Every finding on record at Chase County Care and Rehab

The facility reported a census of 35 residents. Based on observation, record review, and interview, the facility failed to store and prepare food in one of one kitchen under sanitary conditions. This deficient practice placed the residents of the facility at risk for food borne illnesses. Findings included:- On 09/09/25 at 01:15 PM, during a kitchen tour with Dietary Staff BB, observation revealed the following sanitation concerns in the food preparation and storage area:A stainless-steel food preparation table countertop with rust and peeling paint adjacent to the surface Missing trim/door facing on one side of the kitchen door when exiting the dry food storage room, which exposed an unsealed sheetrock surfaceFour broken floor tiles in the dry food storage areaDietary Staff BB confirmed the finding and agreed the surface needed maintenance and was not sanitizable.The facility policy Sanitation F812, dated 09/25, documentation included the food service area shall be maintained in a clean and sanitary manner. Utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair, and shall be free from breaks, corrosion, open seams, cracks, and chipped areas that may affect their use or proper cleaning.

The facility reported a census of 35 residents. The sample included 13 residents. Based on interviews, record reviews and observation, the facility failed to ensure a safe environment in all areas of the facility including those used by visitors and staff. This deficient practice created a risk for impaired safety and cleanliness. Findings included:- Observed on 09/11/25 at 08:30 AM, in the hall one clean utility closet, where clean linen was being stored, there was torn and missing wallpaper on the end of the storage shelf with exposed wood. The fluorescent light cover had a missing piece that exposed the fluorescent bulbs.Observed on 09/11/25 at 08:57 AM, the hall two clean utility closet, storing the clean linen, had numerous holes in the walls with exposed and flaking sheetrock, and the fluorescent light cover was cracked and had a broken area.Observed on 09/11/25 at 09:10 AM, the ceiling in the clean linen storage and folding area had numerous areas with cracks and flaking paint, the attic access door had missed paint, and the framing around the access door had exposed wood; one of the fluorescent lights was missing a light cover.Observed on 09/11/25 at 09:15 AM, the ceiling in the washer and dryer room had missing paint and several holes, the ceiling and the ceiling fan were covered in dust, and the tops of the washers and dryers were covered in dust. Also observed was a window air-conditioning unit behind the dryers that was dirty and covered with dust, along with an attic fan vent that was open and dirty above the washers.Observed on 09/11/25 at 09:20 AM, the oxygen storage closet on hall three had no cover over the closet light fixture; Maintenance U stated that he was unaware the cover had been missing.During an interview on 09/11/25 at 08:33 AM, Administrative Staff A and Maintenance U stated that they were unaware of the broken light fixtures in the clean utility closet and the wall damage in the utility closets.During an interview on 09/11/25 at 08:35 AM, Administrative Staff A stated that there would be an environmental audit established to address environmental issues not covered by the current environmental Performance Improvement Project (PIP- a focused effort to identify and improve a specific area of care or service through data analysis) that had been established.During an interview on 09/11/25 at 09:17 AM, Housekeeping V stated that she was unaware of the ceiling damage and missing light cover in the clean laundry storage room. Housekeeping V also stated that maintenance was notified of concerns through The Equipment Lifecycle System (TELS- a computerized maintenance management system used to streamline maintenance operations) or she texted the issue to the maintenance supervisor. During an interview on 09/11/25 at 09:36 AM, Maintenance U stated that he performed equipment checks weekly and environmental checks bi-weekly and received maintenance requests through TELS. Maintenance U also stated that the roof had recently been repaired due to numerous leaks, but was unaware of the ceiling damage in the laundry area and therapy department. Maintenance U further stated that ceiling vents should not be dirty or rusty and reported that broken light covers and exposed sheetrock were environmental concerns.During an interview on 09/11/25 at 09:40 AM, Administrative Staff A stated that she expected staff to be vigilant and notify maintenance through TELS of all maintenance or environmental concerns; she further stated a monthly in-service was provided to all staff related to using the TELS system. Administrative Staff A also reported that damaged walls and ceilings, including broken light covers, presented environmental concerns.The facility policy Work Orders, Maintenance, dated 10/2024, documented that maintenance work orders would be maintained in order to establish a priority of maintenance service. The policy further documented that work order requests should be placed in the appropriate file basket at the nurses' station and are to be picked up daily or noted daily in TELS.

The facility reported a census of 35 residents; the sample included 13 residents. Based on interviews, record review and observation, the facility failed to ensure a safe, clean home-like environment in the resident's rooms. This deficient practice placed the residents at risk for safety and decreased comfort. Findings included:- During an observation on 09/09/25 at 10:32 AM, the ceiling in Resident (R) 1's room, next to the fluorescent room light, had an approximately five-inch area of paint peeling, and there was a large water stain around the peeled area.During an observation on 09/09/25 at 11:05 AM, R2's room had a large area of wall, next to the bed, scuffed with paint rubbed off. The end of the fluorescent ceiling light had the metal cover bent out with exposed wires, and the wall behind the television had multiple areas of paint chipped off. R2's bathroom door also had multiple areas scraped on the bottom, and there were several holes in the door.Observed on 09/09/25 at 11:48 AM, R5's room had multiple areas on the walls with paint missing, exposing the sheetrock; there were holes in the walls that exposed sheetrock, and the wooden door frame to the bathroom had multiple scraped areas and splintered areas.Observed on 09/11/25 at 08:37 AM, the hall one shower room had missing tiles around the shower drain, missing caulking around the shower floor, missing and hanging trim around the shower ceiling, and a gap on one side of the light switch cover to the shower light.Observed on 09/11/25 at 08:45 AM, while touring the facility with the Administrative Staff A and Maintenance U, numerous ceiling vents in multiple halls were dirty and rusty. Observed on 09/11/25 at 08:53 AM, the ceiling in the therapy department had flaked areas exposing sheetrock and an area that was separating, and numerous water-stained areas on the ceiling.During an interview on 09/11/25 at 09:36 AM, Maintenance U stated that he performed equipment checks weekly and environmental checks bi-weekly and that he received maintenance requests through The Equipment Lifecycle System (TELS- a computerized maintenance management system used to streamline maintenance operations). Maintenance U also stated that the roof had recently been repaired due to numerous leaks, but he was unaware of the ceiling damage in R1's room. He further stated that broken light covers and exposed sheetrock were both environmental concerns.During an interview on 09/11/25 at 09:40 AM, Administrative Staff A stated that she expected staff to be vigilant and notify maintenance through TELS of all maintenance or environmental concerns; she further stated a monthly in-service was provided to all staff related to using the TELS system. Administrative Staff A also reported that damaged walls and ceilings, including broken light covers, presented environmental concerns, and she was unaware of the damage presented to her in the rooms of R1, R2, and R5.The facility policy Safe, Clean, Comfortable, Homelike Environment, dated 10/2024, documented that residents have the right to a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

The facility reported a census of 35 residents. There were 13 residents included in the sample. Based on observation, record review and interview, the facility failed to review and revise the care plans for Resident (R) 16 regarding non-pharmacological interventions for pain, placing the resident at risk for unrelieved pain due to uncommunicated care needs. Findings included:- R16's Electronic Medical Record (EMR) revealed a diagnosis of pain.R16's Annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 12, indicating moderately impaired cognition. The resident had scheduled pain medications with no non-pharmacologic pain interventions attempted. The resident reported her pain in the past five days was seven on a one to 10 pain scale, with 10 being the worst pain imaginable. She reported the pain frequently occasionally affected her sleep and day-to-day activities. She received opioid (a type of drug that is used to treat moderate to severe pain) medication during the assessment period.The Pain Care Area Assessment (CAA), dated 10/29/24, documented the resident had chronic knee pain and received scheduled opioid medications.R16's Quarterly MDS, dated [DATE], documented the resident had a BIMS score of 11, indicating moderately impaired cognition. She had scheduled pain medications with no non-pharmacologic pain interventions attempted. The resident received opioid pain medications during the assessment period.R16's Care Plan, revised 02/05/25, lacked non-pharmacologic pain interventions.On 09/11/25 at 10:03 AM, Administrative Nurse D stated the expectation was for the care plan to include non-pharmacologic interventions for pain.The facility policy for Pain Clinical Protocols and Guidelines, revised 04/2025, included: The facility shall identify appropriate non-pharmacologic interventions to be added to the care plan for residents who require pain management.

The facility reported a census of 35 residents. The sample included 13 residents. Based on interviews, record reviews and observation, the facility staff failed to implement adequate and acceptable infection control practices for Resident (R) 38 and R4 with regard to urinary catheter (a tube inserted into the bladder to drain the urine into a collection bag) tubing and drainage bags resting on the floor. The facility failed to ensure staff implemented proper 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) personal protective equipment (PPE) with cares. This deficient practice placed the resident at risk for infections. Findings included:- Observed on 09/09/25 at 12:04 PM, R38's urinary catheter dignity bag was resting on the floor while attached to the foot of his bed. EBP PPE and signage were present on R38's room door, and the signage indicated gloves and gown PPE were to be utilized for all cares.Observed on 09/10/25 08:38 AM, R38's urinary catheter bag and tubing were resting on the floor. Certified Nurse Aide (CNA) P performed care and re-adjusted R38 in his bed. CNA P removed and changed R38's wet linens with gloves only. During an interview on 09/10/25 at 08:46 AM, CNA P stated that urinary catheter collection bags and/or the tubing should never rest or drag on the floor. CNA P confirmed she should have utilized a gown and gloves when she performed any care for R38; she further confirmed she only used gloves.During an interview on 09/10/25 at 08:48 AM, Administrative Nurse D stated that urinary catheter tubing should not be on the floor and that urinary catheter bags should not be on the floor. She further stated that dignity bags protect the actual urinary collection bag when it rests on the floor. Administrative Nurse D also stated gowns and gloves should be utilized with care of a resident who has any implanted medical device, including urinary catheters.The facility policy Indwelling Urinary Catheters, dated 10/2024, documented that the catheter tubing and drainage bag were to be kept off the floor.

The facility reported a census of 35 residents. Based on observation, record review and interview, the facility failed to display accurate, publicly accessible staffing information that contained the number of actual nursing hours worked on a daily basis, for the 35 residents who resided in the facility. Findings included:- Review of the facility's Daily Staffing Sheets, from 08/16/25 through 09/09/25, revealed the actual hours worked had not been completed on the daily staffing sheets.On 09/10/25 at 12:53 PM, Administrative Nurse D confirmed the Daily Staffing Sheets lacked the actual nursing hours worked.The facility policy for Posting Direct Care Daily Staffing Numbers, revised 11/2023, included: Shift staffing information shall be recorded and posted for each shift and include the total number and actual number of hours worked by staff directly responsible for resident care.

The facility reported a census of 33 residents with four residents selected for review. Based on interview and record review, the facility failed to conduct reference checks for five of five employees reviewed to ensure no abuse to the residents of the facility. Findings included: - Review of the following personnel files for the following staff hired within the past year from 06/26/23 to 06/26/24, revealed lack of documentation for reference checks for the following staff: 1. Certified Nurse Aide (CNA) M with hire date of 02/08/24. 2. CNA N with a hire date of 02/026/24. 3. CNA O with a hire date of 11/2023. 4. CNA P with a hire date of 03/27/24. 5. Housekeeping staff U with a hire date of 05/21/24. Interview, on 06/26/24 at 03:30 PM, with Administrative Staff A, confirmed lack of documentation that reference checks were completed. The facility policy Abuse Prevention Program, Screening of Employees reviewed 09/2023, instructed staff pre-employment screening to consist of at a minimum employment history, information from former employers as available and documentation of status and any disciplinary actions from licensing or registration boards or registries. The facility failed to thoroughly screen employees by completion of reference checks for the prevention of abuse, neglect, and exploitation for the residents of the facility.

The facility reported a census of 32 residents. Based on interview and record review, the facility failed to complete an annual performance review at least once every 12 months for five of the five Certified Nurse Aides (CNA) reviewed, CNA M, N, O, P and Q, to ensure adequate appropriate cares and services provided to the residents of the facility. Findings included: - Review of five employee personnel files, employed by the facility for greater than one year, revealed the following concerns: Review of Certified Nurse Aide (CNA) M, hired 03/08/22, lacked an annual performance review in her personnel file. Review of CNA Q, hired 11/21/22, lacked an annual performance review in her personnel file. Review of CNA N, hired 02/01/22, lacked an annual performance review in her personnel file. Review of CNA, O, hired 09/19/22, lacked an annual performance review in her personnel file. Review of CNA P, hired 07/13/22, lacked an annual performance review in his personnel file. On 01/31/24 at 09:12 AM, Administrative Staff A stated the annual evaluations were not up to date. The facility lacked a policy for employee annual evaluations. The facility failed to complete an annual performance review for these five CNAs, employed by the facility for greater than one year, to ensure adequate appropriate cares and services provided to the residents of the facility.

The facility reported a census of 32 residents. Based on observation, record review and interview, the facility failed to prepare and serve food under sanitary conditions, to the residents of the facility appropriately to prevent the potential for food borne bacteria. Findings included: - During an initial tour of the kitchen on 01/30/24 at 03:15 PM, the following areas of concern were noted: 1. A three-tiered beige rolling cart used to transport food from the walk-in refrigerator to the kitchen area and to deliver meals to residents in their rooms had visible ground-in dirt on all three tiers. 2. A three-tiered plastic rolling cart used to transport food from the walk-in refrigerator to the kitchen area and to deliver meals to residents in their rooms had visible ground-in dirt on the handles used to push the cart. 3. Two buckets with water and chemicals used to clean the dining room tables and work surfaces in the kitchen had the chemical dispensing hose left directly inside of the bucket beneath the water level. 4. A wire shelf used to hold clean dishes had a build-up of dust and debris on all five shelves. 5. Two reach-in refrigerators had a heavy build-up of food debris on the bottom. 6. The fronts of two reach-in refrigerators had dried on food debris. 7. The handle to the walk-in refrigerator had a greasy substance covering the entire handle. 8. The runners of the can rack had a build-up of dust and dried food debris. 9. Shelving paper on a shelf underneath a worktable was peeling back and had dirt and food debris along the edges, making it an unsanitizable area. 10. A worktable had three legs with chipped, missing paint, making it an unsanitizable area. 11. Three colored cutting boards had deep grooves, making them unsanitizable. 12. An oscillating fan which blew directly over the clean dishes rack and a sink had a build-up of dust on the blades and the cage. On 02/01/24 at 10:09 AM, Dietary Staff BB, confirmed the areas above need to be corrected. The facility policy for Sanitation, effective 10/2023, included: Utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracks and chipped areas that may affect their use or proper cleaning. The facility failed to prepare and serve food under sanitary conditions for the residents of the facility appropriately to prevent the potential for food borne bacteria.

The facility reported a census of 32 residents. Based on observation, interview, and record review, the facility failed to electronically submit to Centers for Medicare and Medicaid Services (CMS) with complete and accurate direct staffing information, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS (i.e. Payroll Base Journal (PBJ), related to licensed nursing staffing information, when the facility failed to accurately report 24 hour per day Licensed Nurse coverage on 24 dates between 01/01/23 and 12/31/23. Findings Included: - Review of the Payroll Base Journal (PBJ) Staffing Data Report for fiscal year (FY), Quarter 1 2023 (October 1-December 31) revealed a lack of License Nurse (LN) for 24 hours/seven days a week 24 hour/day on the following dates: On 10/02, Sunday (SU), On 10/09, SU, On 11/12, Saturday (SA), On 11/24, Thursday (TH), On 11/26, SA, On 12/06, Tuesday (TU), On 12/24, SA, Review of the PBJ for FY, Quarter 2, 2023 (January 1-March 31), the following infraction dates the facility failed to have Licensed Nursing Coverage 24 hours/day included: On 01/06, Friday (FR), On 01/07/24, SA, On 01/08/24, SU, On 01/21/24, SA, On 01/22, SU, On 01/28, SA, On 01/29, SU, On 02/18, SA, On 03/04, SA, On 03/05, SU, On 03/26, SU, Review of the PBJ for FY, Quarter 3, 2023 (April 01 - June 30), the following infraction dates the facility failed to have Licensed Nursing Coverage 24 hours/day included: On 04/02, SU, On 04/15, SA, On 05/06, SA, On 05/27, SA, On 05/28, SU, On 06/24, SA, On 02/01/24 at 11:00 AM, Consultant Staff GG stated it was possible the information regarding licensed nurse hours had not been submitted accurately. The facility policy for Payroll Based Journal, effective 09/2023, included: The facility shall submit payroll data in a uniform format to Center for Medicare and Medicaid Services (CMS), including staffing information for the facility, agency, and contract staff. The facility failed to electronically submit to Centers for Medicare and Medicaid Services (CMS) with complete and accurate direct staffing information, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS (i.e., Payroll Base Journal (PBJ), related to licensed nursing staffing information when the facility failed to accurately report 24 hour per day Licensed Nurse coverage on 24 dates between 01/01/23 and 12/31/23.

The facility reported a census of 32 residents. Based on observation, interview and record review, the facility failed to maintain an effective infection control program that would ensure infection surveillance for infections and determine the causative organism when cultured to prevent the spread of infections amongst the residents. Findings included: - Review of the Infection Control logs, revealed the lack of clinical data collection which included lack of causative organisms for infections of cultured infections to determine trends in types of infections and prevalence in the facility. This included the logs for the following months in 2023: February, March, April, June, July, August, September, October, and November. Interview, on 01/30/24 at 03:41 PM, with Administrative Nurse F, revealed she utilized the antibiotic report generated from their providing pharmacy. Administrative Nurse F stated she reviewed new orders daily, and documents those on the log. Interview, on 01/30/24 at 03:34 PM, with Administrative Nurse D, revealed the previous Infection Preventionist did not follow the facility policy for infection surveillance and confirmed the lack of infection surveillance for causative organisms to determine trends in the facility for the above listed months. The facility policy Surveillance for Healthcare Associated Infections revised 05/2023, instructed staff to collect data on the incidence of infections which included pathogens (causative organisms). Staff instructed to organize the data according to pathogenic organism and site of infection. The facility failed to provide infection surveillance to include pathogens to determine trends within the facility to prevent the spread of infections amongst the residents.

The resident reported a census of 32 residents. Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment in the kitchen for residents and staff. Findings included: - During the initial tour of the kitchen on 01/30/24 at 03:15 PM, the following area of concern was noted: The floor throughout the kitchen had areas which contained a build-up of dirt. The parameter of the floor had a heavy build-up of dirt and grime. The floor where table legs stood had a build-up of grime. On 02/01/24 at 10:09 AM, Dietary Staff BB, confirmed the kitchen floor needed to be kept clean at all times. The facility policy for Sanitation, effective 10/2023, included: Utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracks and chipped areas that may affect their use or proper cleaning. The facility failed to provide a safe, functional, sanitary and comfortable environment for residents and staff.

The facility reported a census of 32 residents. Based on observation, interview, and record review, the facility failed to maintain a clean, comfortable and homelike environment on one of three resident hallways of the facility. Findings included: - During an environmental tour on 02/01/24 at 10:27 AM with Consultant Staff GG, the following areas of concern were noted: 1. One resident room had a hole through the sheetrock wall which measured approximately 11 by two inches. The floor of the room had a build-up of visible dirt and grime around the parameter of the room. The shelf in the bathroom over the sink had worn, missing paint and the sink of the bathroom had a large blackened area on the front where the porcelain had worn away. 2. One resident room had broken wood and missing, chipped paint on one closet door. The TV stand had various areas of chipped, missing paint. A seat riser over the bathroom toilet had a large amount of a dried, brownish substance. 3. One wall in a resident room had an area of missing paint approximately eight by three inches, above the TV. The tile flooring behind the toilet of the bathroom was discolored. 4. One wall in a resident room had an area of missing paint, approximately nine by four inches, above the TV. One of the two closet doors had areas with missing, chipped paint. The parameter of the floor had a visible build-up of dirt and grime. 5. One resident room had a fall mat which was heavily soiled with dirt. The toilet riser had rusted areas on all four legs and a rusted area around the drain of the sink. The parameter of the floor had a build-up of dirt and grime. 6. One resident room had multiple areas of missing paint on the wall next to the bed. On 02/01/24 at 10:27 AM, Consultant Staff GG stated the areas identified needed repair, painting and cleaning. The facility policy for Cleaning and Disinfection of Environmental Services, revised 10/2022, included: Routine cleaning and disinfection should be completed of frequently touched or visibly soiled surfaces in resident rooms. The facility failed to maintain a clean, comfortable, and homelike environment for the residents on one of the three resident hallways of the facility.

The facility reported a census of 32 residents with 15 selected for review which included three residents reviewed for transfer to hospital. Based on interview and record review, the facility failed to issue a Bed Hold (a document that indicates a resident's desire to keep their bed available and indicates financial implications if any apply) as required for one Resident (R)13 of the three residents reviewed for transfer to a hospital. Findings included: - Review of Resident (R)13's Physician Order Sheet dated 01/05/24, revealed diagnoses that included myasthenia gravis (abnormal condition that caused muscles to tire and weaken easily). The Admission Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of nine, which indicated moderate cognitive impairment. The ADL (Activity of Daily Living) Functional/Rehabilitation Care Area Assessment (CAA), dated 12/27/23, assessed the resident experienced an exacerbation of myasthenia gravis, and upon return to the facility had difficulty with communication and had functional limitations in her ability to perform ADLs. The Care Plan reviewed 01/18/24, instructed staff the resident required encouragement to participate in conversation and had poor communication/comprehension. Review of the Nurse Note dated 12/19/23, revealed the resident transferred to acute care due to possible flare up of the myasthenia gravis. The resident returned to the facility on [DATE]. Interview, on 01/30/24 at 11:45 AM, with Social Service Staff X, stated the resident was her own responsible party, and was not coherent enough to sign at the time of transfer and that the staff did not discuss the bed hold with the family member who was notified of the transfer. Interview, on 02/01/24 at 01:30 PM, with Administrative Nurse D, revealed she would expect the licensed nurse at the time of transfer to explain the bed hold. The facility policy Bed Hold revised 05/2023, instructed staff to inform the resident of the bed hold policy. The facility failed to issue to this resident/resident representative the bed hold policy, upon transfer to acute care as required.

The facility reported a census of 32 residents with 15 residents sampled. Based on interview and record review, the facility failed to accurately complete a Minimum Data Sets (MDS) for two Residents (R)3, regarding documentation for falls and R 33, regarding discharge. Findings included: - Review of Resident (R)33's electronic medical record (EMR) revealed a diagnosis of a spinal injury (physical damage to the spinal cord which interfere with normal motor, sensory or autonomic function). The Admission Minimum Data Set (MDS), dated [DATE], documented the resident admitted to the facility from an acute hospital. The Discharge MDS, dated [DATE], documented the resident discharged to an acute hospital and his return was not anticipated. Review of the resident's EMR revealed the resident had received a physician's order 12/01/23 to discharge to home with home health. Review of the resident's EMR revealed a Discharge Assessment, dated 12/06/23, which documented the resident was to discharge home. On 02/01/24 at 11:36 AM, Administrative Nurse D stated the 12/08/23 MDS was inaccurate. The resident did not discharge to the hospital but discharged to home. The facility utilized the Resident Assessment Instrument (RAI) in the completion of the MDSs. The facility failed to accurately complete a Discharge MDS, for this resident who discharged to home. - Review of Resident (R)3's electronic medical record (EMR) revealed the following diagnoses: Schizoaffective disorder (mental disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought) and muscle weakness. The Significant Change Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of eight, indicating severe cognitive impairment. He had inattentive behavior continuously and impairment in range of motion (ROM) on one side of his lower extremity. He had two or more non-injury falls since his prior assessment (this section of the MDS was inaccurate) and required substantial to maximal staff assistance for transfers from his bed to a chair. The Falls Care Area Assessment (CAA), dated 11/30/23, documented the resident had three falls since his prior assessment, one with minor injury and one with a major injury, including a fracture. The Admission MDS, dated [DATE], documented the resident had a BIMS score of nine, indicating moderately impaired cognition. He had inattention and disorganized thinking behavior which fluctuated. He required supervision or touching assistance from staff for bed to chair transfers and had no falls since admission. The care plan for falls, revised 10/22/23, instructed staff to anticipate the resident's needs due to him being unaware of his safety needs. Staff were to ensure he had non-skid strips beside his bed and in front of his recliner, the call light was to be within reach of the resident and staff were to encourage him to use it. Staff were to encourage him to ambulate close to the walls and handrails to be able to utilize handrails, if needed and encourage him to wear appropriate footwear. Review of the resident's EMR revealed fall assessments which placed the resident at a high risk for falls, dated, 01/09/24 and 08/31/23. Review of the resident's EMR revealed a fall assessment which placed the resident at a low risk for falls, dated 10/05/23. Review of a Fall Report, dated 12/26/23, and provided by the facility revealed the resident had a fall to the floor in his bathroom after attempting to self-transfer from his wheelchair to the toilet and landing on the floor. The resident complained of pain rated ten out of ten and a physician's order was obtained for an x-ray of his left hip. The x-ray was negative for fractures. The facility's intervention for the fall was to re-educate the resident to request staff assistance before attempting to self-transfer. On 02/01/24 at 08:31 AM, Administrative Nurse D stated the Significant Change MDS, was inaccurate as the resident had three falls since the prior assessment on 10/08/23. One fall was a non-injury fall, one fall was an injury except for major injury and one fall was an injury fall which resulted in fractured ribs. Administrative Nurse D stated it was the expectation for the MDSs to be completed accurately. The facility utilized the Resident Assessment Instrument (RAI) in the completion of the MDSs. The facility failed to accurately complete a Discharge MDS, for this resident who had experienced a total of three falls, one with a major injury.

The facility reported a census of 32 residents with 15 residents included in the sample. Based on observation, record review and interview, the facility failed to review and revise the care plans for one sampled Resident (R)3, regarding fall interventions. Findings included: - Review of Resident (R)3's electronic medical record (EMR) revealed the following diagnoses: Schizoaffective disorder (mental disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought) and muscle weakness. The Significant Change Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of eight, indicating severe cognitive impairment. He had inattentive behavior continuously and impairment in range of motion (ROM) on one side of his lower extremity. He had two or more non-injury falls since his prior assessment (this section of the MDS was inaccurate) and required substantial to maximal staff assistance for transfers from his bed to a chair. The Falls Care Area Assessment (CAA), dated 11/30/23, documented the resident had three falls since his prior assessment, one with minor injury and one with a major injury, including a fracture. The Admission MDS, dated [DATE], documented the resident had a BIMS score of nine, indicating moderately impaired cognition. He had inattention and disorganized thinking behavior which fluctuated. He required supervision or touching assistance from staff for bed to chair transfers and had no falls since admission. The care plan for falls, revised 10/22/23, instructed staff to anticipate the resident's needs due to him being unaware of his safety needs. Staff were to ensure he had non-skid strips beside his bed and in front of his recliner, the call light was to be within reach of the resident and staff were to encourage him to use it. Staff were to encourage him to ambulate close to the walls and handrails to be able to utilize handrails, if needed and encourage him to wear appropriate footwear. The care plan lacked an appropriate intervention for the resident's fall on 12/26/23. Review of the resident's EMR revealed fall assessments which placed the resident at a high risk for falls, dated, 01/09/24 and 08/31/23. Review of the resident's EMR revealed a fall assessment which placed the resident at a low risk for falls, dated 10/05/23. Review of a Fall Report, dated 12/26/23, and provided by the facility revealed the resident had a fall to the floor in his bathroom after attempting to self-transfer from his wheelchair to the toilet and landing on the floor. The resident complained of pain rated ten out of ten and a physician's order was obtained for an x-ray of his left hip. The x-ray was negative for fractures. The facility's intervention for the fall was to re-educate the resident to request staff assistance before attempting to self-transfer. On 01/31/24 at 10:19 AM, Certified Nurse Aide (CNA) N and Licensed Nurse (LN) G entered the resident's room to toilet the resident. Staff used extensive assistance of two staff and the use of a gait belt (belt used to help transfer or stabilize during activity) to transfer the resident from the side of his bed to his wheelchair and from his wheelchair to the toilet. The resident was able to bear full weight and pivot during the transfer. On 01/31/24 at 10:15 AM, CNA O stated the resident was forgetful and did not always remember to use his call light for assistance. He required staff assistance with his Activities of Daily Living (ADL). On 01/31/24 at 10:25 AM, CNA N stated the resident was forgetful and rarely remembered to use his call light. CNA N stated she was unsure of what the resident's fall interventions were. On 01/31/24 at 10:19 AM, Licensed Nurse (LN) G stated the resident was forgetful. When a resident would fall a new intervention would be initiated immediately by the nurse. The nurse would be able to add the intervention to the care plan at the time it was initiated to prevent further falls. On 01/31/24 at 03:54 PM, Administrative Nurse F stated the nurse was responsible for initiating a new intervention at the time of a resident's fall and revising the care plan with the new fall intervention. The resident was forgetful with a low BIMS so an intervention of re-education would not be an appropriate intervention for him. On 02/01/24 at 08:31 AM, Administrative Nurse D stated the resident was forgetful. Re-education was an inappropriate intervention for a fall intervention or him. The nurse on duty would be responsible for revising the resident's care plan with an appropriate intervention at the time of the fall. The facility lacked a policy for reviewing and revising the care plan with new interventions. The facility failed to review and revise the care plan with an appropriate fall intervention following this dependent resident's fall.

The facility reported a census of 32 residents with 15 selected for review. Based on observation, interview and record review, the facility failed to ensure one sampled Resident (R)137 received appropriate treatment to bilateral (both sides) lower extremity cellulitis (skin infection caused by bacteria) and received proper ear care. Findings included: - Review of Resident (R)137's medical record revealed diagnosis that included Parkinson's disease (slowly progressive neurological disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness), schizophrenia (mental disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought), narcolepsy (a chronic neurological disorder that affects the ability to control sleep-wake cycles), and encephalopathy (broad term for any brain disease that alters brain function or structure). The Annual Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of 15 which indicated normal cognitive function. The resident had no impairment in the upper or lower extremities and required supervision for personal hygiene. The Pain Care Area Assessment (CAA), dated 02/12/23, assessed the resident had chronic pain from neuropathy (weakness, numbness, and pain from nerve damage, usually in the hands and feet) in his legs and feet. The ADL (Activity of Daily Living) Functional/Rehabilitation CAA, dated 02/12/23, assessed the resident had a risk for unsteadiness on his feet with use of a walker for ambulation. The resident required staff supervision to limited assistance to complete ADLs. The Care Plan reviewed 12/27/23, instructed staff the resident had significant issues with wax build-up in both ears and saw an audiologist and specialist to get his ears cleaned. The resident was hard of hearing and wore bilateral hearing aids. An entry dated 12/27/23, instructed staff the resident required Debrox solution for wax removal and then peroxide (an antiseptic solution) three drops to left ear twice daily for 10 days per order 01/03/24, and on 01/26/24. Furthermore, the Care Plan reviewed 01/23/24 instructed staff the resident followed with wound clinic as needed for leg weeping/rash. An update on 01/04/24, instructed staff to apply Nystatin cream (a type of medicated cream to treat yeast/fungus) topically to his toes and between the toes and to place gauze in the web space of the toes, apply Atrac [NAME] lotion (a type of medicated lotion that provides extra hydration) to his lower legs daily and to apply a single layer of tubigrip (elasticized tubular bandage designed to provide tissue support in treating strains, sprains, soft tissue injuries, general edema and tissue protection) to his bilateral lower legs per physician order on 01/04/24. On 12/21/23, the physician instructed staff to administer Debrox (a solution that softens ear wax) two times a day to each ear, for four days, and on the fourth day, to perform an ear wash. R137 had an appointment to see the audiologist on 12/27/23. Review of the Medication/Treatment Administration Record MAR/TAR, for December 2023, revealed staff provided the treatment beginning 12/21 once, 12/22, 12/23 and 12/24 twice and once on 12/25/23 with no indication of the completion of the ear wash as ordered. The physician note, dated 12/27/23, indicated the resident's right ear had trauma and the left ear contained blood and bits of cotton in two different areas of the ear canal upon examination and recommended a referral to an ENT (ears nose and throat) specialist. On 12/27/23, the physician instructed staff to administer Miracell ear oil to both ears nightly for seven days related to impacted ear wax. Observation, on 01/30/24 at 09:30 AM, revealed the resident seated in his recliner. The resident had cotton in his right ear. Interview, on 01/31/24 at 11:41 AM, with Licensed Nurse G revealed she did not irrigate the resident's ears prior to his appointment with the audiologist on 12/27/23 and did not know who did the irrigation of the ears. Interview on 01/31/24 at 02:30 PM, with Administrative Nurse F revealed she did not know who provided the ear wash to the resident prior to his appointment on 12/27/23, but thought it was the night nurse. Administrative Nurse E stated she would expect staff to follow the directions on the box of Debrox. Interview, on 02/01/24 at 09:57 AM, with LN H, revealed she did not administer the ear irrigation. Interview on 02/02/24 at 11:00 AM, with Administrative Nurse D, revealed the previous Director of Nursing did not provide guidance for staff to administer the ear irrigation. Administrative Nurse D stated she would expect the licensed nurse to document the results of the ear irrigation and any complications that occurred. Furthermore, on 11/30/23, the physician instructed staff to wash the residents' lower extremities with soap and water, apply Nystatin cream topically to his toes and in the web space between his toes, place gauze in the web space between his toes daily for a total of 10 days. The physician instructed staff to apply Atrac [NAME] lotion to his lower legs daily and single layer tubigrip (elasticized tubular bandage designed to provide tissue support in treating strains, sprains, soft tissue injuries, general edema, and tissue protection) stockings to bilateral lower legs daily. On 01/22/24, the physician instructed staff to wash the resident's legs with mild soap and water, pat dry, and to apply hydrocortisone cream (a cream with steroids) to the rash on his bilateral lower legs daily for two weeks and apply moisturizing lotion the resident's lower legs and feet daily and apply a double layer of tubigrips to R 137's bilateral lower legs. The January 2024 Medication Administration Record (MAR)/Treatment Administration Record(TAR), a physician order dated 01/23/24, instructed staff to apply hydrocortisone cream 1% topically to the resident's lower leg rash for two weeks daily with dressing change. An undated entry on the January 2024 Treatment Administration Record (TAR) instructed staff to apply Atrac-[NAME] cream 10-4% apply every day to the resident's lower legs. An undated entry on the January 2024 TAR, instructed staff to apply nystatin external cream to the resident's toes every day shift for wound care. Review of the January 2024 TAR, revealed an entry date of 01/24/24, which instructed staff to wash the resident's legs with mild soap and water, pat dry, and to apply hydrocortisone cream (a cream with steroids) to the rash on his bilateral lower legs daily for two weeks and apply moisturizing lotion the resident's lower legs and feet daily and apply a double layer of tubigrips to R 137's bilateral lower legs. Observation, on 02/01/24 at 08:01 AM, revealed Licensed Nurse (LN) G, prepared to provide wound care to the wound care to the resident's lower legs. LN G removed the single layer tubi grip stockings. LN G cleansed the resident's legs with soap and water and then applied Nystatin cream to the web space of R137's toes and placed gauze in between his toes. LN G applied Atrac [NAME] cream (a medicated cream to moisturize skin and prevent itching and flaking). And then applied the single layer tubigrips to each leg. LN G stated she did not know that the resident's treatment had changed to hydrocortisone cream to the rash area and moisturizing lotion to the lower legs and feet and double layer of tubigrips on each day shift. Interview, on 02/01/24 at 09:00 AM, with Administrative Nurse D, confirmed on 01/22/24, the physician instructed staff to wash the resident's legs with mild soap and water, pat dry, and apply hydrocortisone cream (a cream with steroids) to the rash on his bilateral lower legs daily for two weeks and apply moisturizing lotion the resident's lower legs and feet daily and apply a double layer of Tubigrips to R 137's bilateral lower legs. LN D state she would expect staff to follow the physician's orders and would clarify with the ordering physician if he still wanted the Atrac [NAME] cream and nystatin to continue. The facility policy Irrigation of Ears dated 01/2024, instructed staff to use a bulb or irrigating syringe and allow the solution and gravity to remove the ear wax and place a cotton ball loosely in the auditory meatus (opening). The facility lacked a policy for following physician orders. The facility failed to provide ear irrigation to this resident in a manner of professional standards to prevent trauma to the resident's ear canal. Furthermore, the facility failed to provide/clarify wound care to this resident's lower legs as ordered.

The facility reported a census of 32 residents with 15 residents sampled, including five residents reviewed for accidents. Based ON observation, interview, and record review, the facility failed to initiate an appropriate intervention following one non-injury fall for Resident (R)3, to prevent further falls. Findings included: - Review of Resident (R)3's electronic medical record (EMR) revealed the following diagnoses: Schizoaffective disorder (mental disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought) and muscle weakness. The Significant Change Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of eight, indicating severe cognitive impairment. He had inattentive behavior continuously and impairment in range of motion (ROM) on one side of his lower extremity. He had two or more non-injury falls since his prior assessment (this section of the MDS was inaccurate) and required substantial to maximal staff assistance for transfers from his bed to a chair. The Falls Care Area Assessment (CAA), dated 11/30/23, documented the resident had three falls since his prior assessment, one with minor injury and one with a major injury, including a fracture. The Admission MDS, dated [DATE], documented the resident had a BIMS score of nine, indicating moderately impaired cognition. He had inattention and disorganized thinking behavior which fluctuated. He required supervision or touching assistance from staff for bed to chair transfers and had no falls since admission. The care plan for falls, revised 10/22/23, instructed staff to anticipate the resident's needs due to him being unaware of his safety needs. Staff were to ensure he had non-skid strips beside his bed and in front of his recliner, the call light was to be within reach of the resident and staff were to encourage him to use it. Staff were to encourage him to ambulate close to the walls and handrails to be able to utilize handrails, if needed and encourage him to wear appropriate footwear. Review of the resident's EMR revealed fall assessments which placed the resident at a high risk for falls, dated, 01/09/24 and 08/31/23. Review of the resident's EMR revealed a fall assessment which placed the resident at a low risk for falls, dated 10/05/23. Review of a Fall Report, dated 12/26/23, and provided by the facility revealed the resident had a fall to the floor in his bathroom after attempting to self-transfer from his wheelchair to the toilet and landing on the floor. The resident complained of pain rated ten out of ten and a physician's order was obtained for an x-ray of his left hip. The x-ray was negative for fractures. The facility's intervention for the fall was to re-educate the resident to request staff assistance before attempting to self-transfer. On 01/31/24 at 10:19 AM, Certified Nurse Aide (CNA) N and Licensed Nurse (LN) G entered the resident's room to toilet the resident. Staff used extensive assistance of two staff and the use of a gait belt (belt used to help transfer or stabilize during activity) to transfer the resident from the side of his bed to his wheelchair and from his wheelchair to the toilet. The resident was able to bear full weight and pivot during the transfer. On 01/31/24 at 10:15 AM, CNA O stated the resident was forgetful and did not always remember to use his call light for assistance. He required staff assistance with his Activities of Daily Living (ADL). On 01/31/24 at 10:25 AM, CNA N stated the resident was forgetful and rarely remembered to use his call light. CNA N stated she was unsure of what the resident's fall interventions were. On 01/31/24 at 10:19 AM, Licensed Nurse (LN) G stated the resident was forgetful. When a resident would fall a new intervention would be initiated immediately by the nurse. The nurse would be able to add the intervention to the care plan at the time it was initiated in order to prevent further falls. On 01/31/24 at 03:54 PM, Administrative Nurse F stated the nurse was responsible for initiating a new intervention at the time of a resident's fall. The resident was forgetful with a low BIMS so an intervention of re-education would not be an appropriate intervention for him. On 02/01/24 at 08:31 AM, Administrative Nurse D stated the resident was forgetful. Re-education was an inappropriate intervention for a fall intervention or him. The facility policy for Falls and Fall Risk, effective 04/2023, included: The staff shall identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falls. The facility failed to initiate an appropriate intervention for this dependent resident following a non-injury fall.

The facility reported a census of 32 residents with 15 selected for review, which included six residents reviewed for unnecessary medications. Based on observation, interview and record review, the facility failed to ensure timely follow-up of the pharmacist's recommendations for two of the six sampled Residents (R)7 and R3. Findings included: - Review of Resident (R)7's Physician Order Sheet dated 11/13/23, revealed diagnoses that included dementia (progressive mental disorder characterized by failing memory, confusion), bipolar disorder (major mental illness that caused people to have episodes of severe high and low moods), hypothyroidism (condition characterized by decreased activity of the thyroid gland) and hyperlipidemia (condition of elevated blood lipid levels). The Care Plan reviewed 11/30/23, instructed staff to review the pharmacy consultant recommendations and to follow-up as indicated. On 08/02/23, the physician instructed staff to administer Depakote (an antiseizure medication with mood altering effects) extended release, 250 milligrams (mg) daily for bipolar disorder. On 08/02/23, the physician instructed staff to administer levothyroxine 50 micrograms (mcg), daily for hypothyroidism. On 08/02/23, the physician instructed staff to administer atorvastatin 10 mg, daily for hyperlipidemia. On 08/02/23, the physician instructed staff to administer Risperidone (an antipsychotic) 1 milligram, daily, for bipolar disorder. Review of the Pharmacy Consultation Report dated 10/04/23, revealed the pharmacist recommended a comprehensive metabolic panel, lipid panel (to monitor cholesterol) every 12 months and a basic metabolic panel every six months. Interview, on 02/01/24 at 01:30 PM, with Administrative Nurse D, confirmed the pharmacy recommendation, dated 10/04/23, was not followed-up on, and as of 02/01/24 the recommended labs were not obtained or performed for this resident to monitor the medications ordered. The facility policy Medication Regimen Reviews, instructed staff that the Director of Nursing and Pharmacy Consultant will agree on time frames for reports and process to be taken for the identified irregularity. The facility failed to follow-up on the pharmacist's recommendation for lab for this resident taking multiple medications to ensure the resident did not have adverse reactions or subtherapeutic levels. - Review of the electronic medical record (EMR) for Resident (R)3, included the following diagnoses: Atrial fibrillation (A-fib--rapid, irregular heartbeat) and chronic embolism (an obstruction in a blood vessel due to a blood clot or other foreign matter that gets stuck while traveling through the blood stream) and thrombosis of deep veins (clot which developed within a blood vessel). The Significant Change Minimum Data Set (MDS), dated [DATE], documented the resident received anticoagulant medication (medication which decreases the blood's ability to clot) during the lookback assessment period. The Admission Minimum Data Set (MDS,) dated 10/08/23, documented the resident received anticoagulant medication during the lookback assessment period. The care plan for A-fib, dated 10/22/23, instructed staff the resident took Eliquis (an anticoagulant medication) due to embolism and thrombosis of the deep veins. Review of the resident's EMR revealed a pharmacy consultant's recommendation, dated 11/09/23 requesting the physician to consider discontinuing (DC) aspirin while the resident was on Eliquis due to an increased risk for serious and potentially fatal bleeding. The physician accepted the pharmacy consultant recommendation and staff noted the order on 12/28/23. Review of the resident's EMR revealed a pharmacy consultant's recommendation, dated 12/05/23 requested the facility follow-up with the recommendation from 11/09/23, regarding DCof the resident's ASA due to the increased risk for serious and potentially fatal bleeding. Administrative Nurse D noted the 12/05/23 pharmacy recommendation on 01/02/24. Review of the resident's EMR revealed the following physician's orders: Eliquis 2.5 milligram (mg), by mouth (po), twice daily (BID) for embolism and thrombosis, ordered 01/26/23. Aspirin (ASA) 81 mg, po, every day (QD), for prevention of peripheral vascular disease (PVD- slow and progressive circulation disorder causing narrowing, blockage, or spasms in a blood vessel), to be given at 04:00 AM when resident was awake, ordered 09/01/23. Review of the resident's EMR revealed the ASA 81 mg was not DC'd until 01/02/24. On 02/01/24 at 08:31 AM, Administrative Nurse D stated the pharmacist consultant reviews resident's medications monthly and will send her an e-mail with the recommendations to be sent to each resident's physician. Administrative Nurse D stated she was not sure what happened with the pharmacy recommendations before she became employed at the facility, but the expectation was for the physician to respond to the pharmacy recommendations within approximately two weeks. Administrative Nurse D confirmed the recommendation to DC the ASA was not acted upon in a timely manner. The facility policy for Medication Regimen Reviews, revised 09/2023, included: The Director of Nursing and the Consultant Pharmacist will agree on time process and steps to be taken once an irregularity has been identified. The facility failed to follow-up and act upon the pharmacist recommendations to DC the ASA for this dependent resident, in a timely manner.

The facility reported a census of 32 residents with a sample of 15 residents, including six residents reviewed for unnecessary medications. Based on observation, interview and record review, the facility failed to prevent two residents from unnecessary medications, including Resident (R)19, regarding giving medication outside of parameters and R 7, regarding the pharmacy consultant's recommendation to acquire labs. Findings included: - Review of the electronic medical record (EMR) for Resident (R)19, revealed a diagnosis of orthostatic hypotension (blood pressure dropping with change of position). The Annual Minimum Data Set (MDS), dated [DATE], documented the resident had a diagnosis of orthostatic hypotension (decrease in blood pressure (BP) with movement). The Quarterly MDS, dated [DATE], documented the resident had a diagnosis of hypertension (HTN- high blood pressure). The care plan, dated 10/11/23, lacked staff instruction regarding the resident's orthostatic hypotension. Review of the resident's EMR revealed the following physician's order: Midodrine 10 milligram (mg), by mouth (po), three times per day (TID) for hypotension. Hold if the systolic blood pressure (SBP-top number, the force your heart exerts on the walls of your arteries each time it beats) greater than 130, ordered 05/09/23. Review of the resident's Medication Administration Record (MAR) for August, September, October, and November 2023, revealed the medication was given on six occasions when the SBP was greater than 130. On 02/01/24 at 08:31 AM, Administrative Nurse D stated she would expect for the staff to hold the resident's medication if the SBP was out of the ordered parameters. The facility lacked a policy regarding the administration of medication. The facility failed to hold this medication when the resident's SBP was out of the physician ordered parameters, to ensure no unnecessary medications or adverse reactions. - Review of Resident (R)7's Physician Order Sheet dated 11/13/23, revealed diagnoses that included dementia (progressive mental disorder characterized by failing memory, confusion), bipolar disorder (major mental illness that caused people to have episodes of severe high and low moods), hypothyroidism (condition characterized by decreased activity of the thyroid gland) and hyperlipidemia (condition of elevated blood lipid levels). The Care Plan reviewed 11/30/23, instructed staff to review the pharmacy consultant recommendations and to follow-up as indicated. On 08/02/23, the physician instructed staff to administer Depakote (an antiseizure medication with mood altering effects) extended release, 250 milligrams (mg) daily for bipolar disorder. On 08/02/23, the physician instructed staff to administer levothyroxine 50 micrograms (mcg), daily for hypothyroidism. On 08/02/23, the physician instructed staff to administer atorvastatin 10 mg, daily for hyperlipidemia. On 08/02/23, the physician instructed staff to administer Risperidone (an antipsychotic) 1 milligram, daily, for bipolar disorder. Review of the Pharmacy Consultation Report dated 10/04/23, revealed the pharmacist recommended a comprehensive metabolic panel, lipid panel (to monitor cholesterol) every 12 months and a basic metabolic panel every six months. Interview, on 02/01/24 at 01:30 PM, with Administrative Nurse D, confirmed the pharmacy recommendation, dated 10/04/23, was not followed-up on, and as of 02/01/24 the recommended labs were not obtained or performed for this resident to monitor the medications ordered. The facility lacked a policy for monitoring labs for ensuring effectiveness of medications. The facility failed to follow-up with the physician regarding labs to monitor this resident taking multiple medications to ensure the resident did not have adverse reactions or subtherapeutic levels.

The facility reported a census of 18 residents, with 8 selected for sample review, including 3 reviewed for accidents. Based on observation, interview, and record review, the facility failed to provide assistive devices and supervision to ensure resident (#2) of the 3 reviewed, remained free of repeated falls. Resident #2 experienced a fall and sustained a [MEDICAL CONDITION]. Findings included: - Resident #2's most recent re-admission, identified the resident returned from the hospital on [DATE]. The physician's orders [REDACTED]. The annual MDS (minimum data set), dated 4/3/18, included a BIMS (brief interview of mental status) score of 8, indicting moderately impaired cognition. The resident expressed little interest in doing things, felt down/depressed, tired and experienced trouble with concentration. The resident required supervision of ADLs (activities of daily living), and used a walker for mobility. The assessment identified 2 or more falls since admission, without injury. The quarterly MDS, dated [DATE], included a BIMS of 8, indicating moderately impaired cognition, exhibited feeling down/depressed, little interest in doing things, little energy, appetite concerns; continued to require supervision for walking and experienced one no-injury fall. The CAA (care area assessment), dated 4/4/18, for falls included the resident experienced a fall last week, occurring while getting into his/her closet independently. The resident wants to continue to do these things without assistance and stated that he/she will ask for help when needed. The three most recent fall risk assessments, all identified the resident was at high risk for falling (10 or greater indicated high risk): On 3/30/18, scored 10. On 6/10/18, scored 14. On 6/22/18, scored 13. The resident's care plan, for falls, dated 4/5/18, included the following: Remind and encourage the resident to ask for assistance, 4/5/18. Self-propels wheelchair to and from the dining room for meals and around his/her room, 4/5/18. Anticipate the resident's needs, 4/5/18. Assist with mobility, 4/5/18. Encourage use of proper footwear, such as non-skid, well-fitted shoes, 4/5/18. Getting into the closet caused a fall recently, because of turning loose of the walker reaching for items, added 6/15/18. Provide 2-person assistance for transfers while recovering from the left [MEDICAL CONDITION], added 6/15/18. Staff to check on the resident frequently and assist with ADL's, added 6/15/18. Moved room closer to nursing desk, for more frequent observation, added 6/15/18. Review of the residents falls identified the resident experienced falls on 1/29/18, 3/30/18, and 6/10/18. Review of the progress notes, dated 6/10/18 at 3:18 PM, identified the resident experienced an unwitnessed fall, found lying on the floor of his/her room, on his/her left side and with the resident's walker lying on top of the resident. Staff documented the resident had a history of [REDACTED]. The staff notified the physician and transferred the resident to the hospital. Observation, of the resident on 7/11/18 at 10:54 AM, identified the resident watching television while seated in his/her wheelchair in his/her room. At 11:50 AM on 7/11/8, the resident responded appropriately to most questions, however, did not recall watching television in his/her room an hour ago. At 1:05 PM on 7/11/18, the resident sat in a recliner in his/her room, reading a book. Direct care staff E reported, at that time the resident requested to be placed in the recliner and denied any need for toileting. Intermittent observations throughout the afternoon identified the resident remained in the recliner, doing word search, reading, and watching television. At 5:07 PM on 7/11/18, direct care staff D transferred the resident using a gait belt and a transfer wheel, moving the resident from the recliner to the wheelchair. The resident declined an offer of toileting. On 7/11/18 at 1:48 PM, direct care staff F reported the resident required extensive assistance of 1 staff for transferring, and previously required limited assistance, prior to the [MEDICAL CONDITION]. Staff reported the resident was always a fall risk, with gripper strips at the bedside and staff providing toileting offers about 4 times a shift. The staff reported since the fall the resident no longer attempted arising unassisted. Staff reported the resident used the call light to ring for assistance, at times. Direct care staff H reported on 7/12/18 at 2:43 PM, the resident was a fall risk and had a [MEDICAL CONDITION] recently. The staff reported the resident required 2-person assistance for transfers at this time, using a pivot disc for the transfers. The staff reported prior to the fall/fracture the resident was a fall risk and needed staff to provide limited to supervised assistance for ADLs, including walking, and that the resident used a front wheeled walker. The staff often found the resident ambulating independently and at one point the staff used an alarm for the resident, to alert staff when the resident got up unassisted. Staff removed the alarm when the resident began doing better about using the call light and the alarm was not in use at the time of the resident's most recent fall. Interview with licensed nursing staff C on 7/12/18 at 3:39 PM, reported the resident was independent with ambulation in his/her room prior to the fall with a fracture. Staff were instructed to assist the resident with getting things out of the closet and staff C reported providing education to the direct care staff regarding obtaining items out of the resident's closet for the resident. Interview with administrative nursing staff B, on 7/12/18 at 4:30 PM, identified on the day of the fall that only 1 CNA (certified nurse aide) staff was on duty. The staff reported that interventions were being followed, because at that time the resident was independent with ambulation in his/her room. The staff also noted the MDS and the care plan were incorrect in the assessment. The staff member further noted the resident had prior falls getting items out of the closet and that the facility failed to implement adequate interventions to prevent the resident from having repeated falls. The facility policy, for falls, dated 5/17, included a risk reduction, fall and injury program, would be used to assess residents to identify and implement appropriate interventions to reduce the risk of falls or injuries while maximizing dignity and independence. The plan of care meeting would address and discuss identified trends and review and revise the plan of care. The facility failed to ensure the provision of assistive devices and adequate supervision to ensure the resident remained free of accidents and injuries. The resident experienced repeated falls, with the most recent fall resulting in a [MEDICAL CONDITION] requiring hospitalization .

The facility reported a census of 22 residents with 14 residents selected for review. Based on observation, interview, and record review, the facility failed to provide appropriate treatment and services to meet the emotional needs of 1 (# 5) resident for behavioral health. Findings included: - The signed physician orders, dated [DATE], of resident # 5, documented the resident admitted on [DATE], with the following [DIAGNOSES REDACTED]. The admission MDS (minimum data set), dated [DATE], revealed the resident had a BIMS (brief interview for mental status) score of 10, that revealed moderate impairment in cognition. The resident's mood scored 5, that revealed moderate depression. The resident had verbal behavior, not directed towards others. He/she had no rejection of cares. The resident did not receive an anti-depressant. The mood cognitive CAA (care area assessment), dated [DATE], did not trigger. The significant change MDS, dated [DATE], revealed the resident had short term and long term memory problems. He/she required modified independence in decision making for daily life. His/her mood scored 13, that revealed moderate to severe depression. The resident received an anti-depressant for 3 days during the look back period. The cognitive CAA, dated [DATE], documented the resident did not respond to interview questions by staff for BIMS or psychological state. He/she had anger, agitation, and refused to cooperate, and the behavior was not normal for the resident. The mood CAA, revealed the resident was not cooperative and he/she refused cares. The resident would be evaluated for behaviors and mood, and staff would be instructed how to approach the resident. Staff hoped the mood change was temporary. The behavior CAA documented the resident had a decline in mood and behavior. The resident had verbal behavior, and he/she attempted to strike out at staff. The dementia care plan, dated [DATE], documented staff should allow the resident time to express his/her feelings if upset. Staff may make a possible referral to a geriatric psychiatric facility. The depression care plan, dated [DATE], documented the resident expressed sadness due to the loss of his/her child, and adjustment to the facility. The resident would cry in his/her room over the loss of his/her child. Staff should check in when the resident cried to determine if the resident was sad or if the resident had discomfort. Offer distractions such as a snack or an activity, such as a puzzle, or talk about his/her family. Review of the nurse's notes, from [DATE] to [DATE], documented on [DATE], the resident's child died . The resident worried about the funeral arrangements. The resident had been emotional and tearful at times. The resident was depressed and had little energy, and he/she had a poor appetite. The child's death affected the resident greatly. The resident had trouble with concentration, and was short-tempered with staff. On [DATE], the death of the resident's child still affected him/her occasionally. On [DATE], the resident had times when he/she was tearful. On [DATE], at 10:45 am, the resident sat in his/her room, and wept, tears flowed down his/her cheeks, and he/she cried so hard, if was difficult for the resident to catch his/her breath. On [DATE] at 8:12 am, the resident was in the dining room, with a picture album. The resident was tearful when he/she looked through the photo album. On [DATE] at 8:34 am, direct care staff D, reported the resident cried a lot, and would also cry in his/her sleep. The resident re-arranges his/her photo album frequently, and talked about his/her child frequently. On [DATE] at 2:19 pm, direct care staff F, reported the resident's child passed away, and the resident went downhill, and was very emotional after the death. He/she reported the resident talked about the child's death frequently. The resident really cried more at night. On [DATE] at 3:30 pm, licensed nursing staff G, reported some days the resident was more tearful than other days. The resident had not been seen by a psychologist or physician. The resident was not on any antidepressant medication to help him/her thru the grief process. On [DATE] at 2:33 pm, administrative nursing staff B, reported staff try to let the resident visit about his/her child's death. He/she was unaware if the staff notified the physician of the resident's emotional concerns. Sometimes, staff would leave him/her alone and let the resident cry, and other times, staff attempted to distract the resident with puzzles. The resident used to cry daily, and more in the evening. The facility staff could probably do more for the resident for her grieving/emotional health. On [DATE] at 3:40 pm, social services staff L, reported he/she visited with the resident occasionally, and verified he/she had not personally visited with the resident from (MONTH) (YEAR) to [DATE]. On the occasional visits with the resident, social services staff L, verified he/she did not report the resident's emotional well-being to staff for further physician notification. The facility failed to ensure the resident received the appropriate medical related social services, after the death of his/her child, to address the resident's grief.

The facility identified a census of 40 residents with 14 residents in the sample. Based on observation, interview, and record review, the facility failed to provide supervision, assistive devices, and effective interventions for 3 of 4 cognitively impaired residents at risk for falls sampled for accidents; residents #23, #36, and resident #21 that experienced a fall that resulted in a hip fracture. Findings included: - Resident #21 had [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] recorded the resident with a Brief Interview for Mental Status (BIMS) score of 7, which indicated severe cognitive impairment. The resident required extensive assistance from staff for transfers, bed mobility, dressing, personal hygiene, toileting, limited assistance with eating, balance was unsteady and he/she was only able to stabilize with staff assistance. The resident required a wheelchair or walker for mobility and was frequently incontinent of bladder while on a toileting plan. Review of the fall risk assessment dated [DATE] recoded a score of (15), which documented a score of 10 or greater placed the resident at high risk for falls. Review of the revised plan of care dated 7/24/14 recorded the resident was at risk for falls related to unsteady balance, poor endurance, and a history of falls. Interventions implemented directed staff: Call light or personal items available and in easy reach. Footwear to prevent slipping. I use a non-skid chair mat (Dycem) in my recliner. Keep environment well lit and free of clutter, to prevent tripping. Utilize a gait belt with transfers, ambulation, and follow with the wheelchair. PSA (personal safety alarm) on at all times due to forgetfulness. The clinical record documented on12/25/13 at 11:40 A.M. the resident lost his/her balance during an assisted transfer and staff lowered the resident to the floor. The clinical record documented the resident with a fall on 4/17/14 at 11:05 A.M., at which time the resident attempted to transfer unassisted and received an abrasion to the right arm and the right leg. Staff responded to the resident 's PSA at 9:45 A.M. and assisted the resident to the bathroom. At 11:05 A.M. staff found the resident on the floor after he/she attempted to self-transfer without assistance and lost his/her balance. The post fall analysis documented the resident had a history of [REDACTED]. Immediate interventions planned for staff to prevent reoccurrence; to encourage resident to utilize call system for staff assistance with all transfers and ambulation. The fall investigation provided by the facility lacked evidence of the staff on duty at the time of the event or interviews of any staff or witnesses. Nursing note dated 12/8/14 at 2:27 P.M. recorded one staff assisted the resident with a gait belt for transfers, ambulation, toileting, and utilized a walker. The resident did not use a call light for assistance, frequently unpinned the PSA (personal safety alarm) in his/her room and got up without staff assistance. Staff redirected and reeducated the resident on safety and the call system. Nursing note on 1/12/15 timed 10:39 A.M., recorded the resident required the PSA at all times and walked to the dining room with a front-wheeled walker, gait belt and standby assistance of one staff member. The weekly nursing summary dated 2/2/15 documented one staff member assisted the resident with a gait belt and walker, for transfers, ambulation, and toileting, and required a PSA at all times. Nursing notes dated 2/8/15 timed 5:32 P.M. recorded an unwitnessed fall and staff found the resident on his/her left side on the floor with the PSA unattached and not sounding, and no assistive device within reach of the resident. The resident cried out in pain when staff examined the resident ' s right lower extremity and called for an emergency transport to a local hospital for treatment and evaluation. Review of the facility investigation documented on 2/8/15 at approximately 4:50 P.M. staff heard the resident yelling, and found the resident in his/her room, lying on his/her left side on the floor. The facility report documented the resident stated he/she was trying to get to the bathroom, lost his/her balance and fell . The resident stated he/she had unpinned the personal alarm so he/she could go to the bathroom. The investigation recorded the staff assisted the resident to the toilet at 1:30 P.M. (3 hours and 20 minutes prior to the resident ' s fall). A situational note on the post fall investigation documented the resident had dementia, poor safety awareness, and a history of falls. The clinical notes recorded the resident 's hospital admission with a right hip fracture on 2/8/15 and readmitted the resident on 2/13/15 after an ORIF (open-reduction-internal-fixation) repair of the right hip fracture. Nursing notes dated 3/2/15 at 2:53 A.M., documented the resident wore a PSA at all times but was noncompliant, believed he/she was capable of doing more than he/she actually was able to do, and would unpin the PSA to take him/herself to the bathroom instead of asking for staff help. The resident transferred with full weight bearing, a gait belt, walker, and assistance of two staff members. Observation on 3/10/15 at 3:35 P.M. revealed the resident reclined in an electric lift recliner with a PSA attached to the resident and the chair back. Direct care staff R and S placed a gait belt around the resident, and with a walker, assisted the resident to the bathroom. The resident walked with a slow shuffling gait. The resident ' s shirt, pants, and recliner seat were soaked with urine. On 3/11/15 at 10:02 A.M. therapy staff GG transfered the resident from the wheelchair with gait belt to the electric lift recliner. The resident struggled to follow therapy instructions to lock the wheelchair brakes before getting up. Therapy staff GG attached the personal alarm to the chair back of the resident 's recliner, raised the footrest, and placed the electric remote to the chair on the bed next to the resident ' s arm. The resident reported, " My leg doesn ' t feel good, but it feels a whole lot better. " During an interview on 3/9/15 at 1:12 P.M., licensed nursing staff G reported the resident experienced a fall that resulted in a fractured hip on 2/8/15 On 3/10/15 at 9:00 A.M. licensed nursing staff H revealed the resident had a personal alarm and unhooked it, fell and fractured his/her hip. On 3/10/15 at 3:35 P.M. direct care staff R reported the resident unpinned his/her alarm, got up, and fell . On 3/10/15 3:40 P.M., direct care staff S reported the staff checked and toileted the resident about every 2 hours and the resident takes off (unpins) the personal alarm. The resident tells staff " I know I shouldn ' t have done that. " On 3/11/15 at 10:02 A.M., therapy staff GG reported the resident required two staff to assist with transfers when he/she came back from the hip repair and had made much progress. 3/11/15 at 10:50 A.M., licensed nursing staff G revealed staff did not assess residents for use of an electric lift chair. On 3/11/15 at 4:00 P.M. direct care staff W reported the resident does not follow the facility direction and takes his/her personal alarm off. The resident took the personal alarm off yesterday and takes the alarm off almost every day. On 3/11/15 at 3:20 P.M., administrative nursing staff D reported staff did not assess residents for use of electric lift chair and the resident had a personal alarm to prevent falls. On 3/12/15 at 8:40 A.M. administrative nursing staff D reported during an investigation of a fall, he/she interviewed staff on duty but did not record the information. Administrative nursing staff D reported, he/she did not know he/she had to document that information. Review of the policy for Falls Management Guidelines dated 1/22/15, during readmission intake, determine if the potential resident has a history of falling or was unsteady in gait. Assure that the appropriate fall interventions were in place prior to the resident ' s admission. All risk residents were identified through a " fall alert " communication system to care givers. During orientation, new employees are educated to the fall management system. The interdisciplinary team evaluates the fall prevention plan of care for residents " at risk " for falls. Following the completion of the MDS, if a resident triggers at risk for falls, the resident has further assessment utilizing the CAA guidelines. The plan of care was updated, if indicated to further minimize the risk of falls. Following a resident ' s fall: appropriate interventions were implemented and the care plan was updated. The facility failed to provide supervision and effective fall prevention interventions for this cognitive impaired resident that unpinned a personal safety alarm, fell and obtained a fractured right hip that required surgical intervention. - Resident #23 had [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] recorded the resident with a Brief Interview for Mental Status (BIMS) score of 10, which indicated moderate cognitive impairment. The resident required extensive assistance from staff for all activities of daily living, used a wheelchair /walker for mobility, and unsteady balance and only able to stabilize with staff assistance. The resident experienced 2 or more falls since the previous assessment. Review of the fall Care Area assessment dated [DATE] that documented the resident at risk for falls related to poor balance and a history of falls. Staff monitored the resident for restlessness and pain, provided footwear to prevent slipping, and kept the environment well lit and free of clutter. Safety strips along the side of bed and in front of chair. Keep bed in low position and keep needed items within reach. PSA (personal safety alarm) at all times. The quarterly nursing assessment on 5/26/14 recorded the resident with a fall risk of (12) which placed the resident at high risk for falls. The quarterly nursing assessment on 12/9/14 recorded the resident with a fall risk of (12) which placed the resident at high risk for falls. The quarterly MDS note dated 3/6/15 documented the resident with a BIMS score 4, severe cognitive impairment. Review of the plan of care dated 12/9/14 identified the resident with functional incontinence and directed staff to: 1) Maintain call light or personal items available and easy reach or provide reacher 2) Monitor for restlessness and pain 3) Footwear to prevent slipping 4) Keep environment well lit and free of clutter 5) Therapy referral as needed 6) Monitor PSA each shift 7) Safety strips beside bed and in front of chair (discontinued 10/22/14) Added on 8/20/14 neuro assessment and vital signs every 72 hours and per facility protocol Added on 2/27/15, neuro checks per facility protocol. Allow resident to rest in bed between meals. The facility reported the resident experienced falls on 8/20/14, 9/3/14, and 2/27/15. Review of a post fall investigation note dated 8/20/14 timed 3:40 P.M. documented the resident with an unwitnessed non-injury fall. The clinical note documented staff toileted the resident at 1:30 P.M. and upon entering the resident ' s room at 3:40 P.M. and found the resident on the floor (2 hours and 10 minutes since last check from staff). The resident unclipped the personal safety alarm and reported he/she needed to use the bathroom. Review of the completed bladder assessment dated [DATE], after the resident ' s fall on 8/20/14, directed a toileting schedule every 2 hours and prn (as needed), including before and after meals, and bedtime. Review of a post fall investigation note dated 9/30/14 documented at 5:29 A.M., staff responded to a noise from the resident ' s bathroom and found the resident in a semi-reclining position on the floor resting against the wall. The resident reported he/she hit his/her head. The investigation revealed staff assisted the resident to the bathroom and left the resident unattended. The staff member was counseled for safety of residents with personal safety alarms were not to be left unattended when toileting. Nursing note dated 12/3/14 at 3:23 A.M. recorded the resident utilized high back wheelchair with staff assistance for distance. The resident ambulates with a gait belt and one staff assistance in his/her room, continent and incontinent of bowel and bladder, did not request toileting, and was on a toileting schedule. Review of post fall investigation dated 2/27/15 revealed staff toileted the resident at 1:00 P.M. and responded to the resident ' s personal safety alarm at 3:55 P.M. (2 hours and 55 minutes after toileting). The resident fell out of the high back wheelchair onto the floor. The resident was alert and confused with bowel incontinence. The fall investigation lacked evidence of causative factors of the residents fall and directed to place the resident into bed between meals. Observation on 3/10/15 at 7:45 A.M. the resident sat in a high back wheelchair with a personal alarm attached to the chair and overbed table in front of the resident. The resident remained in the high back wheelchair at 8:00 A.M. and ate breakfast from small bowls. At 8:15 A.M., 8:30 A.M. 8:45 A.M., 9:00 A.M., and 9:15 A.M. the resident sat picking at the food in the small bowls unattended by staff. Continued observations revealed the resident seated in the high back wheelchair with a PSA attached to the back of the wheelchair on 3/10/15 at 11:45 A.M., 11:45 A.M., 12:00 P.M., 12:15 P.M., 12:30 P.M., the resident continued to sit in the high back wheelchair with overbed table in front unattended by staff. At 12:43 P.M., activity staff Z delivered the lunch tray to the resident. Continued observations revealed at 12:45 P.M., 1:00 P.M., 1:15 P.M., 1:25 P.M. the resident remained seated in the wheelchair. At 1:25 P.M., direct care staff O placed a gait belt and with the front wheeled walker assisted the resident slowly from the wheelchair into the bathroom. During interviews on 3/10/15 at 1:55 P.M. with the three direct care staff on duty, N, P, T reported they had not check or changed the resident at 10:00 A.M. and direct care staff O would have toileted or checked the resident, and the resident would ask when he/she needed toileting. Continued observations on 3/10/15 at 2:00 P.M., 2:15 P.M., 2:30 P.M., 3:00 P.M., 3:15 pm, 3:30 P.M., 3:45 pm, 4:00 P.M., 4:15 pm, 4:30 P.M., 4:45 P.M., 5:00 P.M., 5:15 P.M., 5:45 P.M., the resident lay in her bed with a PSA attached to the resident ' s clothing and the turning bar. During observations on 3/10/15, the resident did not use the call light. On 3/11/15 at 9:29 A.M. while standing in the hallway outside the resident ' s room, direct care staff Q repeatedly asked resident if he/she needed to go to the bathroom, the resident stated, he/she spent all night in the bowling alley. Staff left the resident sitting up in the wheelchair with the overbed table and the resident was not toileted at this time. Observation on 3/11/15 at 2:19 P.M., direct care staff N and S entered the resident ' s room during rounds. The resident reported he/she had to use the bathroom and direct care N and S ambulated the resident with a gait belt and walker to the toilet. During observations on 3/11/15 revealed the resident did not use the call light. On 3/11/15 at 3:20 P.M., administrative nursing staff reported staff checked and changed the resident and offered toileting about every 2 hours or less, whenever the resident wants to go, before meals, after meals, at bedtime and prn, as he/she would allow. Administrative nursing staff D reported he/she was not aware of gaulding in the resident ' s perineal area. Staff based the resident ' s toileting program on the bowel and bladder assessment and care planned, if the resident was capable of following a toileting plan. Otherwise, the resident should be toileted per the schedule. On 3/10/15 at 2:08 P.M., direct care staff T reported staff toileted the residents every 2 hours. On 3/10/15 at 3:40 P.M. direct care staff S reported the resident wore a personal alarm on at all times to prevent falls. On 3/11/15 at 2 P.M. direct care staff N reported the resident fell from the wheelchair trying to pick something up off the floor and has a PSA on all the time. On 3/12/15 at 11:00 A.M., licensed nursing staff J reported the resident rings to go to the bathroom and should probably be toileted 3 or 4 times each shift. The resident has a PA on all the time, had fallen, and staff stayed with the resident in the bathroom. Review of the policy for Falls Management Guidelines dated 1/22/15, during readmission intake, determine if the potential resident has a history of falling or was unsteady in gait. Assure that the appropriate fall interventions were in place prior to the resident ' s admission. All risk residents were identified through a " fall alert " communication system to care givers. During orientation, new employees are educated to the fall management system. The interdisciplinary team evaluates the fall prevention plan of care for residents " at risk " for falls. Following the completion of the MDS, if a resident triggers at risk for falls, the resident has further assessment utilizing the CAA guidelines. The plan of care was updated, if indicated to further minimize the risk of falls. Following a resident ' s fall: appropriate interventions were implemented and the care plan was updated. The facility failed to provide supervision and assistive devices to prevent falls for this cognitively impaired dependent resident. - Resident #36 had a [DIAGNOSES REDACTED]. The annual Minimum Data Set Assessment ((MDS) dated [DATE] recorded the resident with a BIMS (Brief Interview for Mental Status) score of 00, which indicated severe cognitive impairment. The resident required extensive assistance with all activities of daily living, unsteady balance and unable to stabilize without staff assistance. The resident was frequently incontinent of bladder, always incontinent of bowel, and experienced two or more non-injury falls since the previous assessment. Review of the falls Care Area Assessment (CAAs) dated 8/11/14 documented the resident with a history of falls related to altered balance and poor safety awareness. The resident required two staff members for transfers, utilized a wheelchair for mobility and required a PSA (personal safety alarm) at all times. Staff toileted the resident upon arising, before and after meals, and as needed. Staff kept the bed in low position with a fall mat beside the bed and the resident wore non-slip footwear at all times. Review of the bowel and bladder assessment tool with 3-day voiding pattern for urinary incontinence completed on 8/9/14 documented staff toileted the resident before and after meals, every 2 hours during the day, checked and changed the resident 2 hours at night, or toilet as resident allows. Review of the plan of care for fall prevention dated 8/11/14 and reviewed on1/15/15 recorded the resident a fall risk, history of falls, agitation, and restlessness. The care plan documented on 12/15/14 staff observed the resident on his/her knees at bedside. The resident hopped out of a chair landing on his/her right side and obtained a skin tear to the right elbow. On 12/29/14, the PSA sounded and staff observed the resident seated on the floor in front of the recliner. The care plan directed staff to: 1) Activity programming, exercises, TV programs 2) Assess for pain 3) Assess that wheelchair of appropriate size, assess need for footrests, assess for need to have wheelchair locked/unlocked for safety, anti-tipper 4) Call light or personal items available and in easy reach or provider reacher 5) Footwear to prevent slipping 6) Family allowed removal of regular bed. Facility bed to be maintained in low position 7) Gait belt with transfers 8) Keep environment well light and free of clutter 9) Mat beside bed 10) Monitor/anticipate and intervene factors precipitating falls such as bowel and bladder urgency, mobility problems, transferring difficulty 11) Observe for side effect of medications 12) PSA on at all times (added on 8/2/13) 13) Room rearranged so bed was flush with the wall 14) Therapy referral 15) Toilet schedule Review of the fall assessment dated [DATE] documented a score of (14), and indicated a score of 10 or greater placed the resident at risk for falls. Review of the resident care sheet dated 12/4/14 instructed direct care staff to toilet and reposition the resident every 2 hours, apply PSA on at all times due to falls. Clinical notes dated 4/30/14 timed 3:00 P.M. documented the resident ate lunch in the dining hall, staff toileted the resident and then returned the resident in his/her wheelchair in the commons area in a wheelchair to be near the staff and visitors. The resident slid out of the wheelchair in the commons area. The record identified the resident with a history of falls, cognitive deficits, and impaired safety awareness. The record documented the resident was incontinent when toileted, however lacked the time of toileting. The record lacked evidence of the personal safety alarm (ordered 8/2/13) or what staff observed and found the resident. A clinical post fall analysis recorded the resident with a fall on 5/9/14 timed 2:35 P.M. recorded the resident ate lunch at approximately 11:30 A.M. - noon. Staff toileted the resident at 1:15 P.M. and then returned the resident in his/her wheelchair to the lobby. The resident slid out of the wheelchair. The record lacked evidence of the personal safety alarm (ordered 8/2/13). A clinical post fall analysis recorded the resident fell from bed on 5/19/14 at 7:45 A.M. The record documented staff last toileted the resident at 6:00 A.M. (1 3/4 hours after cares). The record lacked evidence of the personal safety alarm (ordered 8/2/13). A clinical post fall analysis recorded the resident fell on [DATE] at 5:05 P.M. The report documented the resident had been in commons area eating snack at 2:05 P.M., staff toileted the resident at 3:00 P.M. and returned the resident to the dining hall. Staff toileted the resident again at 4:45 P.M. and returned the resident in in his/her wheelchair in the lobby area. The resident set off the personal safety alarm several times appearing restless and agitated. The clinical post fall analysis recorded the resident fell on [DATE] 12:50 P.M. Staff brought resident to the dining hall at 9:50 A.M. and provided a milkshake. Staff transferred the resident to a recliner at 10:50 A.M. The resident continued restlessness setting off PSA several times. The resident was continent of urine when staff toileted the resident at approximately 11:50 A.M. Staff returned the resident to the dining room for the noon meal. The resident finished the meal at approximately 12:35 P.M. and remained at the dining table in the dining room until the PSA sounded and staff found resident sitting on floor. The clinical post fall analysis recorded the resident fell on [DATE] at 8 P.M. Staff toileted the resident at 6:00 P.M. After the evening meal, the resident remained in the wheelchair with a PSA in place sitting next to the nurse ' s station. The resident became restless, setting off the PSA and reaching for objects close to him/her. The clinical post fall analysis recorded the resident fell from bed on 12/13/14 at 5:30 A.M. Staff changed the resident ' s incontinent brief at 2:00 A.M., provided care for the resident at 3:30 P.M. The resident set off the PSA at 4:10 A.M. and incontinence brief was dry. At 5:30 A.M., staff found the resident with knees slid off the side of the bed closest to the PSA (not triggering the alarm). The resident 's brief was wet. A skin assessment revealed red areas to both knees, an abrasion above the left knee, three bony prominences to outer right foot were red with an indentation of 0.5 centimeter and red areas to both ankles. Care intervention put in place to rearrange the resident ' s bed flush against the wall. Nursing notes dated 12/26/14 unable to follow simple commands. Sits at feeder table. Staff feeds. Incontinent of bowel and bladder. Extensive assist of two with transfers, bed mobility, incontinence cares, PSA at all times, bed in low, mat on floor at bedside. The clinical record documented on12/29/14 at 4:45 P.M., staff found the resident seated on the floor in the independent dining room in front of the lift recliner. The record documented staff provided care for the resident at 1:00 P.M. The record failed to identify if and when staff toileted the resident prior to the fall. The fall occurred 3 hours and 45 minutes after staff provided cares. Nursing note dated 3/6/15 timed 2:40 A.M., recorded the resident with severe dementia, unable to follow simple commands, incontinent bowel and bladder, required extensive assist from two staff for all transfers and toileting. On 3/9/15 at 12:33 P.M. an interview with residents II, JJ, and KK, seated in the independent dining room, reported staff left the resident sitting on an incontinence pad in a recliner in the independent dining all day and when staff transfer the resident out of the recliner to his/her place to eat, the " smell was overwhelming " . The residents reported staff did not routinely remove the soiled incontinence pad or spray for offensive odors. Observation on 3/10/15 at 7:30 A.M., the resident sat in a wheelchair next to the nursing station with a PSA attached to the wheelchair and back of the resident ' s clothing. During the constant observation, staff assisted the resident with eating, at 8:35 A.M. direct care staff O, and licensed nursing staff H transferred the resident from the wheelchair to the recliner and elevated the resident ' s footrest and attached to personal alarm to the recliner back. On 3/10/15 at 1:30 P.M., direct care staff N and T applied a gait belt, transferred the resident from the wheelchair to the recliner in the independent dining room, and elevated the footrest. During constant observations at 1:45 P.M., 2:00 P.M., 2:15 P.M., 2:30 P.M., 2:45 P.M., 3:00 P.M., 3:15 P.M., and 3:30 P.M., the resident moved about in the recliner, removing one shoe and putting his/her legs through the opening between the chair seat and the footrest. On 3/10/15 at 3:37 P.M., while seated in the wheelchair, the resident attempted to stand and reach over the wheelchair. Direct care staff R and S assisted the resident to an upright sitting position in the wheelchair. On 3/11/15 at 11:00 A.M., the resident independently moved about the dining room in his/her wheelchair with the personal alarm attached to the chair. At 11:21 A.M., the resident leaned over and set off the PSA. Direct care staff N and licensed nursing staff I applied a gait belt and transferred the resident from the wheelchair to the electric lift recliner. Staff held onto the gait belt and under the residents arm. The resident was unable to bear weight on his/her legs. Staff reclined the chair and placed the footrest in the up position with the gap between the seat and the foot. On 3/10/15 at 1:50 P.M. direct care staff P reported the resident leaned forward, was a fall risk, and required the alarm on all the time. Direct care staff P reported staff toileted the resident about every 2 hours. On 3/10/15 at 3:37 P.M., direct care staff S reported the resident was a fall risk and had the alarm on all the time. On 3/11/15 at 10:50 A.M., licensed nursing staff G reported staff did not assess residents for use of electric lift chairs. 3/12/14 at 8:40 A.M., administrative nursing staff D reported during an investigation of a fall, he/she interviews staff on duty but did not record the information. Administrative nursing staff D reported he/she did not know he/she had to document that information. On 3/12/15 at 11:00 A.M. licensed nursing staff J reported the resident leaned forward in the wheelchair and when he/she did that staff placed the resident in the recliner with the legs elevated. The resident had a personal alarm on all the time. When the resident was in the wheelchair, staff observed the resident at the nursing station. Review of the policy for Falls Management Guidelines dated 1/22/15, during readmission intake, determine if the potential resident has a history of falling or was unsteady in gait. Assure that the appropriate fall interventions were in place prior to the resident ' s admission. All risk residents were identified through a " fall alert " communication system to care givers. During orientation, new employees are educated to the fall management system. The interdisciplinary team evaluates the fall prevention plan of care for residents " at risk " for falls. Following the completion of the MDS, if a resident triggers at risk for falls, the resident has further assessment utilizing the CAA guidelines. The plan of care was updated, if indicated to further minimize the risk of falls. Following a resident ' s fall: appropriate interventions were implemented and the care plan was updated. The facility failed to provide supervision, assistive devices, and effective interventions to prevent repeated falls for this cognitively impaired dependent that experienced 8 falls since 4/30/14.