Every finding on record at Essentia Health Northern Pines Medical Center

Based on interview and document review, the facility failed to submit the payroll-based journal system (PB&J) staffing data to Centers for Medicare and Medicaid Services (CMS). This had the potential to affect all 30 residents residing in the facility. Findings included: The facilty's PB&J report 1705D dated 10/11/23, identified the facility failed to submit data for quarter 3 (April 1 - June 30) of fiscal year 2023. During an interview with the administrator and the director of nursing (DON) on 10/23/23 at 2:04 p.m., the DON stated they attempted to submit data for the PB&J but had technical difficulties and believed they had until the 15th of the month to complete it. However, the submission closed at midnight on the 14th and they were unable to submit anything. They had tried to fix it but it was too late and there was nothing they could do.

Based on interview and document review, the facility failed to ensure resident resuscitation wishes were correctly identified in the electronic health record (EHR) based on signed advanced directives for 1 of 16 residents (R8) who's advance directives were reviewed. Findings include: R23's significant change Minimum Data Set (MDS) dated [DATE], identified R8 had mild cognitive impairment and no terminal diagnoses. R8's Provider Orders for Life-Sustaining Treatment (POLST) dated [DATE], identified R8 chose Do Not Attempt Resuscitation/DNR (allow natural death). This directed staff that in the event of acute or impending respiratory arrest, no resuscitation or sustained ventilation would be initiated. R8's electronic health record (EHR) banner identified R8 was a full code. The undated, facility handwritten Full Code list, identified three residents who were full code. R8 was not listed. During an interview on [DATE] at 6:03 p.m., R8 stated she would not want cardiopulmonary resuscitation (CPR). During an interview on [DATE] at 6:15 p.m., registered nurse (RN)-B stated she would look at the handwritten note at the nurses desk. If the resident was listed, it meant a full code and staff started CPR. During an interview on [DATE] at 6:20 p.m., RN-A stated she would look at the handwritten list to determine a resident's code status in the case of an emergency. During an interview on[DATE] at 3:08 p.m., social services (SS)-A stated she reviewed code status and the resident's wishes upon admission. A POLST was always signed by the resident or resident's representative upon admission so the facility had an immediate plan. SS-A mistakenly had not corrected R8's EHR banner but would do so immediately. During an interview on [DATE] at 3:23 p.m., the director of nursing (DON) stated she expected a resident medical record to be accurate in order to reflect the resident's wishes. The faciliy advanced directives policy was requested but not received.

Based on observation, interview, and document review, the facility failed to provide assistance with morning cares for 1 of 4 residents (R23) reviewed for activities of daily living (ADLs) and who was dependent on staff for care. Findings include: R23's quarterly Minimum Data Set (MDS) dated [DATE], identified R23 had moderate cognitive impairment and required partial/moderate assistance with cares. R23's care plan revised 10/23/23, identified R23 had a self-care deficit problem related to cerebrovascular accident (stroke), R23 was at risk for falls, and not getting needs met. Interventions included: - R23 was very methodical during care and had rituals she liked to follow such as washing her knees and rubbing them. R23 liked her back washed a certain way and her hair adjusted a certain way. The facility staff were aware of these nuances. - R23 had no teeth. Set up for oral cares. - Provide assist of one with dressing, undressing, and grooming. Encourage R23 to participate in self-care skills to promote greatest independence as possible. R23 used a wheelchair at all times, propelled by staff or self (able to lift feet on demand/ bilateral wheelchair pedals) and R23 fed self after set up. During an observation on 10/23/23 at 2:39 p.m., R23 was seated in her wheelchair in her room looking out the window. R23's long hair was greasy and disheveled. R23 was wearing pajamas. During an observation on 10/25/23 at 7:02 a.m., R23's room and bathroom door was open, and the bathroom lights were on. R23 was in the bathroom sitting on the toilet. R23 was wearing a long-sleeved t-shirt and R23's pants and brief were around her ankles. R23's wheelchair was in reach and the sink faucet was running. R23 had a wet washcloth draped over her right knee and R23 had a wool ball she was rubbing over the washcloth. R23 stated she was fine, and her joints were finally moving that morning. R23 began rubbing the knuckles of her hands. No staff were with R23. - At 7:10 a.m., nursing assistant (NA)-A entered the room and stated, hey girlie, were you just going to call me? R23 made no comment and continued to rub her knees. NA-A assisted R23 to pick out her clothes and assisted R23 to change from her pajama top to a clean t-shirt. R23 required verbal cues and physical assistance to lift arms and to place arms in sleeves. NA-A assisted R23 to stand and began pulling up R23's pants. R23 stated wait, reached down into her pants, and pulled out the wool ball. R23 stated there's water there and I have to sit. NA-A assisted R23 to turn and sit down in her wheelchair. - At 7:16 a.m., NA-A assisted R23 to sit in front of her sink. The faucet was running, and NA-A set up R23's toiletries and placed a washcloth on the edge of the sink and a dry hand towel on the towel bar. NA-A gathered R23's soiled clothing and trash and left the room. R23 wet her washcloth and draped it over the sink edge, repetitively smoothing the washcloth down. R23 then cleaned the sink with the washcloth and then placed it back on the sink edge to repeat the process. - At 7:22 a.m., R23 dipped the corner of the washcloth into mouthwash and ran it along her tongue, gums, nose, chin, and forehead. R23 took a sip and mouthwash, swished and spit into an empty cup, poured it into the sink then rinsed mouth with water. R23 repeated this process. - At 7:27 a.m., R23 dipped her toothbrush in mouthwash and ran the toothbrush along her eyebrows, hairline and over her eyes. R23 rinsed the toothbrush with water and used the toothbrush along her tongue and gums. - At 7:29 a.m., R23 again picked up her washcloth and used an approximately 1-inch corner of the washcloth to run along her face. R23 used the washcloth to tuck her hair behind her ears. R23 picked up her comb and combed her eyebrows. R23 then rinsed her mouth with mouthwash and repeated the process of combing her eyebrows then rinsing her mouth with mouthwash. R23 used her comb to comb her tongue. - At 7:45 a.m., NA-A stepped into the room and told R23 she was just checking on R23 and asked if she needed help. R23 stated she did not know yet and NA-A reminded R23 she had a dry hand towel on the towel bar. NA-A left the room. - At 7:47 a.m., R23 continued to have dark brown debris embedded under her fingernails. R23 picked up her toiletry bottles and read the labels out loud, but placed each bottle down and did not use the products. R23 began to fold her washcloth, hand towel, three paper towels and a personal wipe in a stack on her lap. - At 7:55 a.m., R23 rolled out of the bathroom into her room where NA-A delivered her breakfast tray. NA-A told R23 she had perfect timing but did not ask R23 if she needed any assistance to complete her morning cares. During an interview on 10/25/23 at 7:57 a.m., NA-A stated R23 was pretty much an extensive assist with dressing but R23 was very peticular. Staff just set R23 up and let her do her thing. If not, R23 would get mad. R23 would use her words but would never hit or scream. R23 would say things like staff didn't listen and might call staff names. Staff just had to let her do her thing, otherwise staff would just be there for hours. During an interview on 10/25/23 at 8:01 a.m., licensed practical nurse (LPN)-A stated R23 used to be able to toilet herself and do all her cares, but hadn't been able to do that for some time. R23 would turn on her call light and ask for staff help. R23 could wash herself but it took a really long time. R23 had pretty bad OCD (obsessive compulsive disorder) and wanted things a certain way. Staff could leave her alone in her bathroom because R23 would sit and fuss a really long time. For example, R23 had to sit and rub her legs for a certain number of times and if she messed up, she had to start all over again. During an interview on 10/25/23 at 10:11 a.m., registered nurse (RN)-B stated she completed all the residents' assessments, new admissions and quarterly. Because of this, she knew the residents in and out. RN-B stated she was not the best care planner, because it could become all-consuming, but she tried to stay up to date on what a resident's needs were. RN-B completed the R23's cares one day and it was time consuming. R23 required limited to extensive assist. R23 would sit in her bathroom and do her rituals. R23 would rub her legs and wash what she could. Staff couldn't stay with her the whole time and walk away for a little bit. R23 was not independent or set up only because she required staff assistance but wanted it her way. R23 could wash what she could reach. Staff needed to wash her bottom for example. Ultimately, R23 dictated what she let staff do and how they do it. However, if staff stayed in the room the whole time it would be at least an hour and the other residents would not receive the care they needed. Certainly, staff had to make a great effort to assist her, but it was difficult. RN-B never cared for someone so ritualistic. R23 was very set in what she would do, how she would do it and needed more monitoring. Staff never considered to obtain a psych consult for R23. R23 was just one of those ladies that when she was at home, everything had to be a certain way. No matter what staff did it just did not match up with what R23 was thinking. During an interview on 10/25/23 at 10:41 a.m., the director of nursing (DON) stated assistance of one with grooming meant the resident required assist of one. Staff needed to be with R23 to assist her with her grooming. The DON never assisted R23 with cares but had been told it was 45 minutes because R23 was ritualistic and required things in a certain way and a certain order. R23 did not have a diagnosis of OCD and had not been evaluated by a mental health provider, but R23 was very particular. The DON stated she expected staff to follow the care plan. The facility policy SNF Activities of Daily Living (ADLs) Standards of Care approved 10/12/22, defined partial/moderate assistance as the helper did less than half the effort. The helper lifted, held, or supported trunk or limbs, but provided less than half the effort. The policy identified fingernails would be kept clean and manicured. Nail care would be provided a minimum of weekly with bathing. Morning and evening cares would include washing face and hands, peri care, oral care and changing clothing.

Based on observation, interview, and document review, the facility failed to ensure urinary catheter care was provided, to prevent contamination and potential urinary tract infection (UTI) for 1 of 1 residents (R22) reviewed for catheter cares. Findings include: R22's annual Minimum Data Set (MDS) dated [DATE], identified R22 had no cognitive impairment and had a indwelling catheter. R22's care plan revised 10/23/23, identified R22 used an indwelling catheter due to a neurogenic bladder. R22 had the potential for concerns related to indwelling catheter use such as: infection, leakage, skin breakdown, pain, injury, and/or embarrassment. Interventions included: Empty bag every shift and as needed; and AM & PM Care: Cleanse cath insertion site BID with soap and water, pat dry. Monitor skin at insertion site for increased redness, odor, pain, or change in character of urine. During an observation on 10/24/23 at 11:30 a.m., nursing assistant (NA)-A applied a gown and gloves and obtained R22's graduate from his bathroom. NA-A placed the graduate directly on the floor under R22's catheter's bag port, opened the port and drained the bag. NA-A cleaned the catheter bag port with an alcohol swab and closed the port, then laid the catheter bed bag on the floor. NA-A poured the urine into the toilet and rinsed the graduate with water. NA-A picked up R22's catheter bed bag off the floor, threaded it through R22's pants leg and placed the catheter bed bag on the end of R22's bed. NA-A then left R22's room. During interview on 10/24/23, at 11:47 a.m., NA-A stated she was nervous and dropped the catheter bed bag on the floor. NA-A figured it was already on the floor and there was nothing she could do about it. Further, the port should have been cleaned before and after opening and there should have been a barrier between the graduate and the floor. During an interview on 10/24/23 at 1:11 p.m., the director of nursing (DON) stated during catheter cares there should be a barrier between the graduate and the floor, the port should be cleaned before and after opening, and the catheter bed bag should not lie directly on the floor because it increased the risk for infection. A facility catheter care policy was requested but not received.

Based on interview and document review, the facility failed to provide the most recent Centers for Disease and Prevention (CDC) education regarding the potential risks and benefits of the pneumococcal vaccine for 2 of 5 residents (R8, R10) reviewed for pneumococcal and influenza immunizations Findings include: R8's significant change in status MDS dated [DATE], identified R8 was admitted to the facility on [DATE], was [AGE] years old and had diagnoses that included hypertension, thyroid disorder, and metabolic encephalopathy (brain dysfunction caused by problems with metabolism) R8's Preventative Health Care vaccination record undated, identified R8 received an PPSV23 on 11/23/16. R8's medical record did not include evidence R8 or R8's representative received education regarding pneumococcal vaccine booster and there was no indication R8 was offered the pneumococcal vaccine per CDC guidance. R10's quarterly MDS dated [DATE], identified R10 was admitted to the facility on [DATE], was [AGE] years old, and had diagnoses that included hypertension. R10's Preventative Health Care vaccination record undated, identified R10 received a PPSV23 on 2/24/11 and on 9/26/16 and received a pneumococcal conjugate vaccine (PCV13) on 9/26/16. R10's medical record did not include evidence R10 or R10's representative received education regarding pneumococcal vaccine booster and there was no indication R10 was offered the pneumococcal vaccine per CDC guidance. During an interview on 10/24/23 at 1:18 p.m., the director of nursing (DON) stated she was responsible for the facility's infection control program and was aware of new pneumococcal vaccine guidance but was unable to recall the specifics. The facility's focus was COVID-19 and influenza vaccinations, but would be addressing pneumococcal vaccines soon. The facility had not yet reviewed residents' eligibility for pneumococcal vaccines or boosters. During an interview on 10/24/23 at 1:45 p.m., the health unit coordinator (HUC) stated she did not have residents sign a vaccination consent form when they refused. The facility's Influenza/Pneumococcal Immunization policy reviewed 2/14/23, identified resident vaccinations were reviewed upon admission. Residents were offered immunization against influenza annually as well as offered the pneumococcal vaccine as the need was assessed. The facility followed the recommendations for the CDC and the influenza vaccinations were offered in the facility October 1 through March 31 annually unless the immunization was medically contraindicated, already immunized or after the provision of education on risks and benefits the resident continued to refuse.

Based on observation, interview and document review the facility failed to ensure food temperatures were measured upon removing food from the oven. In addition, the facility failed to ensure food items and medical equipment (ice packs) were not mixed together in the freezer compartment of the refrigerator in the dining room. This had the potential to affect all 37 residents who resided in the facility. Finding include: During an observation on 12/7/22, at 11:24 a.m. cook (C)-A was in the process of measuring food temperatures of food which had already been removed from the oven and were in the steam table. The stewed tomatoes were 170 degrees Fahrenheit (F), kielbasa slices were 208 degrees F, the hot German potato salad was 185 degrees F, the chopped meat kielbasa was 150 degrees F. Initially C-A stated all the temperatures are okay, when questioned further she stated the temperature for the chopped kielbasa was too low and she would be microwaving it. Dietary manager (DM)-B stated the kielbasa was cooked from raw slices. At 12/7/22, at 11:30 a.m. cook (C)-A re-measured the temperature for the chopped kielbasa after removing it from the microwave. The temperature was 185 degrees F. C-A stated the kielbasa had been chopped up from the cooked kielbasa slices which were cooked from raw. C-A stated she did not check the temperature of the kielbasa slices when they were removed from the oven, she said it was cooked thoroughly and it cooled off because it sits funny in the steam table. C-A stated she just knew the kielbasa was cooked. During an observation on 12/8/22, at 12:23 p.m. the refrigerator and freezer in the dining room were checked. In the freezer compartment ice packs were found loose and not in the zip lock bag which contained several other ice bags. In addition, the zip lock bag containing several ice packs was not sealed shut, the ice pack were mixed in with other food items including (bread, an omelet [dated 7/3/22], a quart of ice cream, a purple silicone mold uncovered [no names or dates]). In the freezer door there were ice packs not in zip lock bags, there were three individual ice creams next to the ice packs. In the refrigerator there was cream cheese, sweet and sour sauce, mustard, no name or dates. There were two unopened whole milk half gallon containers, and one opened fat free milk container and juices with no open dates. On 12/8/22, at 12:28 p.m. the temperatures log located on the side of the refrigerator had temperatures missing for most dates in October and November; the current temperature was 29 degrees F. During an interview on 12/8/22, at 12:46 p.m. DM-B stated she expected the cooks to measure the temperature of foods when they were removed from the oven and before they were placed in the steam table. DM-B stated she thought the cooks were doing this. During an interview on 12/8/22, at 2:00 p.m. the director of nursing (DON), acting for the administrator, stated she would expect to see cold packs in bags and separated from food in the freezer. In addition, she stated she would expect the food to have resident names and dates on them. The DON stated she would expect the kitchen staff to follow regulations for measuring food temperatures after cooking. A policy for measuring the temperatures of food after cooking was requested but not provided. The facility policy titled Food Safety Requirements-Use and Storage of Food and Beverage Brought in For Residents, Food Procurement dated 1/14/21, indicated inadequate cooking and improper holding temperatures may cause food borne illness. The policy further indicated staff would label and date items brought in and leftover foods would be used within three days or discarded.

Based on interview, observation, and documentation the facility failed to ensure personal privacy and confidentiality by posting resident names and diet information in a public area viewable by other residents and visitors. This deficient practice impacted 5 of 5 residents (R14, R6, R8, R7 and R12). Findings include: On 12/05/22, at 6:05 p.m. the dining room steam table had notes taped on both sides. The steam table side facing the nursing station, viewable from hallway, had the following notes: 1. No scrambled eggs for [R14's name]. 2. Document titled Diet Spreadsheet had R8's first name written in red, and notes on spread sheet. 3. No chicken, full name of resident R6. 4. No asparagus with 3 resident names listed below including R7's full name. 5. No Beets with five names listed below The following notes were on the front side of the steam table facing out into the general dining area. 1. Resident R11's full name Skim milk only (only underlined 3 times) note was dated 11/6. 2. R19's first name and room number skim milk at meals, note was dated 7/28. 3. Resident first name no eggs at breakfast give yogurt and cold cereal at breakfast. 4. Highlighted in yellow: Please, please, please do not give R12 (full name) any milk products: no regular milk, no chocolate ensure, no ice cream, no pudding, no cream soups thanks. Two notes were on the fridge in the in the dining area: 1. Resident's first name and last initial, give ensure at supper meal 2. R8 first name last initial, has her own bagels to use for her breakfast please thank you. On 12/06/22, at 9:06 a.m. all notes were still posted on steam table and fridge. On 12/08/22, at 12:09 p.m. all notes were still posted in dining area. On 12/08/22, at 12:14 p.m. dietary Aide (DA)-A and cook-(A) were at steam table. During interview, cook-A stated the notes on the nursing station side of steamtable were used to communicate resident preferences, changes to diet, and dislikes. Cook-A stated the dietary manager posted the notes on the front side for dietary and nursing staff to get updated on resident dietary changes. 12/08/22, at 12:18 p.m. DA-A stated she did not see a concern with posting dietary information about residents on the steamtable and her manager should be asked about the notes. She hadn't thought about privacy or how the notes could get in the way of washing the steam table. 12/08/22, at 12:17 p.m. nursing assistant (NA)-B stated the notes on the dining side of the steam table helped workers get food ready and the notes were in a good place because that is where staff stand when they get juice and milk ready. 12/08/22, at 12:28 p.m. dietary manager (DM)-A stated she takes notes down in care areas when she sees them. DM-A identified some of the notes as nurse notes and some as notes she had posted on the kitchen communication board. DA-A stated the notes from the kitchen should not be on the steam table. She had asked nursing/kitchen staff to send change requests to her because the information should be in the electronic medical record instead of posted somewhere. DM-A pulled notes off steam table and stated it's okay to leave notes about cleaning, but notes with resident names and diet information should not be posted on the steam table. During a interview on 12/08/22, at 12:44 p.m. the director of nursing (DON) stated she was not aware there were notes with resident dietary information posted in the dining area where anyone could see them. The DON stated it was unlikely any harm was caused by the posted notes, but looking at the Health Insurance Portability Act (HIPPA), having the notes posted would be a violation of the rule. The DON stated she would be addressing the notes immediately. During interview on 12/8/22, at 2:30 p.m. R8 stated if there was a note with their name on it about what they do or do not eat, R8 raised voice and stated, no I don't want my name out there for people to see anything about me, that's not needed. The document titled Resident Rights found in the facility admit folder included the right, residents have the right to have one's health status and other personal information kept confidential. The document titled Notice of Privacy Practices dated 9/13 located in the admit folder included the notification: Essentia facilities are required to follow both state and federal laws and regulations that protect health information and if they are different, Essentia must follow the rules that provide the greatest protection of health information and grant greater rights.

Based on observation, interview and document review, the facility failed to ensure residents were supervised by nursing staff during dining for 4 of 6 residents (R12, R13, R14, and R81). Findings include: R12's annual Minimum Data Set (MDS) dated [DATE], indicated R12 had severe cognitive impairment, severe vision impairment and required assistance of one for eating. R12's care plan edited on 12/22/22, indicated he had altered cognitive impairment, dysphagia [difficulty swallowing] and required a mechanical altered diet, was legally blind, and needed staff assistance to be fed, he had problems with swallowing and chewing. Approaches were for staff to assist him with eating at meals. R12's Physician Order Report dated 11/8/22, through 12/8/22, indicated orders for a consistent carb/heart healthy, soft bite sized food with special instructions: bread okay, regular thin liquids, fully upright for meals and 30 minutes after, close supervision with meals. During a continuous observation on 12/8/22, which started at 9:52 a.m. and ended at 10:34 a.m. R12 was observed seated in the dining room with one half of a sandwich in front of him; he had an Ensure Plus on his place mat. There were no nursing staff present in the dining room. - at 10:00 a.m. R12 remained seated in the dining room at the table. He had finished his beverage, the sandwich remained in front of him. - at 10:09 a.m. there were two staff at the nurses's station off of the dining room. The dining room was in view of the nurse's station. -at 10:12 a.m. a staff approached R12 and put his hearing aides in and then left. -at 10:15 a.m. no nursing staff were present in the dining room. -at 10:17 a.m. there were no nursing staff at the nurse's station. -at 10:18 a.m. a staff member approached R12 and poured the rest of his Ensure into his glass and reminded him he had a sandwich in front of him which R12 then picked up and started eating it, the staff member left the area. -at 10:21 a.m. R12 was eating his sandwich on his own; no staff were present. -at 10:22 a.m. R12 remained at the table; no nursing staff were in the dining room. The activities director was running an exercise program in the dining room. During an interview on 12/8/22, at 10:29 a.m. nursing assistant (NA)-A was at the nurse's station, she stated R12 was not a good eater, would not let staff feed him. NA-A stated R12 liked to eat sandwiches, she was unaware if there were any special instructions for R12 during dining. During an interview on 12/8/22, at 10:34 a.m. trained medication aide (TMA)-A stated she thought staff were supposed to be present in the dining area when residents were eating. TMA-A verified nursing staff had not been consistently present during dining. TMA-A stated we're there as much as we can. R13's Face Sheet printed on 12/8/22, indicated diagnoses which included dementia and macular degeneration (an eye disease that causes vision loss). R13's quarterly MDS dated [DATE], indicated R13 was cognitively intact. R14's Face Sheet printed on 12/8/22, indicated diagnoses which included heart disease, heart failure, and type 2 Diabetes Mellitus. R14's quarterly MDS dated [DATE], indicated R14 had moderately impaired cognition and had severely impaired vision. R81's Face Sheet printed on 12/8/22, indicated diagnoses which include dysthymic disorder (depression) and vitreous degeneration of left eye (an eye disease which results in dark specs, floaters, or flashing lights). R81's quarterly MDS dated [DATE], indicated he had moderately impaired cognition. During a continuous observation on 12/8/22, which started at 12:05 p.m. and ended at 12:47 p.m. -at 12:14 p.m. NA-A performed hand hygiene, pulled up a chair and sat down next to R12 and attempted to try to assist him with eating. R12 would say no and spit out the food. He was however drinking a red beverage on his own. NA-A asked R12 if he wanted a bite of cake, he ate this and NA-A left the dining room. -at 12:38 p.m. there were six residents in the dining room; four of them were still eating (R12, R13, R14, R81). -at 12:40 p.m. NA-A poured R12 some juice and then left the dining room. -at 12:44 p.m. staff took R12 out of the dining room. -at 12:45 p.m. nursing staff left the dining room, R13 remained in the dining room eating cake. -at 12:46 p.m. R14 was taken out of the dining room. -at 12:47 p.m. R81 finished eating and wheeled himself out of the dining room. During an interview on 12/8/22, at 2:00 p.m. the director of nursing (DON) verified she would expect nursing staff to remain in the dining room while residents were still eating. A facility policy on residents in the dining room was requested but not provided.

Based on observation, interview, and document review, the facility failed ensure wall mounted kitchen fans that were oscillating on clean dishes and food prep areas were free from dust and debris. This had the potential to affect 27 residents that received food from the kitchen. Findings include: The facility request work order dated 10/26/20, was completed by DM-A requesting kitchen fans to be cleaned. On 7/07/21, at 10:54 a.m. during the initial tour of the kitchen a wall mounted fan located in the dishwashing room had visible dust build up, and was oscillating from the dirty area to the clean area where uncovered coffee cups, drinking glasses, bowls and serving trays were drying. On 7/07/21, at 12:54 p.m. cook(C)-A stated dishes come out of the dishwasher and were kept on drying racks on the clean side of the dishwashing room were put away when they were completely dried. C-A further stated the wall mounted fan circulated air and helped dry the dishes. The wall mounted fan in the dishwashing room oscillating on clean dishes remained to have dust and debris build up. On 7/08/21, at 11:53 a.m. the dietary manager (DM)-A and maintenance engineer (ME)-A were interviewed. DM-A verified the wall fans in the dishwashing room and kitchen had visible dust build up. DM-A stated she completed a maintenance request a few months ago for the fans to be cleaned but they never got done. ME-A stated he received a work order to clean the kitchen fans a few months ago. ME-A stated he was off from work for a while and never got to it. DM-A verified the wall mounted fans oscillated over both dirty and clean dishes, as well cooking and food prep areas, and stated it was a sanitary concern. DM-A stated cleaning the kitchen fans were not on a routine cleaning schedule, and further stated the fans only got cleaned when someone noticed they were dirty, and then would submit a work order for maintenance. On 7/09/21, at 10:04 a.m. the director of nursing (DON) stated maintenance request for cleaning fans were being worked on, and did not want to comment further since she was not the dietary manager. A policy for cleaning kitchen equipment was requested and not provided. A Nutrition Service Department Infection Control was provided, but lacked direction on cleaning kitchen fans.

Based on interview and document review, the facility failed to ensure annual abuse education was completed for 3 of 19 employees E-A, E-B, E-C) whose records were reviewed for abuse education. This had the potential to affect all 27 residents residing in the facility. Findings include: A review of training records indicated: Employee (E)-A was hired on 6/21/00. The facility's employee dementia or abuse training log indicated C-A had dementia training but lacked a date when C-1 had abuse education. E-B was hired on 3/6/17. The facility's employee dementia or abuse training log indicated SW-A completed abuse training last on 5/4/2000. E-C was hired on 3/9/15. The facility's employee dementia or abuse training log indicated PT-C completed abuse training last on 10/18. 7/9/21, at 10:18 a.m. the director of nursing (DON) verified abuse training should be completed annually. The facility's Abuse, Neglect, Mistreatment and Misappropriation of Resident Property policy dated 10/20/20, directed all new employees would receiving training on the facility's abuse policy prior to direct or indirect contact with the residents. The policy further directed attendance at a yearly in-service on the abuse policy was mandatory for all employees.

Based on interview and document review, the facility failed to ensure identification and monitoring of mood and behavior symptoms to determine efficacy of [CONDITION(S)] medications (mood and behavior altering medications) for 3 of 5 residents (R2, R23, and R25) reviewed for unnecessary medications. In addition, the facility failed to identify and monitor side effects and effectiveness of [CONDITION(S)] medications for 1 of 5 residents (R3) reviewed for unnecessary medications. Findings include: R2's Face Sheet undated indicated R2's diagnoses included major depressive disorder, anxiety disorders, and restless leg syndrome. R2's admission Minimum Data Set (MDS) dated [DATE], indicated R2 was cognitively intact, had minimal mood symptoms, and received an antidepressant medication during the assessment period. R2's Physician Order Report dated 7/9/21, indicated R2's medication orders included an order for [MEDICATION(S)] (antidepressant) 25 milligrams (mg) once daily. R2's order's for [MEDICATION(S)] lacked a diagnosis for use and target behaviors or mood symptoms. R2's care plan initiated 6/1/21, indicated R2 received [MEDICATION(S)] for depression, and directed nursing to observe for side effects, and document by exclusion. R2's care plan lacked identification of target behaviors or mood symptoms, and monitoring of target behaviors and mood symptoms related to R2's [MEDICATION(S)] order. R2's General Administration History for 6/9/2, through 7/9/21, lacked identification and monitoring of target behaviors or mood symptoms related to R27's use of [CONDITION(S)] medications. R2's Medications Administration History for 6/9/21, through 7/9/21, lacked identification and monitoring of target behaviors or mood symptoms, and diagnosis related to use of [CONDITION(S)] medications. On 7/8/21, at 1:00 p.m. registered nurse (RN)-A was interviewed and stated the staff know resident behaviors and what interventions to do to help residents. RN-A verified the target behaviors and mood symptoms should be identified and included on the resident's care plan, and should include non-pharmacological interventions to address the resident's mood and behavior symptoms. On 7/8/21, at 1:06 p.m. the director of nursing (DON) stated the staff monitor and use the communication book to communicate mood and behavior symptoms, and then she does a quarterly review. The DON verified the target behaviors and mood symptoms were not addressed on the care plan, and verified new staff may not know how to address a resident's mood and behavior symptoms. The facility policy [CONDITION(S)] Medication reviewed 2/2/21, directed the indication for any [CONDITION(S)] medication would be thoroughly documented in the clinical record to include an appropriate supporting diagnosis, and identification of behavioral symptoms being treated. The facility policy directed a quarterly interdisciplinary team review of [CONDITION(S)] medications, and before initiation or increasing a [CONDITION(S)] medication, symptoms and therapeutic goals must be clearly and specifically identified and documented, to include an evaluation of the resident's physical, behavioral, mental, and psychosocial signs and symptoms. Further, the policy and procedure directed non-pharmacological interventions would be determined based on an individualized assessment, and documentation would reflect attempts to implement care-planned, non-pharmacological approaches and ongoing effectiveness of the interventions. In addition, ongoing documentation must include monitoring for efficacy and adverse consequences. R23's Face Sheet undated, indicated R23's diagnoses included anxiety disorders and palliative care. R23 was under Hospice care. R23's quarterly MDS dated [DATE], indicated R23 had moderately impaired cognition, had no [CONDITION(S)], behaviors or rejection of cares. R23 received an antianxiety medication and an antidepressant during the assessment period. The Physician's Order Report dated 7/9/21, indicated R23's medication orders included: - lorazepam ([MEDICATION(S)], an antianxiety medication) 0.25 mg every four hours as needed - [MEDICATION(S)] (antidepressant) 25 mg once daily R23's care plan dated 5/16/21, indicated R23 used [CONDITION(S)] medications for signs and symptoms of depression. Use of the medication placed R23 at risk for falls injury and side effects from the medication. The care plan directed to observe for side effect and document by exclusion. Look up the medication side effects with any abnormal concerns in the drug hand book which may be associated with [CONDITION(S)] medication use. The care plan further indicated R23 was taking [MEDICATION(S)] to treat anxiety with dyspnea (difficulty breathing). The care plan lacked identification of target behaviors or mood symptoms, monitoring of target behaviors and mood symptoms and non-pharmacological interventions to address R23's mood and behavior symptoms related to R23's lorazepam and [MEDICATION(S)] orders. R23's General Administration History for 6/9/21, through 7/9/21, lacked identification and monitoring of target behaviors or mood symptoms, or non-pharmacological interventions related to R23's use of [CONDITION(S)] medications. R23's Medications Administration History for 6/9/21, through 7/9/21, lacked identification and monitoring of target behaviors or mood symptoms, non-pharmacological interventions, and diagnosis related to use of [CONDITION(S)] medications. R25's Face Sheet printed 7/8/21, indicated R25's diagnoses included mild cognitive impairment, [CONDITION(S)], major depressive disorder, and long term (current) use of anticoagulants. R25's quarterly MDS dated [DATE], indicated R25 was cognitively intact, and received scheduled anticoagulant and antidepressant medications. R25's Physician Order Report dated 7/8/21 indicated the following orders: [MEDICATION(S)] tablet 50 mg tablet, take one tablet once a day. [MEDICATION(S)] (blood thinner) 1 mg tablet, take 3 mg once a day. R25's care plan initiated on 1/14/21, directed nursing to monitor for side effects of medications by looking up the side effects in a drug handbook and documenting by exclusion. R25's care plan lacked indication to ensure identification and monitoring of mood and behavior symptoms. R3's Face Sheet undated, indicated R3's diagnoses included major depressive disorder. R3's quarterly MDS dated [DATE], indicated R3 had severe cognitive impairment, exhibited no behaviors, and received an antidepressant and antianxiety medication during the assessment period. R3's Physician Order Report dated 7/9/21, indicated R3's medication orders included an order for [MEDICATION(S)] (antidepressant) 30 mg at bedtime and [MEDICATION(S)] (antianxiety medication) 5 mg three times a day. R3's physician order for [MEDICATION(S)] and [MEDICATION(S)] lacked target behaviors or mood symptoms. R3's care plan initiated 9/10/20, indicated R3 received [MEDICATION(S)] for depression, and [MEDICATION(S)] for anxiety, and the use of the medications put R3 at risk for side effects. R3's care plan lacked identification of side effects, and monitoring of target behaviors and mood symptoms. R3's Medications Administration History for 6/9/21, through 7/9/21, lacked identification and monitoring of target behaviors or mood symptoms, non-pharmacological interventions, and side effects related to use of [CONDITION(S)] medications. On 7/08/21, at 11:12 a.m. the trained medication aide (TMA)-A viewed R3's electronic medication and treatment record and verified R3's MAR and TAR lacked identification and monitoring of target behaviors or mood symptoms, non-pharmacological interventions, and side effects related to use of [CONDITION(S)] medications.

Based on observation, interview, and document review, the facility failed to ensure hand hygiene was completed between glove changes during incontinent cares for 1 of 2 residents (R11) reviewed for incontinent cares. Findings include: R11's Face Sheet printed 7/9/21, indicated R11's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R11's quarterly Minimum Data Set (MDS) dated [DATE], indicated R11 was cognitively intact, required extensive assistance with his activities of daily living (ADLs), and was frequently incontinent of bowel and bladder. R11's Care Area assessment dated [DATE], indicated R11 toilets as he dictates, is toileted at regular intervals, and is at risk for infection. R11's CAA indicated staff completes perineal care twice daily and as needed. On 7/8/21, at 5:28 p.m. R11 was observed propelling his wheelchair out of his room and stated he was heading to get assistance to go to the bathroom. On 7/8/21, at 5:44 p.m. nursing assistant (NA)-B was observed to wash her hands and prepare R11 for transfer to the toilet. When NA-B lowered R11's brief, R11 expelled liquid stool all over his brief and the toilet, down to the floor. Registered nurse (RN)-A washed her hands and donned gloves, removed R11's dressing from his coccyx (tail bone) and examined his skin. RN-A then wiped up the stool from his buttocks and perineal area with several sanitizing wipes which RN-A removed from the plastic wipe bag-type container, while touching the outside of the container with soiled gloves. RN-A removed her gloves, and donned clean gloves. RN-A did not wash or sanitize her hands between changing gloves. RN-A placed a new [MEDICATION(S)] dressing (foam, absorbent dressing) to R11's coccyx. RN-A then removed her gloves and washed her hands. On 7/8/21, at 6:09 p.m. RN-A verified she should have washed her hands between glove changes. On 7/9/21, at 8:54 a.m. the director of nursing (DON) verified she would expect hand hygiene to be completed between glove changes during incontinent cares. The facility policy Hand Hygiene Standard Work dated 6/20/19, directed hand hygiene to be completed after body fluid exposure, and after glove removal to protect self and environment from harmful germs. The facility policy indicated hands could be sanitized if not visibly soiled, but directed washing with soap and water if visibly dirty, contaminated, or soiled.

Based on interview and document review, the facility failed to ensure a comprehensive care plan included mood and behavior symptoms with non-pharmacological interventions related to [CONDITION(S)] medications (mood and behavior altering medications) for 2 of 6 residents (R2, R23) reviewed for unnecessary medications. Findings include: R2's Face Sheet printed 7/8/21, indicated R2's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's admission Minimum Data Set (MDS) dated [DATE], indicated R2 was cognitively intact, had minimal mood symptoms, and received an antidepressant medication during the assessment period. R2's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] - [MEDICATION(S)] (antidepressant) 25 mg once daily R2's care plan initiated 6/1/21, indicated R2 received [MEDICATION(S)] for depression, and directed nursing to observe for side effects and document by exclusion. R2's care plan lacked identification of target behaviors or mood symptoms, monitoring of target behaviors and mood symptoms and non-pharmacological interventions to address R2's mood and behavior symptoms related to R2's [MEDICATION(S)] order. R2's General Administration History for 6/9/21, through 7/9/21, lacked identification and monitoring of target behaviors or mood symptoms, or non-pharmacological interventions related to R27's use of [CONDITION(S)] medications. R2's Medications Administration History for 6/9/21, through 7/9/21, lacked identification and monitoring of target behaviors or mood symptoms, non-pharmacological interventions, and diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 7/8/21, at 1:00 p.m. registered nurse (RN)-A stated the staff know resident behaviors and what to do that helps them. RN-A verified the target behaviors and mood symptoms should be identified and included on the resident's care plan, and should include non-pharmacological interventions to address the resident's mood and behavior symptoms. On 7/8/21, at 1:06 p.m. the director of nursing (DON) stated the staff monitor and use the communication book to communicate mood and behavior symptoms, and then she does a quarterly review. The DON verified the target behaviors and mood symptoms were not addressed on the care plan, and verified new staff may not know how to address a resident's mood and behavior symptoms. The facility policy [CONDITION(S)] Medication reviewed 2/2/21, directed before initiation or increasing a [CONDITION(S)] medication, symptoms and therapeutic goals must be clearly and specifically identified and documented, to include an evaluation of the resident's physical, behavioral, mental, and psychosocial signs and symptoms. Further, the policy directed non-pharmacological interventions would be determined based on an individualized assessment, and documentation would reflect attempts to implement care-planned, non-pharmacological approaches and ongoing effectiveness of the interventions. In addition, ongoing documentation must include monitoring for efficacy and adverse consequences. R23's Face Sheet printed 7/8/21, indicted R23's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] R23's quarterly MDS dated [DATE], indicated R23 had moderately impaired cognition, and did not have [CONDITION(S)], behaviors or rejection of cares. The MDS further indicated R23 received an antianxiety medication and an antidepressant during the assessment period. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] - lorazepam ([MEDICATION(S)], an antianxiety medication) 0.25 milligrams (mg) every four hours as needed - [MEDICATION(S)] 25 mg once daily R23's care plan dated 5/16/21, indicated R23 used [CONDITION(S)] medications for signs and symptoms of depression, and use of the medication placed R23 at risk for falls injury and side effects from the medication. The care plan directed to observe for side effect and document by exclusion. The care plan further indicated R23 was taking [MEDICATION(S)] to treat anxiety with dyspnea (difficulty breathing). The care plan lacked identification of target behaviors or mood symptoms, monitoring of target behaviors and mood symptoms and non-pharmacological interventions to address R23's mood and behavior symptoms related to R23's lorazepam and [MEDICATION(S)] orders. R23's General Administration History for 6/9/21, through 7/9/21, lacked identification and monitoring of target behaviors or mood symptoms, or non-pharmacological interventions related to R23's use of [CONDITION(S)] medications. R23's Medications Administration History for 6/9/21, through 7/9/21, lacked identification and monitoring of target behaviors or mood symptoms, non-pharmacological interventions, and diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on interview and document review. the facility failed to ensure a written discharge summary with discharge instructions and signed physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: R27's Face Sheet printed 7/8/21, indicated R27 was discharged on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R27's discharge Minimum Data Set, dated dated dated [DATE], indicated R27 was cognitively intact, no signs or symptoms of [CONDITION(S)] or [CONDITION(S)], and had not had any behaviors during the assessment period. R27's MDS further indicated R27 required extensive assistance with bed mobility, locomotion off the unit, dressing, and toilet use, and required limited assistance with personal hygiene, ambulation and transfers. In addition, R27's MDS indicated R27 had received opioid pain medications for 6 of 7 days during the assessment period, for occasional pain which limited her day-to-day activities, and received physical therapy (PT) and occupational therapy while at the facility. R27's progress notes dated 5/6/21, indicated R27 was being discharged the following day on 5/7/21, due to meeting her therapy goals, and the determination had been made she was safe to return home with the use of a walker for safety. R27's progress note indicated arrangements had been made for home care services for therapy, home health aide, meals-on-wheels, life alert, rides from a family member, and friends to check in on her. R27's Admission to Discharge Plan of Care, dated 5/6/21, indicated R27 was admitted from a hospital for short-term transitional care placement following a fall with a pelvic fracture, and was planning to discharge home on 5/7/21, due to sufficient improvement in health and no longer needed services provided by the facility. R27's discharge plan of care indicated a caregiver would be present in the home, and identified services to be provided at home. R27's discharge plan of care was unsigned by the resident or resident representative, but indicated R27 or resident representative understood the discharge plan. R27's progress note dated 5/7/21, indicated R27 had been to an appointment with her physician that day, and orders were received to discharge her home. R27's progress note indicated R27 would go home on [MEDICATION(S)] (diuretic medication), and the nurse explained to her why she was taking the [MEDICATION(S)] and the importance of taking it every day. The nurse further documented R27 had some short-term memory issues and was concerned she would forget, so it was suggested R27 use a pill box and place it near her tooth brush to help her remember. R27's progress note indicated R27 had a follow-up appointment with her physician in 2 weeks. R27's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . R27's progress note indicated R27 continued to be at risk for falls, and would benefit from continued physical therapy. R27's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . R27's signed Physician Note and Orders directed to discharge home, see primary provider and PT face-to-face was done. On 7/8/21, at 12:47 p.m. registered nurse (RN)-A was interviewed and stated she did not send discharge instructions with orders with R27, but reviewed them verbally. RN-A stated she reviewed them with the resident and the niece, since the resident had memory problems. On 7/8/21, at 12:39 p.m. the director of nursing (DON) stated they do review instructions for discharge with the resident, but was not sure if a written discharge summary with discharge instructions had been sent home with R27. The facility policy Discharge Summary reviewed 11/22/20, directed the completion of a discharge plan and recapitulation of stay to facilitate continuity of care following discharge for all residents who had a planned discharge. The facility policy provided directions to include: - a recapitulation of stay with diagnoses, treatments or therapy provided, course of illness and pertinent medical information. -summary of resident's status at the time of discharge -reconciliation of pre-discharge medications with post-discharge medications. -post discharge plan of care, to include arrangements for resident following discharge. -physician verification for discharge and/or transfer -listing of medications per order, correlating diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Further, the physician is to clarify medication orders if there are any discrepancies identified in the reconciliation. The final discharge summary was to be completed and released to the resident and post-discharge care providers on or before the day of discharge with the resident's consent.

Based on observation, interview, and document review, the facility failed to assess and monitor for safety of being left on the toilet while on a mechanical (sit-to-stand) lift for 1 of 1 residents (R18) reviewed for accidents. Finding include: R18's Face Sheet undated, indicated R18's diagnoses included mild cognitive impairment, [CONDITION(S)] (unexplained episode of facial muscle weakness or paralysis), [CONDITION(S)], [CONDITION(S)], hearing loss and a fall history. R18's quarterly Minimum Data Set (MDS) dated [DATE], indicated R18 had a severe cognitive impairment, had moderate difficulty in hearing, and had highly impaired vision. R18's MDS further indicated R18 required extensive assist with bed mobility, transfers, dressing, toileting, and personal hygiene, and was frequently incontinent of bowel and bladder. R18's care plan dated 6/23/21, indicated R18 was incontinent of bowel and bladder and required assistance to the toilet. R18's care plan further indicated R18 was legally blind and was at risk for increased confusion and injury. R18's care plan indicated R18 had an impaired ability to perform activities of daily living (ADLs) such as transferring, walking and toileting, and required the use of a mechanical device for all transfers. On 7/7/21, at 3:05 p.m. R18 was observed being escorted to the nurse's desk. The health unit coordinator (HUC)-A welcomed R18 back from his appointment, and took paperwork from him. At 3:13 p.m. R18 remained sitting at the nurse's station. Nursing assistant (NA)-B brought R18 into the shower room. On 7/7/21, at 3:49 p.m. NA-B was interviewed while she was passing water to residents. NA-B stated she had not seen R18 for a while, and thought R18 was either in the dining room or outside. When asked if R18 was due to be toileted, NA-B stated she was unsure of the time R18 was last toileted, and stated R18 may be due to be toileted. NA-B continued to pass water jugs to resident rooms. On 7/7/21 at 3:54 p.m. HUC-A stated R18 had gone to a dental appointment earlier that day, and was picked up around 1:00 p.m. and returned around 3:00 p.m. HUC-A stated if R18 was not in his room, to check the large dining room or outside. On 7/7/21 at 3:56 p.m. yelling was heard coming from the shower room. The director of nursing (DON) was observed coming out of the shower room yelling for help. The DON stated she would assist R18, but did not don't know how to use the mechanical lift. R18 was left in the shower room while the DON went down the hall and summoned NA-B. NA-B went into the shower room to assist R18 off the toilet. On 7/7/21, at 4:00 p.m. NA-B came out of shower room, escorted R18 to the small dining room, and removed R18's mask. NA-B talked to R18 for a few minutes, left, and returned with a banana for R18. On 7/7/21, at 4:02 p.m. HUC-A was interviewed again. HUC-A stated when R18 came back from his dental appointment, she received his paperwork, and documented his return time about 3:00 p.m. HUC-A further stated after she received the paperwork, NA-B took R18 straight to the shower room. On 7/7/21, at 4:04 p.m. NA-B stated R18 was sitting at the nurse's station, and she had forgotten R18 went out went to a dental appointment earlier in the day. NA-B stated she brought R18 to the shower room to use toilet after he returned from his dental appointment. NA-B stated she did not hand R18 the call light when she left the shower room, but R18 had access to the call light, and further stated R18 would not know how to use it. NA-B stated admitted she forgot R18 had been in the shower on the toilet, and further stated R18 was only on the toilet for 20 minutes. On 7/7/21, at 4:44 p.m. the DON and administrator were interviewed. The DON stated she heard someone yelling from her office, went into the hall and heard yelling coming from the shower room next her office. The DON stated she opened the shower room door and saw R18 sitting on the toilet strapped onto the mechanical lift. The DON stated she did not see a call light in reach of R18, and the administrator stated all of the shower rooms had call lights. The DON further stated R18 had a visual deficit and she was unsure if R18 could use the call light even if R18 had it near him. The DON stated it would be appropriate for R18 to be left alone on the shower room toilet, but she was unable to say what would be an acceptable length of time. The DON stated R18 had not been assessed for the length of time he could be left alone on the toilet for safety or for skin integrity. The DON stated leaving R18 on the toilet unattended for over 30 minutes was too long. The DON further stated the negative outcomes could be alterations of the skin, pain, and a risk for falls, but did not feel it was a dignity concern. The administrator agreed 40 minutes was an unacceptable time to be left alone on the toilet. A facility policy on toileting was requested and not received.

Based on interview and document review, the facility failed to ensure the medical record accurately identified the resident's resuscitation status per their wishes for 3 of 12 residents (R2, R177, R180) reviewed for advance directives. Findings include: R2's Face Sheet printed [DATE], indicated R2's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's Provider Orders for Life-Sustaining Treatment (POLST) dated [DATE], and signed by R2 and R2's attending physician on [DATE], indicated R2 did not wish to have resuscitation attempted, do not resuscitate (DNR). R2's Care Plan created [DATE], lacked resuscitation status. R177's Face Sheet printed [DATE], indicated R177's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R177's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R177's POLST dated [DATE], and signed by R177 and by R177's attending physician indicated R177 wished to have cardiopulmonary resuscitation (CPR) in the event of no pulse and not breathing. R177's Care Plan created on [DATE], lacked resuscitation status. R180's Face Sheet [DATE], indicated R180's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R180's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R180's POLST dated [DATE], and signed by R180's power of attorney (POA) and R180's attending physician indicated R180 wished to be a do not resuscitate (DNR) status. R180's Care Plan created on [DATE], lacked resuscitation status. On [DATE], at 7:04 p.m. the director of nursing (DON) was interviewed The DON verified R2, R177, and R180 lacked resuscitation status in their electronic medical record (EMR). The DON stated this was a concern so that each resident's individual resuscitation status could be followed. The DON stated if staff was unable to find a resident's resuscitation status, they would do cardio-pulmonary resuscitation (CPR) until a code status was figured out. On [DATE], at 7:10 p.m. registered nurse (RN)-B was interviewed. RN-B stated if a resident was unresponsive (not breathing and no heartbeat) and did not have a resuscitation status in their EMR, she would initiate CPR until the code status was sorted out. On [DATE], at 10:44 a.m. (SW)-A was interviewed. SW-A stated a POLST was part of the admission packet. SW-A stated she reviewed the POLST with the resident, then would ask the physician to sign the document. After the document was signed, she would upload it into the EMR. The policy for resuscitation status was requested but not provided.

Based on interview and document review, the facility failed to complete annual performance evaluations for 5 of 5 nursing assistants (NA-A, NA-B, NA-C, NA-D, and NA-E) who had been employed by the facility for over one year. In addition, the facility failed to ensure 12 hours of annual inservice training was completed by 2 of 5 nursing assistants (NA-B, NA-C) whose personnel records were reviewed. This had the potential to affect all 29 residents who resided at the facility. Findings include: An undated position description roster provided by the facility indicated the following: NA-A's hire date was 1/21/19. No annual performance evaluation had been completed by 2/12/20. NA-B's hire date was 9/3/09. Last annual performance evaluation was completed on 12/17/18. NA-C's hire date was 11/27/89. Last annual performance evaluation was completed on 12/11/18. NA-D's hire date was 3/6/17. Last annual performance evaluation was completed on 12/10/18. NA-E's hire date was 2/3/14. Last annual performance evaluation was completed on 12/21/18. On 2/11/20, at 2:01 p.m. the director of nursing (DON) stated she did not complete any nursing assistant performance evaluations in 2019. The DON stated the last time any nursing assistant performance evaluations were completed was December, (YEAR). On 2/12/20, at 11:58 a.m. the administrator was interviewed and stated performance evaluations should be completed annually. The facility policy Employee Talent and Performance Management revised 11/12/19, directed leaders to conduct development conversations 2-4 times per year. NA-B was hired on 9/3/09. Her employee record indicated she had completed 5.5 hours of the 12 required training hours from 9/3/18, to 9/3/19. NA-C was hired on 11/27/89. Her employee record indicated she had completed 5.2 hours of the 12 required training hours from 11/27/18, to 11/27/19. The facility policy Facility assessment dated [DATE], addressed the required in-service training for nurse aides. In-service training must: Be sufficient to ensure the continuing competence of nurse aides, but must be no less than 12 hours per year.

Based on observation, interview, and document review, the facility failed to maintain clean and sanitary conditions in the kitchen by storing clean glasses and cups on a rack in the dishwasher room, using a towel to dry pots and pans, dusty and greasy spice containers, and not maintaining clean fans. This had the potential to affect 28 of the 29 residents that received food from the kitchen. Findings include: On 2/10/20, at 1:25 p.m. during the initial tour of the the kitchen the dietary manager (DM)-A stated the dishwasher likes to wash the pots and pans despite the fact that some will fit in the dishwasher. DM-A stated the pots and pans go on a rack to air dry unless there are too many, in which case the dishwasher dried the pots and pans with a towel to make more room. At 1:40 p.m. clean dishes were observed on a rack in the dishwashing room. The rack was located to the right of the doorway, where carts with dirty dishes passed by after each meal service. On 2/11/20, at 11:06 a.m. a follow up tour was completed. Cups and glasses were observed stored uncovered in the dishwasher room. A wall-mounted fan in the dishwashing room had visible dust build up, and was oscillating from the dirty area to the clean area. The wall-mounted fan in the main kitchen also had visible dust build up. Spice containers were noted to have a buildup of dust and grease. Clean cups and glasses were stored uncovered in the dishwashing room. On 2/12/20, at 9:19 a.m. the dietary manager (DM)-A was interviewed and verified the cups and glasses were stored on the drying rack in the dishwasher room. DM-A also verified dirty dishes were moved past this storage area after each meal, and the drying rack was a permanent fixture in the dish room. DM-A verified the wall fans had visible dust build up, and stated dishes were not supposed to be dried with a towel to prevent cross contamination. DM-A stated they do not have enough space to air dry pots and pans. The facility cleaning schedule directed cleaning and organizing the spices was scheduled weekly on Fridays, and documented as completed for the month of (MONTH) 2020, and through (MONTH) 7, 2020. Cleaning fans was not part of the kitchen cleaning schedule. A policy for cleaning kitchen equipment was requested but not received.

Based on observation, interview, and document review, the facility failed to ensure proper hand hygiene was performed during medication administration observation for 2 of 2 residents (R12, R24) to prevent cross contamination. Findings include: R12's Face Sheet printed 2/13/20, identified R12's [DIAGNOSES REDACTED]. R24's Face Sheet printed 2/13/20, identified R24's [DIAGNOSES REDACTED]. On 2/12/20, at 7:45 a.m. licensed practical nurse (LPN)-A was observed passing medications in the dining room. LPN-A administered R24's eye drops, removed soiled gloves, walked over to the medication cart, donned clean gloves, grabbed R24's hearing aids from the medication cart, and put in R24's hearing aids. LPN-A then removed the soiled gloves, and did not perform hand hygiene before preparing and administering R12's medications. LPN-A was interviewed and stated she should have performed hand hygiene after the removal of gloves, and before preparing and administering R12's mediations. LPN-A stated the importance of performing hand hygiene was to prevent cross contamination. On 2/12/20, at 1:39 p.m. the director of nursing (DON) stated hand hygiene should be performed after the removal of gloves, and before and after administering medications in between residents to prevent cross contamination. The facility policy Medication Administration-General Guidelines dated 8/6/12, directed staff to wash hands before and after administration of topical, ophthalmic, otic, [MEDICATION NAME], enteral, rectal, and vaginal medications. A policy on hand hygiene was requested and not received.

Based on observation, interview, and document review, the facility failed to ensure nail care assistance was provided for 1 of 2 residents (R15) reviewed for activities of daily living (ADLs), who were dependent upon staff for assistance with grooming. Findings included: R15's Face Sheet printed 2/12/20, identified R15 [DIAGNOSES REDACTED]. R15's care plan dated 12/9/19, indicated R15 had a self care deficit related to [MEDICAL CONDITION], and required assistance with bed mobility, dressing, grooming, bathing, and personal cares. R15's care plan further indicated R15's shower days were on Monday and Friday. On 2/10/20, at 6:27 p.m. R15 was observed to have long fingernails on both hands. R15's family member (FM)-A verified R15's fingernails were on the longer side, and stated R15's nails should be trimmed. FM-A stated she has trimmed R15's fingernails in the past, and should not have to. FM-A stated nail care should be completed on shower day because the nails are softer and easier to trim. On 2/12/20, at 8:43 a.m. R15 was observed during a Hoyer transfer (a mobility tool used to help with transferring) and his fingernails remained long. Nursing assistant (NA)-B stated nail care was completed on bath days, and R15's shower days were on Mondays and Fridays. NA-B verified R15's fingernails were long and needed to be trimmed. NA-B further stated R15 had a shower two days ago, and R15's nails were not trimmed on his shower day. On 2/12/20, at 1:39 p.m. the director of nursing (DON) stated she would expect nail care to be completed on bath day, or sooner if needed. The DON further stated if a resident refused nail care, staff should re-approach the resident, and if continued to refuse notify the nurse. The facility policy Activities of Daily Living Review dated 9/20/19, directed a resident who is unable to carry out activities of daily living will receive the necessary service to maintain good nutrition, grooming, and personal and oral hygiene.

Based on observation, interview, and document review, the facility failed to ensure ongoing assessments to determine causal factors, and implement appropriate interventions in an attempt to prevent falls for 2 of 3 residents (R19, R39) reviewed for accidents. The facility failed to investigate and comprehensively assess resident falls to determine if new interventions could be implemented to prevent falls, which resulted in a significant injury for R83. The facility's failure resulted in an immediate jeopardy (IJ), with serious harm and injury for R83. The immediate jeopardy began on 1/8/16, when R19 fell , was sent to the emergency room and was diagnosed with [REDACTED]. The administrator and the director of nursing were notified of the IJ for R19 on 3/2/16, at 5:42 p.m. The immediate jeopardy was removed on 3/8/16, at 11:23 a.m. but noncompliance remained at the lower scope and severity of a G, which indicated actual harm that was not immediate jeopardy. Findings include: R19 sustained multiple falls, some with significant injury, and the facility failed to comprehensively assess risk factors related to the continued falls. In addition, interventions to prevent falls were not consistently implemented. R19's Admission Record identified [DIAGNOSES REDACTED]. The annual Minimum Data Set ((MDS) dated [DATE], identified R19 had significant cognitive impairment, had no behavioral issues, required no transfer help or assistance ambulating in his room, was on no toileting plan but occasionally incontinent, and did not ambulate in the hallway. The significant change MDS dated [DATE], indicated R19 had severe cognitive impairment, required extensive assistance of two staff with transfers, required extensive assistance of one staff for wheelchair mobility, and did not ambulate. The MDS also indicated R19 had occasional incontinence of bowel and bladder, required extensive assistance of two staff for toileting, and was not on a toileting program. The MDS further identified R19's balance during transfers (moving from a seated to standing position, moving on and off the toilet, and surface-to-surface transfers) as not steady, only able to stabilize with assistance. The MDS also identified R19 had falls since the prior assessment, with no injuries. R19's Care Area Assessment (CAA) dated 2/5/16, identified R19 had a hearing deficit, poor balance and a history of falls, with no diuretic or psychotropic medication use. The CAA indicated to follow up with the fall and safety committee, to modify interventions as needed, and to see the care plan for safety interventions. R19's fall risk assessment dated [DATE], identified R19 was at risk for falls, had 3 or more falls in the last quarter, had a weakened state, and to continue current plan of care. However, the assessments failed to comprehensively assess R19's risk for falls to include but not limited to trends/patterns to falls, factors that may be causing the falls, and effectiveness of interventions. R19's care plan dated 12/22/15, identified a goal: R19 will remain free from injury from falls. The care plan identified the following interventions: check frequently after assisting to bed to assure he is settled in and not restless; if restless offer to assist to wheelchair; assure staff is attentive in main dining room during events such as the walk of honor; change wheelchair cushion; if propels near room assess for needs; if he wheels himself to room, assist to lie down or stay with him; redirect him to areas of better supervision; sit/stand lift for transfers; anticipate needs for toileting, rest and intakes; assess pain, reassure and cue; attempt to assist him with a.m. cares and transfer prior to 7:00 a.m. to hinder self-transfers; cue and assist when symptomatic, place in areas of high visibility; offer nightlight, cue for fluids, snacks and toileting when awake at night; regular mattress, bed at standard height, no siderails; keep wheelchair locked at bedside at night; anti-rollbacks on wheelchair; toilet daily at 10:00 a.m., and by 1:30 p.m. and 4:30 p.m. also toilet before bed and upon rising. Review of R19's fall incident reports since 9/15, indicated the following: - 9/7/15, at 4:30 a.m. R19 was found on the floor in his room. R19 stated he fell out of bed. R19 sustained a 5 centimeter (cm) x 4 cm red area to his right upper forehead and was transported to the emergency room (ER). The ER provider diagnosed R19 with a scalp contusion. New interventions implemented: keep wheelchair locked at bedside as able. An inter-disciplinary team (IDT) meeting was held on 9/8/15, with the following conclusion: will continue to monitor, observe orthostatic blood pressures. On 3/2/16, at 12:58 p.m. registered nurse (RN)-A was interviewed and stated no root cause analysis of the fall had been completed. - 9/24/15, at 11:35 p.m. staff was alerted by roommate that R19 had fallen in his room. Staff indicated the fall was caused by R19 attempting to self-transfer, and only one wheelchair brake was locked. R19 did not sustain an injury. New interventions implemented: continue to check on resident at various times making sure both wheelchair brakes were locked. Remind resident to lock both wheelchair brakes. An IDT meeting was held on 9/14/15, with the following: R19 was functioning at his baseline, he propelled himself in his wheelchair and transferred independently. Attempt keeping wheelchair locked at bedside and cue to toilet at night before sleep. On 3/2/16, at 12:58 p.m. RN-A stated no root cause analysis of the fall had been completed. - 10/20/15, at 12:25 a.m. R19 was in his wheelchair in the hallway when he attempted to stand up, lost his balance and fell . Staff indicated the fall was caused by increased confusion, impulsiveness and attempts to self-transfer. R19 did not sustain an injury. New interventions implemented: none. An IDT meeting was held on 10/26/15, with the following: this recent fall seems to be isolated and related to acute illness. Res is back to his baseline. On 3/2/16, at 1:11 p.m. RN-A was interviewed and stated the root cause of the fall was isolated and related to R19's acute illness. - 10/27/15, at 10:15 p.m. staff witnessed R19 attempt to stand up and walk into another resident's room to go to bed when he went to sit back down on his wheelchair and fell . Staff indicated the fall was caused by attempting to go to bed, restless movements. No injury. New interventions implemented: anti-rollbacks to wheelchair. An IDT meeting was held on 10/27/15, with the following: witnessed fall in hallway was attempting to stand up and walk into another resident's room to go to bed went to sit on wheelchair and landed on floor. On 3/2/16, at 1:20 p.m. RN-C stated the root cause analysis of the fall was completed; and it was determined R19 had an acute condition that resulted in weakness. - 10/28/15, at 8:40 a.m. R19 was found face down on the floor of his room. Staff indicated the fall was caused by urgency of bowel movement. R19 sustained a head contusion, was transported to the ER, and was diagnosed with [REDACTED]. New interventions implemented: none. An IDT meeting was held 12 days later on 11/9/16, with the following: R19 was screened by therapy and orders received for physical therapy (PT) 3 times a week to improve transfers, standing and ambulation with walker. Continue to follow up as needed. On 3/2/16, at 1:25 p.m. RN-A stated the root cause analysis of the fall had not been completed. - 1/8/16, at 7:20 a.m. R19 was found on the floor in his room. Staff indicated the fall was caused by weakness secondary to pleural effusion (a buildup of fluid between the tissues that line the lungs and chest). R19 was transported to the ER, where he was diagnosed with [REDACTED]. New interventions implemented: rearranged furniture in room. An IDT meeting was held on 1/8/16, and a review of the fall was completed, but no conclusion. On 3/2/16, at 1:35 p.m. RN-C was interviewed and stated the root cause analysis of the fall was completed with the conclusion R19 fell because he gets acute respiratory issues and he falls. - 1/11/16, at 3:50 p.m. R19 was found on the floor in his room. R19 stated he was moving his car out of the way. R19 did not sustain an injury. New interventions implemented: none. - 1/11/16, at 6:30 p.m. R19 was found on the floor in his room. Staff indicated the fall was caused by R19 trying to transfer self to bed and slid off of the bed to the floor. No injury. New interventions implemented: assess pain, reassure and cue. - 1/12/16, at 11:40 p.m. R19 was found on the floor in his room. Staff indicated the fall was caused by resident attempting to self-transfer out of bed. R19's right hand was bleeding, he had a laceration to the 5th finger, and he was transported to the ER. The ER record indicated R19 received sutures to the right 5th finger. New interventions implemented: consider room design changes. An IDT meeting was held on 1/12/16, reviewing the falls of 1/11/16, and 1/12/16, with the following: will have physical therapy (PT) and occupational therapy (OT) screen for transfers in room, adjustment to room layout may need to be made, and will have pharmacy perform a medication review. On 3/2/16, at 1:45 p.m. RN-C verified a root cause analysis was not completed. - 1/30/16, at 8:00 p.m. R19 was found on the floor of his bathroom. R19 did not sustain an injury. Staff indicated the fall was caused by a general decline. R19 did not sustain an injury. New interventions implemented: attempt to assist to recliner or bed after supper, use sit/stand lift for transfers. An IDT meeting was held on 2/1/16, with the following: R19 has had a general decline in condition and was now enrolled in hospice. He was more sleepy and interacted less. He was on a scheduled toileting plan. Staff to anticipate needs and offer toileting and rest periods at frequent intervals. If he seemed restless offer food, fluids, rest and toileting. May need to go to bed earlier in the evening or relax in the recliner. On 3/2/16, at 1:49 p.m. RN-C stated R19 got weak, short of breath and didn't know what to do. RN-A stated the scheduled toileting plan didn't work, and now staff just asked him if he needed to go to the bathroom. -2/4/16, at 10:30 a.m. R19 was found on the floor in his room. No injury. Staff indicated the fall was caused by impulsiveness, resident believed he was capable of transfers. New interventions implemented: continue to keep in area of high visibility and check/redirect frequently. An IDT meeting was held 5 days later on 2/9/16, with the following: staff have been redirecting him with success that morning was impulsive, thought he was capable to rise on his own and shouldn't be alone in room without staff nearby to view him. Very alert that day compared to others. Try not to leave him alone in room, stay with him or redirect to area of supervision and visibility. On 3/2/16, at 1:54 p.m. RN-A verified there was no root cause analysis of the fall. - 2/14/16, at 8:40 p.m. R19 was found on the floor in his room. R19 sustained a small excoriation on his left buttock. Staff had not indicated what the fall was caused by. New interventions implemented: bed in lowest position, call light within reach. - 2/16/16, 2:00 p.m. R19 was in the dining room, sleeping in his wheelchair, when he slid out of the wheelchair and landed on the floor. R19 did not sustain an injury. Staff indicated the fall was caused by sleeping in the wheelchair. New interventions implemented: wheelchair cushion to offer more support at front of seat. An IDT meeting was held 8 and 6 days later on 2/22/16, reviewing the falls for 2/14/16, and 2/16/16, with the following:wheelchair cushion changed for better positioning and decided to have staff in the dining room during special events. On 3/2/16, at 2:19 p.m. RN-A verified there was not root cause analysis for either fall. - 2/26/16, at 5:40 a.m. R19 was found on the floor in his room. R19 stated the bed slipped. Staff indicated the fall was caused by self-transfer. R19 sustained a laceration to the left eyebrow, and was transported to the ER. The ER record indicated the laceration was treated with steri-strips. New interventions implemented: 1:1 when restless. An IDT meeting was held on 3/1/16, with the following: Staff to be aware to check frequently after assisting to bed to assure he is settled in and not restless. On 3/2/16, at 2:20 p.m. RN-A verified no root cause analysis of the fall was completed. On 3/2/16, at 7:21 a.m. R19 was observed in his room. Nursing assistant (NA)-E was providing personal cares for R19, who was sitting on the side of his bed. At 7:23 a.m. NA-E told R19 she was going to leave the room to get the transfer lift. NA-E left the room, and shut the door, leaving R19 sitting on the side of the bed unattended. At 7:25 a.m. NA-E returned to the room, used the stand assist lift to transfer R19 into his wheelchair. NA-E stated R19 had a lot of falls. When asked what interventions were in place to prevent falls, NA-E stated the staff was supposed to keep an eye on him, see where he was at. NA-E stated R19 was not on a toileting program, he was supposed to have assistance to the bathroom, but R19 was quick, and they helped him if they noticed him going into the bathroom, he shouldn't be in there alone. On 3/2/16, at 8:26 a.m. R19 was observed alone in his room, propelling himself in his wheelchair. On 3/12/16, at 11:50 a.m. R19 was observed alone in his room. On 3/2/16, at 12:26 p.m. R19 was observed alone in his room, going through his top dresser drawer. On 3/2/16, at 1:05 p.m. R19 was observed in the dining room, sleeping in his wheelchair. There was no staff in the area monitoring R19 in the dining room. On 3/2/16, at 11:48 a.m. activity director (AD)-A stated R19 did not come out for activities. R19 doesn't participate much in activities. R19 liked visiting with others so staff did 1:1 visits with him, but there were no specific activities for him. R19 had a book about his experience as a veteran he enjoyed looking at, however, family took that home. R19 was a mechanic and liked to tinker with stuff. AD-A stated it would be nice to get an engine or something for R19 to work on but she was not sure where they would put it. On 3/3/16, at 8:25 a.m. NA-A stated R19's fall interventions included looking in on him if passing his room and if alone in his room try and get him out or stay with him. However, now he was on a 1:1 and staff has been toileting him more often. NA-A acknowledged R19 was quick. On 3/3/16, at 8:32 a.m. NA-C stated interventions for R19 included safety checks, toileting him according to his schedule, ambulation to get rid of excess energy, distract him - talk about World War II. NA-C acknowledged not being on the schedule for the last 8 days so was unaware of any changes in the plan of care for R19. On 3/3/16, at 10:40 a.m. NA-B stated fall interventions for R19 included looking in on him whenever staff walked by, offer coffee and ice cream, going to the gathering place. NA-B stated R19 had a 1:1 right now and she didn't believe the toileting plan had changed. On 3/2/16, at 5:15 p.m. licensed practical nurse (LPN)-A stated R19 was to be toileted every 2 hours, but he didn't always agree to go. Staff was to check on him often, leave the call light within reach and remind him to use it, try not to leave R19 alone in his room, and offer a nap. LPN-A stated R19 really didn't use the call light but staff still needed to remind him to use it. On 3/2/16, at approximately 3:00 p.m. the director of nursing (DON) was interviewed. The DON stated the facility completed a post-fall huddle immediately after each fall, and immediate interventions were put into place. The DON also stated an IDT meeting was held at least weekly, and falls were reviewed at that time. During this meeting, a root cause analysis was completed on each fall. The immediate jeopardy that began on 1/8/16, was removed on 3/8/16, when the facility implemented the following interventions to minimize the risk of falls for R19: 1:1 supervision with removal plan Activities to provide interesting mechanic type tinkering toys Attempt positioning in recliner for comfort Coordinate with Hospice for fall prevention and volunteer 1:1 Extra bed removed from room to decrease clutter Wider bed to be delivered 3/9/16 Head of bed raised 30 degrees Morphine at bedtime Offer to sit on edge of bed and use urinal, or offer to toilet Provide an afternoon nap Transfer with one staff and contact guard assist When he appeared restless or attempting to stand ask if he was hungry, thirsty or needed to use the bathroom Use short understandable language to evoke yes or no answers Attempt to anticipate his basic needs and keep him comfortable However, noncompliance remained at the lower scope and severity level of G - isolated, scope and severity level, which indicated actual harm that is not immediate jeopardy because R19 had 3 falls that resulted in injuries requiring medical intervention: a fractured clavicle, a laceration of the finger requiring sutures, and a laceration of the head requiring steri-strips,which identified him to be at high risk for significant injury. R39 had 12 falls in the past 6 months, and the facility failed to comprehensively assess and implement appropriate interventions to minimize the risk for ongoing falls. R39's Admission Record identified [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE], indicated R39 had severe cognitive impairment, required standby assistance of 1 staff for transfers, was independent with ambulation in his room, and required standby assistance of 1 staff for ambulation in the hallway. The MDS also indicated R39 was always continent of bowel and bladder, and was independent with toileting (with staff supervision/cues). The MDS further identified R39's balance during transfers (moving from a seated to standing position, moving on and off the toilet, and surface-to-surface transfers) was not steady, but able to stabilize without assistance. R39's CAA dated 8/19/15, identified R39 was at risk for falls, and had physical limitations such as weakness, limited range of motion, poor coordination and poor balance. The fall risk assessment dated [DATE], indicated R39 was at risk for falls, and had three or more falls in the previous three months. R39's care plan dated 8/10/15, identified a goal: R39 will remain free from injury. The care plan identified the following interventions: remind him to use his walker and keep it next to him; once tucked into bed for the evening check on him often to cue him until asleep; keep call light within reach; keep pathways free of obstacles; gripper socks/bare feet when in bed; and non-skid footwear while up. Review of R39's fall incident reports since 9/15, indicated the following: - 9/22/15, at 4:10 p.m. R39 stated he had fallen when coming out of his bathroom, and had gotten himself up off the floor. R39 sustained a skin tear to his left elbow. New interventions implemented: add a toilet riser to toilet in bathroom. On 3/7/16, at 10:32 a.m. RN-C was interviewed and stated no root cause analysis of the fall had been completed. - 10/16/15, at 3:40 p.m. R39 stated had fallen when he came out of the bathroom, and had gotten himself up off the floor. R39 did not sustain an injury. New interventions implemented: monitor bowel movements, encourage him to use the call light. On 3/7/16, at 10:34 a.m. RN-C was interviewed and stated no root cause analysis of the fall had been completed. - 11/10/15, at 12:45 p.m. R39 stated he fell in his room, and had gotten himself up off the floor. R39 did not sustain an injury. New interventions implemented: bedside commode. On 3/7/16, at 10:36 a.m. RN-C verified no root cause analysis of the fall was done. - 11/10/15, at 2:00 p.m. R39 was found sitting between the bed and the dresser in his room. R39 stated he had needed to go to the bathroom. R39 did not sustain an injury. New interventions implemented: R39 was given a stool softener. On 3/7/16, at 10:37 a.m. RN-C stated the root cause analysis for the fall was R39 had a suppository earlier that morning and had become dizzy. - 11/12/15, at 11:00 a.m. R39 was standing outside of his room only wearing his shirt. Staff asked if he was all right, and R39 stated he had fallen in the bathroom during an incontinent episode. R39 did not sustain any injury. New interventions implemented: room rearranged and commode placed in room. On 3/7/16, at 10:39 a.m. RN-C was interviewed and verified no root cause analysis of the fall was done. - 11/24/15, at 8:10 p.m.: R39 was standing in doorway of his room when he lost his balance and fell backward onto floor. R39 did not sustain an injury. New interventions implemented: none. On 3/7/16, at 10:41 a.m. RN-C verified no root cause analysis of the fall was done. - 12/26/15, at 9:30 a.m. R39 was walking down the hallway and stated he needed help. R39 stated he had fallen in his room, and gotten himself up. No injury. New interventions implemented: remind to use call light for assistance. On 3/7/16, at 10:44 a.m. RN-C verified no root cause analysis of the fall was done. - 12/28/15, at 5:30 p.m. R39 was ambulating in the hallway when he lost his balance and fell . R39 sustained lacerations and required a trip to the ER (medical record lacked description of the injury). New interventions implemented: R39 was told to walk slower. On 3/7/16, at 10:48 a.m. RN-C stated the root cause analysis of the fall was gastroenteritis. - 1/30/16, at 5:50 p.m. R39 fell in his room. No injury. New interventions implemented: none. On 3/7/16, at 10:50 a.m. RN-B was interviewed and stated R39 was given a walker to use. RN-B stated no root cause analysis of the fall was done. - 2/3/16, at 1:30 p.m. R39 found in room, sitting next to his bed. R39 did not sustain an injury. New interventions implemented: comprehensive pain assessment. On 3/7/16, at 10:55 a.m. RN-C verified no root cause analysis of the fall was done. - 2/6/16, at 4:00 p.m. R39 was found on the floor in his room. R39 sustained a 3 cm skin tear to his left elbow. New interventions implemented: R39 was given a wheelchair to use until he could be re-evaluated. On 3/7/16, at 10:57 a.m. RN-C stated R39 had not been using his walker at the time, and was given a wheelchair, but only used for one day. RN-C verified no root cause analysis of the fall was done. - 2/6/16, at 6:30 p.m. R39 was found on floor in his room. R39 sustained contusions (medical record lacked description of the contusions) and was treated in the ER. New interventions implemented: resident will be in recliner at gathering place to ensure safety. On 3/7/16, at 10:59 a.m. RN-C was interviewed and verified a root cause analysis of the fall was not done. On 3/1/16, at 1:58 p.m. R39 was observed ambulating in the hall, using a walker. On 3/2/16, at approximately 3:00 p.m. the DON was interviewed. The DON stated the facility completes a post-fall huddle immediately after each fall, and immediate interventions are put into place. The DON also stated an IDT meeting is held at least weekly, and falls are reviewed at that time. During this meeting, a root cause analysis is completed on each fall. The clinical record lacked a comprehensive reassessment of R39's risk for falls. The undated facility policy and procedure on Fall Prevention, directed at the point of a fall, a fall scene investigation will be completed to determine the root cause of each fall. The licensed staff will put an immediate intervention in place to prevent further fall.