colored bruises under the resident's eyes bilaterally, and the left side of the residents's jaw with purple colored bruise. On 1/6/14 at 8:15 A.M. the resident sat at a dining room table in his/her wheelchair. Observation revealed the hematoma and the bruising on the resident's jaw and underneath his/her eyes still present. Further observation revealed a personal body alarm (PBA) in place and the resident wore a soft C-collar (device used to give stability to the neck). On 1/6/14 at 1:25 P.M. observation revealed the resident's bed without a positioning bar as planned. The resident's bed had a pressure reducing mattress with built in wings/bolsters. On 1/6/14 at 3:30 P.M. at 3:30 P.M. observation revealed bilateral 1/2 length bed rails on the resident's bed. On 1/6/14 at approximately 3:00 P.M. nursing administrative staff E stated the facility placed the 1/2 length side rails between 1/2/14 and 1/6/14 per the resident's family request. Nursing administrative staff E stated the resident used a hand rail/mobility bar prior to the placement of the side rail. Nursing administrative staff E stated the facility implemented the PBA after the resident's fall on 1/1/14. Nursing administrative staff E confirmed the resident's care plan did not include side rails. On 1/6/14 at approximately 4:40 P.M. direct care staff P stated the resident was at risk for falls, and staff visually checked on the resident every 15 to 20 minutes. Direct care staff P stated the facility implemented the PBA, side rail and the winged mattress after the resident's fall on 1/1/14. On 1/8/14 at 2:43 P.M. licensed staff H stated staff checked on the resident every 15 to 30 minutes, and the resident did not have a history of falling out of bed. Licensed staff H stated the facility implemented the PBA after the resident fell on [DATE]. On 1/8/14 at 3:00 P.M. nursing administrative staff D stated the resident had never fallen out of bed. Nursing administrative staff D stated the resident was use to sleeping in a larger bed and when the resident rolled/turned over he/she was probably attempting to reach the hand bar and rolled out of bed on 1/1/14. The facility's fall prevention program revised 9/28/10 included residents who sustained a fall would have fall interventions implemented by the charge nurse on the day of the fall. The Director of Nursing or MDS Coordinator reviewed all falls and vitals. Further interventions would be added as needed. The facility failed to implement effective and timely interventions for this cognitively impaired dependent resident with a history of falls who fell and sustained a hematoma, and vertebral fracture after falling/rolling out of bed on 1/1/14. - Resident #47's significant change Minimum Data Set (MDS) 3.0 dated 12/4/13 identified the resident scored 8 (moderately impaired cognition) on the Brief Interview for Mental Status, had verbal behaviors 1 to 3 days of the 7 day look back period, was independent with bed mobility, required staff supervision with transfers, walking in the room, required limited staff assistance with walking in the corridor, and locomotion on/off the unit, and required extensive staff assistance with dressing, toilet use and personal hygiene. The MDS coded the resident was not steady but able to stabilize without staff assistance when walking, turning around and facing the opposite direction and surface to surface transfers. The MDS coded the resident was steady when moved from seated to standing and moving on/off the toilet, did not use mobility devices, and was occasionally incontinent of urine. The MDS included the resident had not fallen since the prior assessment and did not receive antipsychotic medications. The resident's Cognitive Loss/Dementia (progressive mental disorder characterized by failing memory, confusion) Care Area Assessment (CAA) dated 12/5/13 included the resident had impaired cognition and staff cued and reminded him/her regarding all activities of daily living (ADLs). The resident had short and long term memory impairment and forgot to use his/her call light. The resident's ADL CAA dated 12/5/13 documented the resident was ambulatory, had impaired vision, and the staff cued and assisted the resident with ADLs. The resident sometimes had problems with his/her balance and used a walker. The resident's Fall CAA dated 12/5/13 documented the resident was a fall risk, had a history of [REDACTED]. The resident's balance problems fluctuated depending upon the day. The resident utilized a walker, and staff accompanied him/her with long distances due to the resident's history of past falls. The resident sometimes forgot to use his/her walker, the resident safely transferred from his/her recliner, and the Certified Nurse Aides frequently checked him/her. The resident's care plan had the following interventions in place since 6/18/13: The resident needed staff assistance to complete his/her ADLs, the resident had dementia, was at risk for falls and ambulated with a walker. The resident needed staff to walk him/her to the dining room table, the resident forgot to use his/her call light, and staff frequently checked on the resident during rounds and when they passed the resident's room. The resident required standby assist of 1 staff when ambulating outside of his/her room. The resident tended to run into things with his/her walker, and veered off to the right with it. An entry dated 12/11/13 documented staff assisted the resident out of the room where he/she could be viewed easier and the resident continued with the positioning bar. An entry dated 12/19/13 included the resident required stand by assist when he/she ambulated with the walker and the resident could use the wheelchair for long distances and if fatigued. An entry dated 1/6/14 included staff checked the resident for orthostatic hypotension (drop in blood pressure when positions changed), 1 staff assisted the resident with transfers, and the resident may use the wheelchair. The resident fall risk increased when he/she was in his/her room and staff brought the resident out of his/her room after dressing for easier view. Staff frequently checked on the resident, at night very frequently when passing his/her room if awake, one staff assisted him/her with all transfers, and staff did not leave the resident unattended. A nurse's note dated 5/22/2013 and timed 6:59 A.M. documented at 5:15 A.M. the resident put on his/her call light, the resident was on the floor in his/her bathroom beside the toilet. The resident had a cut on his/her right eye brow. A nurse's note dated 12/4/2013 and timed 5:48 P.M. documented the resident returned from a physician's appointment with a new order to start Zyprexa (an antipsychotic) 2.5 milligrams(mg) everyday. A nurse's note dated 12/7/2013 and timed 1:45 P.M. documented the resident laid on his/her left side, the resident's head was on the floor and staff observed a small amount of blood on the resident's nose and cheek. The resident complained of pain to his/her nose, bruising and a small laceration was noted at the top of the resident nose. The resident stated he/she rolled out of bed. Interventions included staff frequently checked on the resident, staff left the resident's room door open, staff positioned the resident in the middle of the bed, and placed a mattress on the floor next to the resident's bed. A nurse's note dated 12/9/2013 and timed 3:34 A.M. documented at 12:20 A.M. staff observed the resident sitting on the floor beside his/her mattress on the floor scooting himself/ herself along. Intervention included staff frequently checked on the resident and offered toileting to the resident before/after meals, before going to bed, and upon awakening. A nurse's note dated 12/11/2013 and timed 2:40 P.M. documented the resident was in a common bathroom, turned on the call light, staff went to check on the resident and the resident was sitting on the floor in front of the toilet. The resident stated he/she hit his/her head on the toilet. The fall review sheet did not include an intervention. A nurse's note dated 12/23/2013 and timed 8:46 P.M. documented the facility received a physician's orders [REDACTED]. A nurse's note dated 1/6/2014 and timed 2:38 A.M. included at about 2:20 A.M. staff found the resident next to his/her bed, and the resident's back was against the bedside cabinet. The resident stated he/she stood up, could not remain standing, so he/she sat down on the floor. A nurse's note dated 1/7/2014 timed 3:30 P.M. documented at 1:30 P.M. the resident was down by the dining room doors, stood up out of his/her wheelchair and ambulated. The resident tripped over his/her own feet on the way back to the wheelchair and hit the back of his/her head on the door frame between the two doors. Staff applied an ice pack to the back of the resident's head. On 1/2/14 at approximately 12:15 P.M. the resident sat in his/her wheelchair at a dining room table. On 1/6/14 at 8:45 A.M. the resident self propelled his/her wheelchair in the hallway. On 1/6/14 at 1:10 P.M. (1) staff transferred the resident from his/her wheelchair to a recliner in the television room. On 1/7/14 at 6:55 A.M. the resident laid in bed. Observation revealed the resident had a hand rail/positioning bar on the left side of his/her bed. Further observation revealed the resident's bed approximately 5 inches from the ground. The observation revealed 3 non skid strips by his/her bed. On 1/7/14 at 4:35 P.M. direct care staff P stated staff placed a thin mat beside the resident's bed when the resident was in bed, the resident's bed was 5 or more inches from the ground and the resident had a positioning bar on his/her bed. On 1/8/14 at 2:53 P.M. licensed nurse H stated staff checked on the resident every 15 to 30 minutes. The resident was at risk for falls, fell on [DATE] and did not utilize a mat on the floor. The resident had declined and now used the wheelchair most of the time. On 1/8/14 at approximately 3:40 P.M. nursing administrative staff D stated the resident was at risk for falls and staff frequently checked on the resident. Administrative nursing staff D stated the resident started on Zyprexa during the middle of December and the facility had not reviewed/accessed the resident to see if there was a possible correlation between the resident's increase in falls and the start of the Zyprexa. The facility's fall prevention program revised 9/28/10 included residents who sustained a fall would have fall interventions implemented by the charge nurse on the day of the fall. The Director of Nursing or MDS Coordinator reviewed all falls and vitals. Further interventions would be added as needed. The facility failed to thoroughly assess and provide effective interventions for the prevention of falls for this cognitively impaired resident. - The January 2014 physician's orders [REDACTED]. The quarterly Minimum Data Set 3.0 ((MDS) dated [DATE] noted a Brief Interview for Mental Status (BIMS) score of 11 (8 to 12 indicated moderately impaired cognition). It documented the resident required supervision for transfers, and was steady when moving from a seated to a standing position. It revealed the resident had not fallen. The Care Area Assessment (CAA) dated 4/7/13 for cognition did not trigger. The CAA dated 4/7/13 for falls indicated the resident was a fall risk and had declined in his/her walking endurance. He/she had a fall prior to an illness in March. The care plan dated 7/10/13 noted staff left the call light within reach of the resident. Staff checked on the resident frequently and left the bathroom light on. Staff kept the pathway to the bathroom free from clutter, including the wheelchair. Staff used one on one conversation and anticipated the resident's needs. It noted the resident was reluctant to call for help. A fall risk assessment dated [DATE] noted a score of 17 (10 or above indicated a high risk for falls). The nurse's notes dated 3/26/13 at 11:30 A.M. documented the resident fell in his/her room while making his/her bed. The clinical record lacked documentation of new interventions or evaluation of the current interventions. The nurse's notes dated 8/29/13 at 3:36 P.M. documented there were no complaints of discomfort from the fall "yesterday'. The nurse's notes lacked further documentation about a fall on 8/28/13, any new interventions, or evaluation of the current interventions. The nurse's notes dated 9/30/13 at 6:29 P.M. revealed staff found the resident on the floor, and was transported to the emergency room . The x-ray report dated 9/30/13 noted there was a fracture of the right hip. The fall investigation noted staff were to keep the resident's door open and pull the divider curtain. Staff failed to place these interventions on the care plan. The nurse's notes dated 10/11/13 at 10:09 A.M. documented the resident was observed sitting on the floor in the TV room. The fall investigation noted staff were to keep the resident within the line of sight, to keep the light on in the TV room, and to keep the TV on a channel the resident prefers. Staff failed to place these interventions on the care plan. The nurse's notes dated 10/15/13 at 8:31 P.M. documented the direct care staff found the resident in the TV room on his/her back laying on the floor. The fall investigation noted staff were to toilet the resident often and visit with the resident when he/she was anxious. These interventions failed to be placed on the care plan. The nurse's notes dated 10/29/13 at 3:15 P.M. documented the resident fell in his/her room while making his/her bed. The fall investigation noted staff were to make the resident's bed, and this was added to the care plan. A nurse's note dated 11/2/13 timed 8:38 P.M. documented the resident made poor judgements and attempted to climb over the foot rest of the recliner. The nurse's notes dated 11/9/13 at 9:25 P.M. documented the resident was found sitting on the floor. A fall investigation was not provided for this date. A nurse's noted dated 11/15/13 timed 8:12 P.M. documented the resident's gait was unsteady at times and used unsafe ambulation, such as not using the walker, ambulating with one shoe on and only a sock on the other foot. The nurse's note dated 11/21/13 at 2:05 P.M. documented the resident was in the TV room, went to sit in his/her wheelchair, the chair wheeled backwards, and he/she sat on the floor. The fall investigation noted staff needed to know where the resident was. This interventions failed to be placed on the care plan. The nurse's note dated 11/25/13 at 3:47 P.M. documented the resident was observed sitting on the floor in the great room. The fall investigation noted to involve the resident in more activities. This was added to the care plan. The nurse's note dated 11/26/13 at 6:15 A.M. documented staff found the resident laying on the floor in his/her room. The fall investigation noted the night shift staff were to check on the resident more frequently at night. This was added to the care plan. The nurse's note dated 11/30/13 at 1:16 P.M. documented the resident was found laying next to the recliner with his/her head against the wall. The fall investigation lacked documentation of new interventions or evaluation of the current interventions. The nurse's note dated 12/2/13 at 1:03 P.M. documented the resident was observed sitting in the hallway up against the director of nursing's door. The fall investigation lacked documentation of new interventions or evaluation of the current interventions. The fall investigation dated 12/4/13 documented a fall. The nurse's notes lacked documentation about a fall on 12/4/13. The fall investigation lacked documentation of new interventions or evaluation of the current interventions. The fall investigation dated 12/5/13 documented a fall. The nurse's notes lacked documentation about a fall on 12/5/13. The fall investigation lacked documentation of new interventions or evaluation of the current interventions. The nurse's notes dated 12/21/13 at 3:03 A.M. the resident was observed by staff laying on the floor in the hall outside of his/her room. The fall investigation lacked documentation of new interventions or evaluation of the current interventions. Observation on 1/6/13 at 2:30 P.M. the resident sat in a recliner with the foot rest elevated. He/she scooted out to the edge of the foot rest. The resident attempted several times to stand up, and eventually succeeded. He/she sat back down before staff noticed he/she was standing. The resident continued to try to stand back up. A nurse sat at the nurse's station nearby. When staff noticed the resident trying to stand up, staff transferred the resident to a wheelchair. Interview on 1/7/13 at 4:40 P.M. direct care staff P stated the resident was a fall risk. He/she made a point to check on the resident at every chance in order to prevent further falls, he/she checked on the resident frequently, assisted the resident around the facility, and ensured his/her needs were met. Interview on 1/8/14 at 1:15 P.M. licensed nursing staff I stated the resident was a fall risk, and staff should check him/her every 15 minutes. Interview on 1/8/13 at 2:50 P.M. licensed nursing staff H stated the frequent checks were not documented. Interview on 1/8/14 at 3:40 P.M. administrative nursing staff D stated this resident was a fall risk. Staff had evaluated this resident's medications and monitored for behaviors to prevent further falls. Staff were to use redirection and keep within sight. Staff were expected to check on the resident at every opportunity. On 1/9/13 at 2:30 P.M. physician KK was unavailable for interview. The facility's policy "Fall Prevention Program", dated 9/28/10, noted possible contributing factors were explored after each fall. The facility failed to implement effective interventions for this cognitively impaired resident who fell and fractured his/her hip and continued to fall.