Every finding on record at Highlandspring of Ft Thomas

Based on observation, interview, and review of the facility's policies, the facility failed to store food under sanitary conditions. Observations of the kitchen on 02/08/2026 revealed undated cans on the rack, four packages of vanilla wafers out of the box and not dated, a large clear plastic container with the appearance of white rice not labeled or dated, and one undated bag of chocolate chips out of the box. Continued observation on 02/08/2026 revealed three of five clear plastic covered cereal containers with no label or date in the second floor serve kitchen. Also, observation on 02/09/2026 in the kitchen revealed the bucket sanitizer had no documentation of the date or time the sanitizer was checked or changed. The deficient practice had the potential to affect all 136 current residents.The findings include:Review of the facility's policy titled, Food Storage, not dated, revealed it was the policy of the facility that food storage areas be maintained in a clean, safe, and sanitary manor. Food storage areas shall always be clean. All opened, potentially hazardous food items would be labeled, dated, covered, and discarded within seven days. Review of the facility's policy, untitled and dated 09/2023, revealed the facility used Quat Sanitizer Solution to sanitize kitchen surfaces, using the manufacturer's directions for preparation, which stated the sanitizing solution should be made fresh daily and as needed. Per the policy, prior to its use, testing of the sanitizing solution should be done using the appropriate test strips that were not outdated or expired. Observation on 02/08/2026 at 11:27 AM during the initial tour of the kitchen revealed the dry storage can rack contained number 10 cans, with no visible expiration dates on the bottom or top of the cans. Observation on 02/08/2026 at 3:36 PM of the second floor serve kitchen revealed three of five large clear plastic covered cereal containers with a blue lid which had no date or label. Return observation on 02/08/2026 at 3:48 PM of the second floor serve kitchen again revealed three of five large clear plastic covered cereal containers with a blue lid which had no date or label.Observation on 02/08/2026 at 3:55 PM on the return tour of the kitchen dry storage room revealed a four-pound package of mini semi-sweet chocolate chips with no date, four vanilla wafers out of the box in the packaging without a date, and a large clear lidded bin of breadcrumbs (with the appearance of white rice) with no date or label.Observation on 02/09/2026 at 8:28 AM with the Chef revealed the sanitizer bucket had no documentation of the date or time the sanitizer was changed. In an interview with the Chef on 02/09/2026 at 8:28 AM, she stated they did not document when the sanitizing solution was changed in the sanitizer bucket. She stated the cook checked and changed the solution after each food prep, and the diet aides changed the sanitizing solution after meals. She stated she expected the sanitizing solution to be changed every two hours or if became soiled. She stated food should be labeled and dated with the date received if taken out of the box, the opened date, and the date of expiration. In an interview with the Director of Nursing (DON) on 02/11/2026 at 9:30 AM, she stated she completed a walk through in the kitchen weekly and looked for cleanliness and that cans were dated. She stated she expected dietary staff to follow the facility's policy and procedure for properly dating and labeling stored food.In an interview with the Administrator on 02/11/2026 at 10:48 AM, she stated she expected the food to be labeled and dated and the sanitizer regularly changed.

Based on interview, record review, and review of the facility's policy, the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and describe the services to be furnished to attain or maintain a resident's highest practicable physical, mental, and psychosocial well-being for 2 of 27 sampled residents, Resident (R) 52 and R79.The facility admitted R52 and R79 with known histories of Post-Traumatic Stress Disorder and histories of known triggers. However, in the residents' admission care plans, no interventions were in place to prevent potential adverse behaviors.The findings include: Review of the facility's policy titled, Quality of Care-Care Planning, dated 10/2022, revealed the facility would provide resident centered care with the aim of providing individualized Comprehensive/Interdisciplinary Care Plans for each resident. Per the policy, the facility would incorporate trauma-informed care into the person-centered, culturally competent plan of care for each resident to ensure their needs were met. The policy defined trauma informed as a means of recognizing that people often had many different types of traumas in their lives, and people who had been traumatized needed support and understanding from those around them. Per the policy, often trauma survivors could be inadvertently re-traumatized by caregivers and visitors. The policy revealed the process to address past trauma was based on assessment, identifying the trauma type and triggers, and care planning to address past trauma. 1. Review of the admission Record for R52 revealed the facility admitted the resident on 12/08/2025 with multiple co-morbidities, including hemiplegia and hemiparesis because of a stroke that affected his left, non-dominant side, major depressive disorder, anxiety, insomnia, and post-traumatic stress disorder (PTSD). Further review revealed R52 was discharged from the facility on 02/08/2026 and admitted to an acute care hospital for observation and treatment related to an acute behavioral episode. The State Survey Agency (SSA) Surveyor was unable to make a direct observation of this resident. Review of R52's admission Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 12/19/2025, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 14 out of 15, indicating his cognition was intact. It also revealed his functional abilities were limited to one side, and he utilized a wheelchair for assisted mobility. PTSD was listed as an active diagnosis. Review of R52's Social Services admission Assessment, dated 12/08/2025 and performed by the Social Worker, revealed a Trauma Informed Care Assessment was included. Further review revealed a PTSD diagnosis was listed with the triggers noted only as loud. No further information was provided. Review of Resident 52's Comprehensive Care Plan [CCP], dated 12/08/2025, revealed no documented evidence that any care planned interventions had been formulated for the resident's diagnosis of PTSD since admission. Review of R52's hospital records from the emergent admission on [DATE] revealed the resident had no acute infections that might have caused the adverse behaviors. Psychiatric Consult records indicated the resident had a diagnosis of PTSD, and his reported baseline anger issues had worsened since returning from the Vietnam War. Per the Psychiatric Consult, the right-sided stroke that occurred in 2022 likely contributed to his worsened emotional management status. Per the record, R52 was admitted to intensive care for psychiatric care. During an in-person interview on 02/08/2026 at 1:38 PM with R52's family member (FM), he stated R52 had an anger management issue. He stated he was not free to discuss it further at that time. During a follow-up interview with R52's FM via telephone on 02/09/2026 at 1:16 PM, he stated R52 had always been very rigid and temperamental. He stated his family was the typical 1950's family that did not share personal information or go to a therapist. He stated he did not think R52 had ever been treated for any psychological issues. He stated R52 had served in two or three tours of Vietnam and had experienced angry outbursts for as long as he could remember. He stated, historically, it was loud noises that triggered R52, but R52's temperament was always an issue. During an interview on 02/11/2026 at 8:50 AM with R52's primary care Nurse Practitioner (NP), she stated she was aware of his diagnosis of PTSD but was not aware of specific triggers for him. She stated she was unaware of any physiological causes for his current behaviors, such as an acute urinary tract infection. She stated it was her understanding that R52 was currently in restraints at the hospital and was admitted for psychiatric care. During an interview on 02/10/2026 at 1:35 PM with the Psychiatric Nurse Practitioner, he stated PTSD symptoms were often lifelong and required treatment or intervention. He stated identified triggers could create distress at any point in the future. He stated he had not received a request to consult with R52 since his admission, but requests were often made when he was in the building, and he had been out sick for a couple of weeks. He stated there were always on-call psychiatric services available for urgent needs. During an interview on 02/09/2026 at 2:11 PM with the Director of Physical Therapy, he stated R52 was limited in his mobility but could push himself short distances, such as out of the dining room. He stated that it was likely his new baseline. He stated he had personally never seen the resident physically aggressive. He stated he was unaware of any specific triggers regarding the PTSD diagnosis. During an interview on 02/09/2026 at 11:10 AM with the Social Services Director, she stated she spoke with R52 upon admission, and it was her understanding that loud noises were no longer a trigger for his diagnosed PTSD. She stated the resident told her if it was a concern, he would let her know. She stated she was unaware if symptoms of PTSD were ever cured or absolved. She stated if loud noises continued to be a trigger for R52, it could result in resident distress and anxiety. During an interview on 02/11/2026 at 9:30 AM with the Director of Nursing (DON), she stated she was aware of the PTSD diagnosis for R52. However, she stated she was unaware of the resident's history of adverse behaviors, as his FM relayed in his interview with the SSA Surveyor. She stated she felt certain that this specific outburst was not related to his diagnosis of PTSD or a trigger such as a loud noise, although she was not present during that episode. 2. Review of Resident 79's admission Record revealed the facility admitted the resident on 10/29/2024 with diagnoses of PTSD, anxiety, and type 2 diabetes mellitus. Review of R79's admission MDS, with an ARD of 11/04/2024, revealed the facility assessed Resident 79 to have a BIMS score of 15 out of fifteen 15, indicating she was cognitively intact. Continued review revealed R79 triggered for PTSD. Review of R79's CCP, dated 10/29/2024, revealed no documented evidence of a care plan formulated for the resident's PTSD upon admission and for over a year. However, on 11/05/2025, a focus of stress was added because the resident had a diagnosis of PTSD due to sexual assault from her stepfather, and loud voices could be triggering. The goal, with a target date of 04/30/2026, was R79 would receive as much social support as wanted. Interventions/tasks, initiated 11/05/2025, were coordination of resources to address social needs, education about breathing techniques, and education about mindfulness-based stream reduction program. Review of R79's quarterly Social Service Assessment and History, dated 05/02/2025 and 08/13/2025, both revealed the resident had anxiety disorder, unspecified; conversion disorder with seizures or convulsions; depressive disorders; and PTSD. During an interview with R79 on 02/11/2026 at 10:44 AM, she stated she made her preference and request for female caregivers upon admission. During an interview with State Registered Nurse Aide (SRNA) 4 on 02/11/2026 at 9:16 AM, she stated R79 preferred female staff for care and did not like loud noises. She stated she did not know why and did not know if R79 had PTSD. During an interview with the NP on 02/11/2026 at 9:05 AM, she stated she was aware of R79's PTSD, and the resident had a compulsive nature. During additional interview with the Social Services Director on 02/11/2026 at 10:24 AM, she stated she was responsible for updating the care plans and creating the base line care plan. She stated the comprehensive care plan changes could be made by other staff. She stated she had team discussions with staff members about the needs of the residents. She stated care plan interventions carried over to the State Registered Nurse Aide (SRNA) Kardex. During an interview on 02/11/2026 at 9:30 AM with the Director of Nursing (DON), she stated clinical staff was educated about the care needs of a resident based on the care plan. She stated, in the absence of complete information and/or interventions in a care plan, staff would not be aware of how to best care for residents. During an interview with the Administrator on 02/11/2026 at 10:51 AM, she stated Social Services was responsible for residents' care plans and would talk to the resident and/or family to identify any triggers related to the diagnosis of PTSD. Then, she stated information relayed by Social Services would be discussed in the Interdisciplinary Team (IDT) meetings to develop or add to the care plan. She stated specific triggers on the care plans identified what the staff was reviewing concerning residents' care, and care plans would be how interventions were communicated. She stated staff used the interventions to provide the most accurate care for residents. She stated the admission assessments carried to the care plan.

Based on observation, interview, and review of the facility's documents, the facility failed to make the location of the results of the State Inspection book available to residents without asking. In an interview with the Resident Council members on 02/09/2026, they stated they did not know the state survey results were available for their review and did not know the location of the survey results without asking. This deficient practice had the potential to affect all 136 current residents.The findings include: Review of the facility's document Federal Resident Rights, not dated and found in the admission Agreement packet, revealed reports of the facility's survey certifications, complaint investigations, and plans of correction made during the three preceding years be available for any individual to review upon request. Review of the facility's document State Resident Rights, not dated and found in the admission Agreement packet, revealed a resident had the right to examine the results of the most recent survey of the facility conducted by federal or state surveyors and any plan of correction in effect with respect to the facility. Per the document, the results shall be posted by the facility in a place readily accessible to residents. Review of the facility's handbook titled, Skilled Nursing Facility Handbook, dated 2018, revealed nursing facility patients were granted specific rights under both State and Federal law. The handbook stated copies of these laws could be found with the resident's admission documentation, as well as requested from the front office at any time. In an interview during the Resident Council meeting on 02/09/2026 at 10:30 AM, residents stated they did not know about the survey book, location of the survey book, and the survey findings. Observation on 02/09/2026 at 3:15 PM and 3:18 PM on the first and second floors in the living rooms revealed the state survey results were kept on each floor in the bookcase on the shelf labeled Family Resident Handbook. In an interview with the Director of Nursing (DON) on 02/11/2026 at 9:37 AM, she stated the survey book was kept in the living room areas. She stated residents were told about the survey book upon admission, and if they asked a question about the survey, they would inform the family/resident about the survey book location. In an interview with the Administrator on 02/11/2026 at 10:48 AM, she stated information about the location of the survey book was posted by the front door of the facility. In resident council, she stated, residents were informed of the location of the survey book in each unit's living room. She also stated residents were provided the survey information upon request.

Based on observation, interview, record review, review of the facility's policy, review of the Facility Assessment Tool, and review of the Payroll-Based Journal Staffing Data Report, the facility failed to have sufficient qualified nursing staff available at all times to provide nursing and related services to meet the residents' needs safely and in a manner that promoted each residents' rights, physical, mental, and psychosocial well-being. During interviews with seven interviewable residents, Residents (R) 6, R34, R69, R82, R101, R108, and R116, they all stated they had concerns and care issues as a result of low staffing with wait times from 30 to 45 minutes for assistance. During interviews with Resident Representatives for R81 and R52, they stated they had concerns with low staffing. The findings include: The facility did not provide a policy regarding staffing. Review of the undated policy titled, [Facility] Federal Residents Rights and Facility Responsibilities, indicated the facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the residents. Review of the facility's policy titled, Facility Assessment Tool, revised 07/2024, indicated staffing for licensed nurses, medication aides, and nurse aides were based on the current census and resident acuity in the facility. Further review revealed no evidence the tool contained the number of licensed nurses, medication aides, and nurse aides the facility needed each shift based on the resident acuity and resident census. Review of the Payroll-Based Journal (PBJ) Staffing Data Report, with the due date of submission, 08/14/2024, revealed the facility triggered for excessively low weekend staffing during the third Fiscal Quarter, from April 1st to June 30th, 2024. 1. Review of R108's Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 03/14/2024, revealed R108 had a Brief Interview for Mental Status [BIMS] score of 15 out of 15, which indicated R108 was cognitively intact. In an interview on 12/03/2024 at 10:44 AM with R108, she stated her biggest complaint was with the STNAs on evening and night shifts, from 7:00 PM to 7:00 AM, not answering the call lights when she needed help. She stated she had waited an hour to get help in going to the bathroom. She stated, I try to hold my bowel movement until I receive help but there are times I have to hold it, and it causes me to become constipated. I have gotten hemorrhoids from holding my bowels. I have left side paralysis and need assistance in going to the restroom. She stated the morning staff was better about assisting her. Observation on 12/03/2024 at 10:59 AM revealed R108 was talking with her daughter on the phone, and her daughter was concerned that staff at the front desk did not answer the phone. Her daughter stated she had tried calling for the last two days, and no one had answered the phone when she tried calling either in the morning or at night. 2. Review of R6's quarterly MDS, with an ARD of 11/12/2024, revealed R6 had a BIMS score of 10 out of 15, which indicated the resident was moderately cognitively impaired. In an interview on 12/03/2024 at 9:30 AM with R6, she stated, They ain't got a nurse when you need one, stating she had to holler, holler, and holler to get help. R6 stated the issue had been happening for a while, and it happened more on the weekends. 3. Review of R34's quarterly MDS, with an ARD of 09/13/2024, revealed R34 had a BIMS score of 15 out of 15, indicating R34 was cognitively intact. In an interview on 12/03/2024 at 9:45 AM with R34, she stated, Facility is short of help on dayshift. She stated when she used her call light it took 30 plus minutes for it to get answered by staff. 4. Review of R69's admission MDS, with an ARD of 09/09/2024, revealed R69 had a BIMS score of 15 out of 15, indicating R69 was cognitively intact. In an interview on 12/03/2024 at 10:27 AM with R69, he stated his big concern was the staffing at nights and on the weekends. He stated the facility was short staffed. R69 stated he had complained to management, but they just smiled at him and nodded in agreement, but nothing was ever changed. 5. Review of R82's quarterly MDS, with an ARD of 10/01/2024, revealed R82 had a BIMS score of 15 out of 15, indicating R82 was cognitively intact. In an interview on 12/03/2024 at 12:27 PM with R82, she stated she had to wait an hour to go to the bathroom because of staff not coming to help. 6. Review of R101's quarterly MDS, with an ARD of 08/01/2023, revealed R101 had a BIMS score of 14 out of 15, which indicated R101 was cognitively intact. In an interview on 12/03/2024 at 9:50 AM with R101, he stated it took 45 minutes for his call light to get answered. He stated he called out this morning at 6:30 AM to get up and ready for the day, and no one came to his room until 7:15 AM. 7. Review of R116's MDS, with an ARD of 08/26/2024, revealed R116 had a BIMS score of 15 out of 15, which indicated R116 was cognitively intact. In an interview on 12/03/2024 at 9:45 AM with R116, he stated his concern was staffing on the weekends. He stated it took a long time to get help. 8. In an interview on 12/03/2024 at 2:25 PM with R81's Representative, she stated when she called the facility after 8:00 PM no one answered the phone. She also stated she had three different numbers to call, and she did not get an answer for any of them. 9. In an interview on 12/03/2024 at 2:38 PM with R52's Representative, she stated low staffing was an issue. She stated it took hours to get a response when the call light was used. She also stated there was one STNA and one nurse for a floor at times. In an interview on 12/04/2024 at 10:11 AM with STNA9, she stated they worked short staffed on most days. She stated they were usually short staffed due to call-ins, and weekends were worse. She stated on good days she would be responsible for approximately 16 residents, and on bad days she would be responsible for 20 plus residents. In an interview on 12/06/2024 at 8:53 AM with Kentucky Medication Aide (KMA) 1, she stated low staffing was a problem, and it could be difficult to get all her work done by the end of the shift. During an interview on 12/05/2024 at 9:50 AM with the Staffing Coordinator and Director of Nursing (DON), the Staffing Coordinator stated she started in April 2024. They both stated staffing was based on the residents' acuity and how many residents needed assistance with care. They both stated they discussed acuity in the building with the Assistant Director of Nursing (ADON) and the Administrator. They both stated they used the sheet from the day prior to look at the acuity and census in order to determine the staff needed for the following day, and if call-ins occurred, they would all jump in and help. In an interview on 12/06/2024 at 2:57 PM with the Administrator, she stated she was aware of staffing issues in April, May, and June 2024, and short staffing was triggered by the Payroll Based Journal (PBJ). She stated she was not at the facility during that period but was working to develop better staffing to cover the weekends.

Based on observation, interview, review of medication package inserts, and review of the facility's policy, the facility failed to label drugs and biologicals in accordance with currently accepted professional principles and include the expiration date when applicable for 6 of 6 sampled medication carts. Review of the six medication carts revealed four opened bottles of eyedrops without a date on the container, one bottle of expired potassium chloride tablets, one opened Advair inhaler without a date on the container, three expired bottles of nasal spray, 10 opened bottles of nasal spray without a date on the container, and one opened/used vial of lidocaine that was undated. The findings include: Review of the facility's policy titled, Medication Storage, revised 12/2021, revealed medications and biologicals should not be retained longer than recommended by the manufacturer or supplier. Further review revealed once any medication or biological package was opened, the facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Per the policy, facility staff should record the date opened on the medication container when the medication had a shortened expiration date once opened. Review of the manufacturer's package insert prescribing information for fluticasone propionate (a corticosteroid nasal spray for allergies) revealed the medication should be discarded after 120 sprays. Further review revealed the dosage for adult patients was one to two sprays per nostril twice daily. Review of the manufacturer's package insert prescribing information for azelastine hydrochloride (a nasal spray for allergies) revealed the medication should be discarded after 120 sprays. Further review revealed the dosage for adult patients was one to two sprays per nostril twice daily. Review of the manufacturer's package insert prescribing information for Advair Diskus (inhaled glucocorticoid used to treat asthma or chronic obstructive pulmonary disease (COPD)) revealed the medication should be discarded after 120 uses. Further review revealed the dosage for adult patients was one inhalation twice daily. Review of the manufacturer's package insert prescribing information for latanoprost ophthalmic solution (an eye drop used to treat glaucoma) revealed the medication should be discarded six weeks after opening. Observation on 12/05/2024 at 8:31 AM of the 1200 Hall medication cart revealed one opened undated box of fluticasone propionate nasal spray. Observation on 12/05/2024 at 12:46 PM of the 1100 Hall medication cart revealed one bottle of potassium chloride tablets with an expiration date of 11/2024; one bottle of saline nasal spray with an expiration date of 10/2024; one bottle of calcitonin nasal spray (used to treat osteoporosis) with an expiration date of 12/01/2024; two bottles of fluticasone propionate that contained opened dates on the packaging, but not on the medication containers; and one bottle of opened fluticasone propionate nasal spray that was not dated on either the container or the packaging. Observation on 12/05/2024 at 12:56 PM of the 2200 Hall medication cart revealed one bottle of fluticasone propionate nasal spray with an expiration date of 10/14/2024 and one bottle of latanoprost eye drops that contained an opened date on the packaging, but not on the medication bottle. Observation on 12/05/2024 at 1:02 PM of the 2300 Hall medication cart revealed one opened, undated vial of lidocaine and one opened, undated bottle of fluticasone propionate nasal spray. Observation on 12/05/2024 at 1:02 PM of the 2100 Hall medication cart revealed one opened, undated bottle of fluticasone propionate nasal spray; one opened, undated bottle of azelastine nasal spray; and the following eye drops that contained an opened date on the packaging, but not on the medication containers: one bottle of dorzolamide timolol eye drops (used to treat glaucoma), one bottle of moxifloxacin eye drops (used to treat eye infections), and one bottle of polymyxin eye drops (used to treat eye infections). Observation on 12/05/2024 at 1:14 PM of the 1300 Hall medication cart revealed the following that contained an opened date on the packaging, but not on the medication containers: one Advair Diskus inhaler, one bottle of azelastine nasal spray, and three bottles of fluticasone propionate nasal spray. In an interview on 12/05/2024 at 8:31 AM with State tested Nurse Aide (STNA) 3, who was also a Kentucky Medication Aide (KMA), she stated medications were dated as soon as they were opened on both the package and the medication container. STNA3 stated it was important medications were dated when opened because outdated medications lost their effectiveness over time and were potentially harmful to residents. She further stated, when she found undated or expired medications, they were discarded and reordered. In an interview on 12/05/2024 at 12:46 PM with STNA15, who was also a KMA, she stated medications were dated on both the packaging and the medication container when opened. She further stated if expired medications were found in the cart, she gave them to the nurse in charge. STNA15 stated expired or outdated medications were less effective after the expired dated and were potentially harmful if given to residents. In an interview with the Pharmacy Technician on 12/05/2024 at 1:41 PM, she stated they checked carts at the facility at least monthly for expired medications. She further stated any expired medications were removed from the cart, reordered, and taken back to the pharmacy. In an interview with Licensed Practical Nurse (LPN) 4 on 12/05/2024 at 1:46 PM, she stated when she opened a medication, she dated the box with both the opened date and the discard date because medications lost effectiveness over time. LPN4 stated she did not always date both the packaging and the container because the container was typically in the original packaging. She further stated she had not previously found medications separated from their original packing in her medication cart, but it made sense to date both in case the packaging was misplaced or discarded. LPN4 stated nurses on the floor checked carts for expired and undated medications. In an interview with the Director of Nursing (DON) on 12/06/2024 at 2:34 PM, she stated nurses checked carts for expired medications, and pharmacy performed audits on the medication carts at least once a month. The DON stated medications should be dated when opened, but stated an opened date on the packaging alone was sufficient because the prescription number on the packaging correlated with the prescription number on the container. When asked what staff would do if a medication was found undated without packaging, she stated that was something she had not witnessed, but if that occurred the opened date would be unknown. She further stated expired medications were discarded because of potential adverse effects to residents. In an interview on 12/06/2024 at 3:18 PM with the Administrator, she stated she expected opened medications were labeled and dated both on the packaging and the medication container. She further stated nurses on the carts checked for expired medications, and pharmacy checked the carts at least once a month. The Administrator stated if medications were not properly labeled, they could be administered to the wrong resident, and if not properly dated, were less effective and potentially harmful. The Administrator stated she monitored for compliance through spot checks of the medication carts. She further stated, if issues were identified with outdated or undated medications, those medications were discarded and reordered, and staff received immediate education.

Based on observation, interview, record review, and review of the facility's policies, the facility failed to implement a comprehensive person-centered care plan for each resident to meet the resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 2 of 29 sampled residents, Resident (R)23 and R82. R23 and R82 were not provided Activities of Daily Living (ADL) care per their care plan. Reference F677 The findings include: Review of the facility's policy titled, Quality of Care - Care Planning, dated 10/2022, revealed the facility would provide resident/patient centered care aiming to provide individualized Comprehensive/Interdisciplinary Care Plans for each resident. A care plan was developed to identify strengths or possible barriers to guide the resident in reaching their maximum functional level while encompassing a holistic approach including medical, nursing, psycho-social, nutritional, activities, therapy, spiritual, and educational interventions. Per the policy, the ultimate objective was to assist the resident in meeting their personal goals with optimal functional level and a more fulfilled/enhanced quality of life. Review of the facility's policy titled, Resident Rights & Facility Responsibilities, not dated, revealed the resident had a right to choose schedules of health care services consistent with her plan of care. 1. Review of R82's Face Sheet revealed the facility admitted R82 on 09/01/2022 with diagnoses which included malignant neoplasm of unspecified part of left bronchus of lung, polyneuropathy, and heart failure. Review of R82's quarterly Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 10/01/2024, revealed the facility assessed R82's cognition as intact with a Brief Interview for Mental Status [BIMS] score of 15, which indicated the resident was interviewable. Review of R82's Comprehensive Care Plan for Activities of Daily Living, dated 11/20/2024, revealed the resident required extensive assistance with bathing. Continued review revealed R82 was care planned to adjust ADLs as needs dictated. Review of R82's Shower/Bath Schedule revealed showers were scheduled for Tuesday and Friday. However, review of R82's Documentation Survey Report v2, dated 09/2024, 10/2024, and 11/2024, revealed R82 only received three showers/baths in September 2024, three showers/baths in October 2024, and three showers/baths in November 2024. Observation of R82 on 12/03/2024 at 12:30 PM revealed the resident was lying in bed; her hair was not combed. During interview with R82 at the time of the observation, she stated she did not always receive showers when she needed them. During interview with State Trained Nursing Assistant (STNA) 12 on 12/04/2024 at 3:55 PM, she stated if a resident refused a shower, she let the nurse know. However, she stated she did not say anything about asking the resident if she would like the shower later or if she would pass it on to the next shift. During interview with STNA8 on 12/06/2024 at 3:06 PM, she stated if a resident refused a shower, she encouraged them to take one and let them know they might not get a shower because they were scheduled twice a week. She stated she then told the nurse. During interview with Licensed Practical Nurse (LPN) 9 on 12/06/2024 at 3:09 PM, she stated when she was informed a resident refused a shower, she talked to the resident and called the family to let them know. During interview with the Director of Nursing (DON) on 12/05/2024 at 2:11 PM, she stated residents received two showers a week, and that was documented in the electronic medical record (EMR). The DON stated when residents refused a shower initially, staff offered again. Also, if residents refused again, a shower or bath was not given, but it was added to the schedule and given another day. 49267 2. Review of R23's, Face Sheet revealed the facility admitted the resident on 05/16/2023 with diagnoses including type 2 diabetes, osteoarthritis, and other diseases of the musculoskeletal system and connective tissue. Review of R23's quarterly MDS, with an ARD of 11/21/2024, revealed the resident had a BIMS score of 10 out of 15, which indicated the resident was moderately cognitively impaired. Additional review of the MDS revealed no rejections of care, functional range of motion (ROM) was limited due to impairment on one side, and dependent for bath and shower care. Review of R23's, Comprehensive Care Plan, dated of 05/16/2023, revealed the resident had an ADL self-care performance deficit related to impaired mobility, impaired balance, pain, and musculoskeletal impairment, and ADLs would be met as evidenced by neat, clean appearance, being free of body odor, and dressed in clothing appropriate for the season. Further review revealed interventions for extensive assistance with one staff member for bathing and assistance with ADLs as needed. Additional review of R23's care plan revealed the resident was assessed for altered cardiopulmonary status and risk for skin impairment with interventions that included assist with toilet and hygiene as needed, keep skin clean and dry, and shower/bath per schedule and as needed. Review of R23's Shower/Bath Schedule revealed R23 was scheduled a bath or shower on Monday and Thursday of each week for the months of October, November, and December of 2024. Review of R23's Shower Sheets, from 11/07/2024 to 12/05/2024 revealed the resident received only one bath/shower each week. Observation and interview of R23 on 12/04/2024 at 9:45 AM revealed the resident was in bed, and her hair was greasy and uncombed. R23 stated she did not remember when she last had her hair washed or received a bed bath. She further stated baths were not offered regularly, and she just wanted to get her hair washed. R23 stated, It makes me feel better when I'm clean and my hair is clean. R23 also stated she preferred a bed bath. In an interview with STNA16 on 12/05/2024 at 2:47 PM, he stated if residents refused their scheduled shower time, he reapproached the resident the same day and provided education and encouragement. He stated they did not always have time for make-up showers the following day. STNA16 stated the nurses and Kentucky Medication Aides (KMA) informed him if there were changes made to a resident's care. He further stated he also looked at the care plan because resident care information was required on their care plan. In additional observation and interview with R23 on 12/06/2024 at 1:57 PM, she stated she did not refuse showers or baths when offered. She further stated she received a bath yesterday, her hair was washed, and she felt so much better. Observation of R23 revealed she smiled as she spoke, and her hair was clean and combed. In an interview on 12/06/2024 at 2:09 PM with the Wound Care Certified Nurse (WOCN), she stated she had worked one year as WOCN and prior to that was a floor nurse at the facility for [AGE] years. She stated residents received two showers or baths a week with their hair washed if desired. However, the WOCN stated residents had complained that showers were not always received. She further stated a resident's ADL care plan was how staff determined a resident's needs. The WOCN stated it was important care plans were updated as needed so care was current, and it was important to follow the care plan so resident needs were met. In additional interview with the DON on 12/06/2024 at 2:16 PM, she stated she expected staff to follow the resident's care plan for ADL care because it was important they received correct care, and it was necessary for the overall well-being of the resident. During an interview with the Administrator on 12/06/2024 at 3:18 PM, she stated she expected residents to receive their showers and baths per their plan of care and that all ADL care was provided based on care planned needs. The Administrator stated it was important staff followed a resident's care plan so proper care was provided.

Based on observation, interview, record review, and review of the facility's policies, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal hygiene for 2 of 29 sampled residents, Resident (R) 23 and R82. R82 reported showers were not given as needed. Review of R82's electronic medical record (EMR) revealed showers/baths were to be given two days a week, but R82 only received three showers/baths in September 2024, three showers/baths in October 2024, and three showers/baths in November 2024. R23 stated she preferred bed baths, but they were not offered regularly. Review of R23's EMR revealed showers/baths were to be given two days a week, but from 11/07/2024 to 12/05/2024, R23 received only one bath/shower each week. The findings include: Review of the facility's policy titled, Bathing and General Hygiene, revised 03/2021, revealed the facility wanted to give patients as much choice as possible in relation to bathing and their general hygiene. Further review revealed residents' hair was washed each week, and refused scheduled baths were reported to the Charge Nurse by the State tested Nurse Assistant (STNA). Per the policy, the resident's refusal was documented in the medical record. Review of the facility's policy titled, Activities of Daily Living [ADL] Care, revised 08/2024, revealed staff would ensure residents who were unable to carry out ADLs received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. 1. Review of R82's Face Sheet revealed the facility admitted R82 on 09/01/2022 with diagnoses which included malignant neoplasm of unspecified part of left bronchus of lung, polyneuropathy, and heart failure. Review of R82's quarterly Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 10/01/2024, revealed the facility assessed R82's cognition as intact with a Brief Interview for Mental Status [BIMS] score of 15, which indicated the resident was interviewable. Review of R82's Shower/Bath Schedule revealed showers were scheduled for Tuesday and Friday. Review of R82's Documentation Survey Report v2, dated September 2024, revealed R82 did not receive a shower on Tuesday, 09/03/2024; refused a shower on Friday, 09/06/2024; received a shower on Tuesday, 09/10/2024; refused a shower on Friday, 09/13/2024; received a shower on Tuesday, 09/17/2024; refused a shower on Friday 09/20/2024; received a bed bath on Tuesday, 09/24/2024; and did not receive a shower on Friday, 09/27/2024. Review of R82's Documentation Survey Report v2, dated October 2024, revealed R82 received a bed bath on Tuesday 10/01/2024; received a shower on Friday 10/04/2024; refused a shower on Tuesday, 10/08/2024; and did not receive a shower on Friday, 10/11/2024. Continued review revealed on Tuesday, 10/15/2024, R82 did not receive a shower; on Friday 10/18/2024, R82 received a shower; on Tuesday, 10/22/2024, R82 did not receive a shower; and on Friday, 10/25/2024, R82 refused a shower. Review of R82's Documentation Survey Report v2, dated November 2024, revealed R82 received a shower on Friday, 11/01/2024; R82 refused a shower on Tuesday, 11/05/2024; R82 did not receive a shower on Friday, 11/08/2024; R82 did not receive a shower on Tuesday, 11/12/2024; R82 received a bed bath on Friday, 11/15/2024; R82 refused a shower on Tuesday 11/19/2024; R82 received a bed bath on 11/22/2024; and R82 did not receive a shower on Tuesday, 11/26/2024 or on Friday, 11/29/2024. Observation of R82 on 12/03/2024 at 12:30 PM revealed the resident was lying in bed; her hair was not combed. During interview with R82 at the time of the observation, she stated she did not always receive showers when she needed them. 49267 2. Review of R23's Face Sheet revealed the facility admitted the resident on 05/16/2023 with diagnoses including type 2 diabetes, osteoarthritis, and other diseases of the musculoskeletal system and connective tissue. Review of R23's quarterly MDS, with an ARD of 11/21/2024, revealed the resident had a BIMS score of 10 out of 15, which indicated the resident was moderately cognitively impaired. Additional review of the MDS revealed no rejections of care, functional range of motion (ROM) was limited due to impairment on one side, and dependent for bath and shower care. Review of R23's Shower/Bath Schedule revealed R23 was scheduled a bath/shower on Monday and Thursday of each week for the months of October, November, and December of 2024. Review of R23's Point of Care [POC] documentation for 10/2024 revealed no bath or shower was documented for Monday, 10/07/2024, or Thursday, 10/31/2024. Additionally, Monday, 10/14/2024, was documented as not given due to resident refusal. Review of R23's POC documentation for 11/2024 revealed the resident had not received a bath or shower on Monday, 11/04/2024, Monday, 11/11/2024, or Monday, 11/25/2024, and those dates were documented as resident refusal. Review of R23's POC documentation for 12/01/2024 to 12/05/2024 revealed no documented bath or shower for Monday, 12/02/2024. Review of R23's Shower Sheets, from 11/07/2024 to 12/05/2024, revealed the resident received only one bath/shower each week. Review of R23's Progress Notes, from 10/01/2024 to 12/05/2024, revealed one entry, dated 12/05/2024, related to shower/bath documentation. Further review revealed that entry stated staff approached the resident twice on 12/05/2024 about a shower, and it was given after lunch. Observation and interview of R23 on 12/04/2024 at 9:45 AM revealed the resident in bed, and her hair was greasy and uncombed. R23 stated she did not remember when she last had her hair washed or received a bed bath. She further stated baths were not offered regularly, and she just wanted to get her hair washed. R23 stated, It makes me feel better when I'm clean and my hair is clean. R23 also stated she preferred a bed bath. In additional observation and interview with R23 on 12/06/2024 at 1:57 PM, she stated she did not refuse showers or baths when offered. She further stated she received a bath yesterday, her hair was washed, and she felt so much better. Observation of R23 revealed she smiled as she spoke, and her hair was clean and combed. During interview with STNA12 on 12/04/2024 at 3:55 PM, she stated if a resident refused a shower, she let the nurse know. However, she did not say anything about asking the resident if the resident would like the shower later or if STNA12 would pass it on to the next shift. In an interview with STNA16 on 12/05/2024 at 2:47 PM, he stated if residents refused their scheduled shower time, he reapproached the resident the same day and provided education and encouragement. He further stated there was not always enough time for make-up showers the following day. In an interview with STNA14 on 12/05/2024 at 9:53 PM, she stated residents typically received showers twice a week, and they had scheduled shower days. In an interview with STNA17 on 12/06/2024 at 1:46 PM, she stated residents were showered or bathed twice a week. She further stated after completion, the shower or bath was documented in the resident's EMR under POC and in the shower binder at the nurse's station. STNA17 stated sometimes showers were missed because staff was too busy. Additionally, she stated if a resident refused a shower or bath, she returned later in the day and asked again; if the resident refused again, she notified the nurse. STNA17 also stated she explained to residents their showers were important and helped them feel better. During interview with STNA8 on 12/06/2024 at 3:06 PM, she stated if a resident refused a shower, she encouraged the resident and let the resident know he/she might not get a shower because showers were scheduled twice a week. STNA8 stated she informed the nurse of the refusal. During additional interview with STNA14 on 12/06/2024 at 3:14 PM, she stated if a resident refused a shower, she tried to encourage the resident or offer to do the shower later. She stated she tried twice, or if the resident was agitated, she let the nurse know. During interview with Licensed Practical Nurse (LPN) 9 on 12/06/2024 at 3:09 PM, she stated when she was informed a resident refused a shower, she talked to the resident and called the family to let them know of the refusal. In an interview on 12/06/2024 at 2:09 PM with the Wound Care Certified Nurse (WOCN), she stated she had worked one year as WOCN and prior to that was a floor nurse at the facility for [AGE] years. She stated residents received two showers or baths a week with their hair washed if desired. The WOCN stated nursing aides usually reapproached residents later the same day if a resident refused their bath or shower. She further stated if the resident continued to refuse, the aide notified the nurse, and the resident was educated on the shower schedule and the need for personal hygiene. The WOCN stated residents had complained that showers were not always received. She further stated when she worked as a floor nurse and a shower was missed, she asked the resident if they refused, and if not, she then spoke to staff and determined the reason it was skipped. In an interview with the Director of Nursing (DON) on 12/05/2024 at 2:11 PM, she stated residents received two showers a week, and that was documented in the EMR under POC. She further stated there were quite a few residents that refused regularly, and when that occurred, refusals were put on their care plan, and families were made aware. The DON stated when residents refused a shower initially, staff offered again; if the resident refused again, a shower or bath was not given, and it was added to the schedule and given another day. In additional interview with the DON on 12/06/2024 at 2:16 PM, she stated neither staff nor residents had notified her that showers and baths were missed. She further stated residents frequently refused showers, and aides did not always document properly. She stated she thought the problem was a combination of both of those things. During an interview with the Administrator on 12/06/2024 at 3:18 PM, she stated she was not aware of missed showers. She stated she expected residents to receive their showers and baths as scheduled, as needed, and when they chose. She further stated she expected residents who refused were offered a shower later, and staff documented that information in the resident's EMR.

Based on observation, interview, record review, review of the Centers for Disease Control and Prevention (CDC) signage, and review of the facility's policies, the facility failed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 29 sampled residents, Resident (R)10, R231, and R26. Observation on 12/04/2024 revealed R10 was in Enhanced Barrier Precautions (EBP), but State Trained Nurse Aide (STNA) 11 and STNA12 changed R10's brief and the bed linen without wearing a gown. Observation on 12/04/2024 revealed STNA11 and STNA12 used a gait belt to transfer R10 to a wheelchair, and then they then attempted to use the same gait belt to transfer her roommate, R231. Observations on 12/03/2024 and 12/05/2024 revealed R26's wound vacuum (vac) tubing was on the floor. The findings include: Review of the facility's policy titled, Infection Control Transmission Based Precaution, revised 04/2024, revealed when possible, dedicate the use of non-critical resident-care equipment items such as a stethoscope, sphygmomanometer, or bedside commode to a single resident to avoid sharing between residents. Per the policy, if the use of common items was unavoidable, then adequately clean and disinfect them before use for another resident. Further review revealed for residents on EBPs, a gown and gloves was required when performing high contact activities with residents. Review of the facility's policy titled, Standard Precautions, revised 09/2024, revealed for staff to wear a gown (clean, non-sterile) to protect skin and prevent soiling of clothing during procedures and resident care activities that were likely to generate splashes or sprays of blood, body fluids, secretions or excretions, or cause soiling of clothing. Per the policy, staff should ensure that reusable equipment was not used for the care of another resident until it had been appropriately cleaned and reprocessed. Review of the facility's signage for Enhanced Barrier Precautions, undated and with the CDC logo on the bottom right of the sign, revealed Everyone Must: Clean their hands, including before entering and when leaving the room. Providers and Staff Must Also: Wear gloves and a gown for the following High-Contact Resident Care Activities. Dressing, Bathing/Showering, Transferring, Changing Linens, Providing Hygiene, Changing Briefs or Assisting with Toileting. 1. Observation on 12/04/2024 at 2:04 PM revealed an EBP sign on the right wall. There was also a magnetic STOP sign on the left side of the bathroom door. The sign stated, ENHANCED BARRIER PRECAUTIONS, room [ROOM NUMBER]-1 BED DOOR. R10 was in the bed by the door. Continued observation revealed STNA11 and STNA12 changed R10's brief, and both staff members were wearing gloves but no gown. Further, after they cleaned and dressed R10, they put a gait belt around her waist. They then held R10 under each arm and held the gait belt with the other arm. They transferred R10 to the wheelchair and removed the gait belt. Then, STNA12 placed the gait belt on R10's dresser. 2. Continued observation revealed R231 requested to get in her wheelchair. STNA12 picked up the gait belt off R10's dresser and attempted to put it on R231. Before that happened, the State Survey Agency (SSA) Surveyor asked STNA11 and STNA12 to step into the hall. During immediate interview with STNA12 in the hall, she stated she had been trained in infection control, but they did not go over what to do with the gait belt. She stated each resident did not have their own belt; they used the gait belt they had with them to transfer each resident without cleaning the belt between residents. On 12/04/2024 at 2:23 PM Licensed Practical Nurse (LPN) 4 came to the SSA Surveyor, STNA11, and STNA12. LPN4 asked if she could help. During immediate interview with LPN4, she stated she was last trained in cleaning a gait belt years ago when she was an STNA. She stated the computer training she received at this facility did not include gait belt use on residents. During interview with STNA11 after interview with LPN4, she stated she had not been trained to clean the gait belt after use. She stated each resident did not have their own gait belt. During interview with the Director of Nursing (DON) on 12/04/2024 at 2:40 PM after she arrived on the unit, she stated staff had been trained in EBPs. She stated STNA11 and STNA12 should have put on a gown prior to changing R10. She further stated there was no reason to clean gait belts between residents unless they were visibly soiled. She also stated if they were visibly soiled, they were put in a bag and sent to the laundry. During interview with the Assistant Director of Nursing (ADON) on 12/04/2024 at 2:45 PM, she stated the same gait belts were used on each resident unless they were visibly soiled. She further stated if a gait belt was used on a resident who was in EBP, it would depend on what reason they were in EBP to determine if the same gait belt could be used on another resident who was not in EBP. She stated she made rounds to monitor staff to see if they were maintaining infection control. She stated she did not document the findings. During interview with the Administrator on 12/06/2024 at 2:58 PM, she stated she had not been made aware of staff using the same gait belt on residents without cleaning the belt. She stated she expected staff to maintain infection control precautions. 49267 3. Observation on 12/03/2024 at 12:35 PM revealed R26 in the first-floor dining room at lunch in her wheelchair. R26's wound vac was secured to the back of her wheelchair, and the wound vac tubing was observed on the floor. Observation on 12/05/2024 at 8:42 AM revealed STNA14 asked STNA3 (also a Kentucky Medication Aide (KMA)) how R26's wound vac should be positioned prior to transport in the wheelchair, and R26 was in her room with the wound vac attached to the back of her wheelchair. The wound vac tubing was again observed on the floor. In an interview with STNA14 on 12/05/2024 at 9:53 AM, she stated earlier in the morning she asked STNA3 how wound vac tubing should be positioned when residents were transported because she was unsure of its placement. STNA14 further stated when residents with a wound vac were transported, the tubing was positioned high enough, so it was kept off the floor because of the risk for infection. In an interview with STNA3 on 12/05/2024 at 10:05 AM, she stated if a resident's wound vac tubing was found on the floor, it needed replacement tubing because of potential infection control concerns. In an interview with STNA17 on 12/06/2024 at 1:46 PM, she stated R26's wound vac was managed by nursing, but she knew the tubing was kept off the floor because of the risk for infection. She further stated if she found tubing on the floor or the machine beeped, she notified the nurse immediately. In an interview with the Wound Care Certified Nurse (WOCN) on 12/06/2024 at 2:09 PM, she stated she had worked for a year as WOCN and prior to that she was a floor nurse at the facility for [AGE] years. The WOCN stated nursing aides notified nursing if there was an issue with a wound vac. She further stated nursing typically contacted her for concerns with a wound vac, but they addressed issues as well. The WOCN stated the wound vac canister was changed weekly and as needed and the wound vac itself (with tubing) was changed three days a week and as needed. The WOCN stated tubing was kept off the floor because of the risk for infection. She further stated when a resident with a wound vac was transported in a wheelchair, the device (in its bag) was attached to the back of the wheelchair, and the tubing wrapped around the straps of the bag. The WOCN stated if she observed wound vac tubing on the floor, it was corrected immediately through staff education, and the tubing was replaced. In additional interview on 12/06/2024 at 2:16 PM with the DON, she stated she expected staff to follow infection protocols, and wound vac tubing was kept off the floor. She further stated if tubing was observed on the floor, it was cleaned/changed immediately, and staff was reeducated on proper infection control processes. In an interview on 12/06/2024 at 2:29 PM with the Infection Preventionist (IP), she stated nursing aides received education regarding wound vacs. She stated education included if a wound vac or the tubing was leaking, beeping, came off, or fell on the floor, they notified nursing right away. The IP stated when residents with wound vacs were transferred, the wound vac case was attached to the back upper portion of the wheelchair, and the tubing was wrapped around the case and kept off the floor. She further stated, if noncompliance was noticed by her, it was corrected immediately, and education was provided to staff. The IP stated anytime tubing was found on the floor, it was changed because of infection concerns. In an interview with the Administrator on 12/06/2024 at 3:18 PM, she stated tubing of any kind, including wound vac tubing, was never left on the floor. The Administrator stated she made rounds throughout the day, and any identified noncompliance was corrected and addressed immediately with staff through reeducation. She further stated staff education was important, so they understood the potential infection concerns with tubing left on the floor.

Based on observation, interview, and review of the facility's policy, it was determined the facility failed to ensure all drugs and biologicals were in locked compartments to permit only authorized personnel to have access. An observation, on 11/06/2020, revealed a medication cart on the 1200 Hall was unlocked and unsecured for seven (7) minutes with multiple empty medication capsules left on top of the cart. The findings include: Review of the facility's policy, Medication Storage, revised August 2018, revealed the purpose of the policy was to ensure only authorized facility staff had possession of the keys, which opened the medication cart or medication storage. Further review of the section titled, Procedures, revealed medications and biologicals, including treatment items, were to be securely stored in a locked cabinet/cart or medication room so unauthorized individuals (such as residents, visitors and staff) did not have access to them. Observation, on 11/06/2020 at 9:53 AM, revealed a medication cart on the 1200 Hall was unlocked and unsecured with multiple empty medication capsules left on top of the cart. The cart was left unlocked and unattended for seven (7) minutes, from 9:53 AM until 10:00 AM, while Licensed Practical Nurse (LPN) #1 was assisting a resident in room [ROOM NUMBER]. This unlocked medication cart contained individual drawers of medications for residents on the unit and other supplies in the larger bottom drawers. Continued observation, on 11/06/2020 at 9:53 AM, revealed several staff members passed by the unlocked and unsecured computer. The observation showed two (2) staff members approached the cart; one (1) aide removed a pair of gloves located in a box on the medication cart; and another aide disposed of trash in the trash bin located on the side of the cart. Further observation revealed a resident was seated in near proximity of the cart in his/her wheelchair, self-ambulating. Additionally, per interview, there were five (5) residents located on the first floor (the same vicinity) who were known wanderers. Interview with LPN #1, on 11/06/2020 at 10:01 AM, revealed she was called to assist another staff member and was aware she had left the medication cart unlocked when she went down the hall to room [ROOM NUMBER]. Further interview revealed this was not acceptable practice, and she should have ensured the medication cart was locked and secured prior to leaving the cart unattended. LPN #1 stated it was important to keep the medication cart locked to maintain safety and security for residents and to ensure no one had access to medication from the cart. Interview with the Director of Nursing (DON), on 11/06/2020 at 3:51 PM, revealed nursing staff should always follow facility policies related to storage of medications and use of the medication carts. Per interview, the DON stated it was not acceptable, under any circumstance, for LPN #1 to leave a medication cart opened or leave the cart unlocked and unsupervised. The DON stated the medication cart should not have been left opened and unattended, and LPN #1 should have locked the medication cart so unauthorized individuals did not have access to medications. Per interview, the DON stated it was important to keep the medication cart locked, when unattended, to maintain safety and security for residents and to ensure no one had access to medications from the cart.

Based on observation, interview, and record review, it was determined the facility failed to ensure the security and confidentiality of medical records for one (1) of four (4) sampled residents, Resident #1. Personal Health Information (PHI), including documentation from Resident #1's Electronic Medical Record and Medication Administration Record, [REDACTED]. The findings include: Review of the facility's policy, Resident Rights, not dated, section (7), State Resident Rights, revealed all residents would have confidential treatment of [REDACTED]. Further review of the policy, section (5), Kentucky Administrative Regulations, and section (e), Federal Resident Rights, revealed the resident would have the right to personal privacy and confidentiality of his/her personal and clinical records. Review of Resident #1's medical record revealed the facility admitted the resident, on 12/23/15, with [DIAGNOSES REDACTED]. Review of Physician orders [REDACTED]. The pain medications included [MEDICATION NAME], and [MEDICATION NAME]. There were also several heart medications listed. Observation, on 11/06/2020 at 9:53 AM, revealed a computer, on a medication cart in the 1200 Hall, was left unlocked and unsecured with Resident #1's PHI exposed, including the resident's name, room number, date of birth, and current list of medications. The computer was left unlocked and unattended for seven (7) minutes, from 9:53 AM until 10:00 AM, while Licensed Practical Nurse (LPN) #1 was assisting a resident in room [ROOM NUMBER], several doors down from where the medication cart was positioned, and it was out of LPN #1's sight. In addition, this observation revealed Resident #1's MAR indicated [REDACTED]. LPN #1 left the MAR indicated [REDACTED]. Continued observation, on 11/06/2020 at 9:53 AM, revealed several staff members passed by the unlocked and unsecured computer. The observation showed two (2) staff members approached the cart; one (1) aide removed a pair of gloves located in a box on the medication cart; and another aide disposed of trash in the trash bin located on the side of the cart. Further observation revealed a resident was seated in near proximity of the cart in his/her wheelchair, self-ambulating. Additionally, per interview, there were five (5) residents located on the first floor (the same vicinity) who were known wanderers. Interview with LPN #1, on 11/06/2020 at 10:01 AM, revealed she was called to assist another staff member. LPN #1 stated she was aware she had left the computer unlocked, opened, and unsecured when she went down the hall to room [ROOM NUMBER]. LPN #1 also stated she was aware she left the MAR indicated [REDACTED]. LPN#1 stated she did not realize that she had been away from the medication cart for seven (7) minutes. Further interview with LPN #1 revealed leaving the computer opened and unattended was not an acceptable practice. LPN #1 stated she should have ensured the computer containing PHI was closed and locked, and the MAR indicated [REDACTED]. Interview with the DON, on 11/06/2020 at 3:51 PM, revealed nursing staff should always follow facility policies related to Resident Rights and confidentiality of personal and clinical information. Per interview, it was not acceptable for the nurse to leave the MAR indicated [REDACTED]. The DON stated the computer should have been minimized, locked, and never should have been left unlocked and unattended. The DON stated LPN #1 should have locked the computer so that unauthorized individuals did not have access to the residents' PHI. Further interview with the DON revealed it was important to keep computers locked and secured to maintain the security, confidentiality, and integrity of all residents' personal and clinical information. Interview with the Administrator, on 11/06/2020 at 3:45 PM, revealed she expected all staff to follow facility policies related to Residents Rights and confidentiality of personal and clinical information. Per interview with the Administrator, it was not acceptable, under any circumstance, for the nurse to leave the MAR indicated [REDACTED]. The Administrator stated it was important to secure PHI to maintain the confidentiality of all residents' personal and clinical information.

Based on observation, interview, record review and review of facility Policy, it was determined the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance of his or her quality of life for one (1) of twenty-six (26) sampled residents (Resident #65). Interview with Resident #65 on 09/24/19, revealed State Registered Nurse Aide (SRNA) #10 told the resident that he/she was wetting his/her pants and vomiting purposefully and it made SRNA #10 mad (date unknown). Further, Resident #65 complained SRNA #10 was sometimes rude and accused him/her of frequently ringing the call light and always ringing the call light at the end of the shift when she needed to leave to get her kids on the school bus. The findings include: Review of the Resident Rights document, undated submitted by the facility for review, revealed each resident shall be treated with consideration, respect, and full recognition of his dignity and individuality, including privacy in treatment and care for his personal needs. Review of the Resident #65's clinical record revealed the facility admitted the resident on 03/04/19 and readmitted the resident on 08/22/19 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 08/28/19, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15), indicating the resident had no cognitive impairment. Interview with Resident #65, on 09/24/19 at 12:51 PM, revealed he/she had been nauseated off and on for quite a while. Further interview revealed at therapy earlier today the resident was unable to complete his/her therapy due to nausea. Continued interview revealed Resident #65 felt his/her care was good except for one (1) staff member who was rude. Per interview, State Registered Nurse Aide (SRNA) #10 told Resident #65 about a week ago, that he/she was wetting his/her pants and vomiting purposefully and it made SRNA #10 mad. Resident #65 further stated SRNA #10 was not always rude, but if it was a busy day or if he/she needed frequent assistance, SRNA, #10 was not nice. Continued interview with Resident #65, revealed SRNA #10 told him/her in the past, he/she had been ringing the call light too often. Resident #65 was unable to recall a specific date; however, he/she stated one morning right before the shift change, SRNA told him/her that he/she always rang the call bell right before shift change and she (SRNA #10) needed to hurry to finish up, so she could leave in time to get her kids on the school bus. Further interview revealed Resident #65 did not report the incident because it was partially his/her fault for ringing the call bell too often. Continued interview revealed Resident #65 had not seen SRNA #10 in the last few days and he/she was happy when he/she rang the call light and it was not SRNA #10 who answered. Resident #65 stated he/she did not feel SRNA #10 was abusive towards him/her, but she re-iterated SRNA was rude at times. Post survey phone interview with SRNA #10, on 10/04/19 at 5:50 PM, revealed she denied mistreating Resident #65 and stated she did not recall telling the resident he/she was incontinent or vomiting on purpose, and if she did mention anything like that, it would have been in a joking manner. She stated she did remember an incident with Resident #65 when she jokingly told the resident he/she would often ring the call light right before shift change. Further interview revealed she did not remember if she mentioned anything about the need to put her children on the school bus, but she may have said something while providing care. Continued interview revealed Resident #65 did call for assistance often at 7:00 AM, at the end of SRNA #10's shift. SRNA #10 stated when Resident #65 rang the call light one particular day recently the resident stated, I thought I had waited long enough for the shift to end. Oh, I thought you might have gone. SRNA #10 stated she and Resident #65 had no issues and perhaps her statements to the resident were taken the wrong way due to her tone of voice. Interview on 09/27/19 at 12:52 PM, with Licensed Practical Nurse (LPN)/Unit Manager, who worked the unit in which Resident #65 resided, revealed it was her expectation each resident was treated kindly. She stated she had not heard any complaints with SRNA #10's name mentioned. Further interview revealed if a staff member accused Resident #65 of vomiting or of urinary incontinence purposefully that would be a dignity issue. Further, if a staff member spoke to a resident and made them feel as if they should not use their call light when needed, that would be a dignity issue which would need to be reported to the Director of Nursing (DON) and the Administrator. Continued interview revealed Resident #65 had not reported any negative incidents. Interview with the Director of Nursing (DON), on 09/27/19 at 1:09 PM, revealed if an employee was suspected of abuse or if a staff member did not treat a resident with dignity, the staff member would need to immediately clock out. The DON stated she was unaware of the allegations related to SRNA #10 telling Resident #65 he/she was vomiting and incontinent on purpose; and telling the resident he/she rang the call bell frequently and right before shift change until the State Agency Representative brought it to the attention of the Administrator. The DON stated SRNA #10 had not worked the floor after it was reported. Continued interview revealed it was her expectation all residents were treated in a kind and [MEDICATION NAME] manner. Per interview, staff was not to disagree with a resident and was to honor their requests. Interview with the Administrator, on 09/27/19 at 1:28 PM, revealed staff was to always act in an an appropriate manner and have work place behavior. Per interview, it would be inappropriate for a staff member to tell Resident #65 he/she was purposefully vomiting and being incontinent. Further, if a staff member was providing care at the end of a shift, it would be expected for them to complete the care to the resident and not complain to the resident. Continued interview revealed the facility provided customer service training for staff and they should be aware of how to talk to a resident. Further interview revealed after the Administrator was informed of the allegations related to Resident #65, SRNA #10 was questioned and denied saying anything inappropriate to Resident #65. Continued interview revealed there had been no issues with SRNA #10's behavior in the past; however, after she learned of the allegations, SRNA #10 was re-educated concerning customer service.

Based on observation, interview and review of facility Policy, it was determined the facility failed to ensure dietary sanitation. Review of the Dish Machine Worksheets on 12/12/18 at 8:44 AM, during kitchen tour, revealed the dish machine temperatures were not consistently documented for the wash and rinse cycles before starting the dish machine at each meal for 10/2018, 11/2018, and 12/2018, as per Policy. The findings include: Review of the facility Policy titled Dish Machine Temperature Checks dated 06/2015, revealed the dietary employee or janitor will check the temperatures of the the dish machine wash and rinse cycle and record the temperatures on the dish machine worksheet before starting the dish machine at each meal. Continued review revealed instructions for the staff to check temperatures BEFORE running the dishes through the dish machine. Review of the facility Dish Machine Worksheets dated 10/2018, revealed the breakfast dish machine temperatures for wash and rinse were not recorded for 10/01/18, 10/02/18, 10/03/18, 10/04/18, 10/05/18, 10/06/18, and 10/07/18. On 10/11/18, the breakfast dish machine wash temperature was not recorded. On 10/16/18, the dish machine wash and rinse temperatures were not recorded at lunch or dinner. The dates of 10/17/18 and 10/18/18 were not listed on the dish machine worksheet and there was no documentation of the temperatures for wash or rinse cycles for those dates. On 10/20/18, the dish machine wash temperature was not recorded at breakfast. On 10/21/18, the dish machine wash temperature was not recorded at dinner. On 10/29/18 and 10/31/18, the dish machine temperatures for wash and rinse were not recorded at breakfast. On 10/30/18, there was no documentation of the dish machine temperatures for the wash or rinse cycles. Review of the Dish Machine Worksheets dated 11/2018, revealed the dates of 11/01/18 and 11/02/18 were not listed on the dish machine worksheet and there was no documentation of the dish machine temperatures at meals for the wash or rinse cycles. On 11/03/18 and 11/04/18, the dish machine wash and rinse temperatures were not recorded at the breakfast meal. On 11/05/18, 11/06/18, 11/07/18, 11/08/18, 11/09/18, 11/10/18 and 11/11/18, there was no documentation of the dish machine wash and rinse temperatures at meals. On 11/12/18, the wash temperature at breakfast was not recorded. On 11/13/18 and 11/14/18, the dish machine wash and rinse temperatures were not recorded at dinner. The breakfast dish machine temperatures were not recorded for 11/16/18, 11/17/18, 11/19/18, 11/20/18, and 11/21/18. On 11/22/18, the lunch and dinner dish machine temperatures were not recorded. The dish machine wash and rinse temperatures at breakfast on 11/26/18 was not recorded. The dish machine temperatures for 11/27/18 and 11/28/18 were not recorded at breakfast, lunch and dinner. The dish machine temperatures for 11/30/18 were not recorded at breakfast and lunch. Review of the Dish Machine Worksheets dated 12/2018, revealed on 12/01/18 and 12/02/18 dish machine wash and rinse temperatures were not recorded at any meal. In addition, there was no documentation of the dish machine temperatures at meals for the wash or rinse cycles for 12/06/18, 12/08/18 and 12/11/18. Interview on 12/12/18 at 4:48 PM, with the Chef, revealed the staff were responsible to record all dish machine temperatures every day at all meals. Continued interview revealed it was important to ensure the dish machine temperatures were high enough to kill bacteria, and sanitize the dishware for the residents' protection. Interview on 12/13/18 at 8:53 AM, with Cook #1, revealed staff were to document dish machine temperatures and let maintenance know or tell the Chef if the machine was not reaching high enough temperatures. Per interview, the high temperatures kill the bacteria, and sanitize the dishes. Interview on 12/13/18 at 8:56 AM, with Prep Cook #1, revealed it was important to obtain and document the dish machine temperatures to ensure the dishware was sanitized. Interview on 12/13/18 at 8:58 AM, with Dietary Aide #1, revealed it was important to obtain and record dish machine temperatures to ensure temperatures were high enough to sanitize the dishware. Interview on 12/13/18 at 5:10 PM, with the Director of Nursing (DON), revealed it was her expectation for dietary staff to follow dietary policies. Interview on 12/13/18 at 11:59 AM, with the Administrator, revealed it was his expectation for staff to obtain and record temperatures of the Dish Machine as per Policy to ensure dietary sanitation.

Based on observation, interview, and review of facility policy, it was determined the facility failed to ensure medications were secure and inaccessible to unauthorized staff and residents. Observation on 12/13/18 on the HC2 hall for the 2200 rooms, revealed two (2) tablets of [MEDICATION NAME] 100 milligram [MEDICATION]) was left unattended on top of the medication cart. The findings include: Review of the Medication Storage Policy, dated 08/2018, revealed medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors. Observation on 12/13/18 at 10:00 AM, revealed two (2) tablets of [MEDICATION NAME] 100 milligram tablets on top of the HC2 medication cart for the 2200 rooms, in the central common area with residents present. Continued observation revealed there was no nurse or staff present in the vicinity of the medication cart. Interview on 12/13/18 at 10:05 AM, with Licensed Practical Nurse (LPN) #3, who was assigned to the 2300 hallway revealed the medication cart belonged to LPN #2. During this interview, LPN #2 walked up the hall to the medication cart with the [MEDICATION NAME] tablets which had the unsecured [MEDICATION NAME] tablets. Interview with LPN #2 on 12/13/18 at 10:07 PM, revealed she pulled the [MEDICATION NAME] in error and set the medication on top of the cart, then got distracted with another resident and left the medications unsecured. Interview with the Assistant Director of Nursing (ADON) on 12/13/18 at 4:30 PM, revealed it was her expectation all medications be secured in the locked medication cart or locked medication storage area. Per interview, medications should never be left unattended. She further stated a resident could have consumed the [MEDICATION NAME] medication which could have resulted in adverse consequences. Interview with the Director of Nursing and the Administrator, on 12/13/18 at 5:00 PM, revealed it was their expectation medications be stored appropriately. Per interview, staff should follow the policies and procedures regarding medication storage. Continued interview revealed there should never be a time medications were left unattended. Further interview revealed there could be a possible negative outcome if a resident consumed the medication that was left on top of the medication cart.

Based on observation, interview, record review, and review of facility policy, it was determined the facility failed to ensure each resident receives adequate supervision to prevent accidents for one (1) of five (5) residents sampled residents reviewed for falls out of a total sample of twenty-nine (29) residents (Resident #72). Resident #72's Minimum Data Set (MDS) Assessment, dated 11/06/18, revealed the resident required assist of two (2) staff for transfers; and the resident's Comprehensive Care Plan had an intervention for two (2) persons for transfer. However on 12/10/18, the resident was transferred with the assist of one (1) staff and sustained a fall. The findings include: Review of the facility's Fall and Accident Management Policy, dated 05/2016 revealed the facility will identify patients at risk of falls and other accidents. Further review revealed interventions will be implemented and evaluated to reduce the risk of injuries, falls or other accidents. Review of Resident #72's medical record revealed the facility admitted the resident on 11/17/16 with [DIAGNOSES REDACTED]. Review of Resident #72's Annual Minimum Data Set (MDS) Assessment, dated 11/06/18, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15) indicating the resident was cognitively intact. Further review of the MDS Assessment, revealed the facility assessed the resident as requiring two (2) person physical assistance for transfers to and from: bed, chair, wheelchair, and standing position. Review of Resident #72's Comprehensive Care Plan, undated, revealed the resident had an Activities of Daily Living (ADL) self-care performance deficit related to Impaired Mobility, [MEDICAL CONDITION], and [MEDICAL CONDITION]. The goal stated the resident would maintain current level of function with ADLs through the review date. The interventions listed included: extensive assistance times two (2) staff for bed mobility and extensive assistance times two (2) staff for all transfers. Review of Resident #72's Nurse's Notes, dated 12/10/18 at 5:56 AM, revealed the resident was being transferred to the wheelchair by a State Registered Nurse Aide (SRNA), when the resident had to be lowered to the floor. According to the Note, the resident had no injuries from the fall. Review of the Interdisciplinary Team Follow Up Note, dated 12/10/18, revealed a Nurse Aide was attempting to transfer Resident #72 from the bed to the wheelchair, when the resident's leg caught underneath him/her and the resident started to fall. Per the Note, the resident was lowered to the ground. Further review revealed staff was to utilize assist times two (2) (staff) with all transfers. Interview with Resident #72, on 12/13/18 at 11:00 AM, revealed in the past he/she had always been transferred by two (2) staff. Further interview revealed on the morning of 12/10/18, he/she was being transferred to the wheelchair by only one (1) SRNA, when he/she had to be lowered to the floor. The State Agency Representative attempted a phone interview on 12/13/18 at 2:00 PM, with with SRNA #8, who was the SRNA who transferred the resident independently on 12/10/18. A message was left to return the call; however, the SRNA did not return the call. Interview with the Director of Nursing (DON) and the Administrator, on 12/13/18 at 5:00 PM, revealed in investigating the root cause of Resident #72's fall, it was identified the resident would tell staff when he/she required the assistance of two (2) persons, and the resident would let staff know when he/she was too weak to transfer with just one (1) person. Per interview, the resident was transferred with the assist of one (1) staff on 12/10/18 and sustained a fall. Continued interview revealed staff were to follow the Care Plans related to transfers.

Based on observation, interview, record review, and review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, dated (MONTH) (YEAR), it was determined the facility failed to ensure services were provided as outlined in the Comprehensive Care Plan for one (1) of twenty-nine (29) sampled residents (Resident #72). Resident #72's Comprehensive Care Plan had an intervention for two (2) to assist with transfers; however, on 12/10/18, one (1) staff member assisted the resident to transfer, and the resident sustained [REDACTED]. The findings include: Review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, dated (MONTH) (YEAR), revealed the Comprehensive Care Plan is an interdisciplinary communication tool and must include measurable objectives and time frames and must describe the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Further review revealed the services provided or arranged must be consistent with each resident's written Plan of Care. Review of Resident #72's medical record revealed the facility admitted the resident on 11/17/16 with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) Assessment, dated 11/06/18, revealed the facility assessed Resident #72 as having a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15) indicating the resident was cognitively intact. Additional review of the MDS Assessment, revealed the facility assessed the resident as requiring two (2) person physical assistance for transfers to and from: bed, chair, wheelchair, and standing position. Review of Resident #72's Care Assessment Area (CAA), dated 11/06/18, revealed the resident had balance problems during transitions and had a prior history of falls. Further review revealed Resident #72's had a [DIAGNOSES REDACTED]. Review of the Comprehensive Care Plan, undated, revealed Resident #72 had an Activities of Daily Living (ADL) self-care performance deficit related to Impaired Mobility, [MEDICAL CONDITION], and [MEDICAL CONDITION]. The goal revealed the resident would maintain current level of function with ADLs through the review date. The interventions included: extensive assistance times two (2) staff for bed mobility and extensive assistance times two (2) staff for all transfers. Review of the Nurse's Notes, dated 12/10/18 at 5:56 AM, revealed Resident #72's was being transferred to the wheelchair by a State Registered Nurse Aide (SRNA), when the resident had to be lowered to the floor. Further review of the Note, revealed the resident had no injuries from the fall. Review of the Interdisciplinary Team Follow Up Note, dated 12/10/18, revealed a Nurse Aide was attempting to transfer Resident #72 from the bed to the wheelchair, when the resident's leg got caught underneath him/her and the resident started to fall. Per the Note, Resident #72 was lowered to the ground. Continued review revealed staff was to utilize assist times two (2) (staff) with all transfers. Interview with Resident #72, on 12/13/18 at 11:00 AM, revealed in the past he/she had always been transferred by two (2) staff members. Further interview revealed on the morning of 12/10/18, he/she was being transferred to the wheelchair by only one (1) SRNA, when he/she started to fall and had to be lowered to the floor. The State Agency Representative attempted a phone interview on 12/13/18 at 2:00 PM, with with SRNA #8, who was the SRNA who transferred Resident #72 independently on 12/10/18. Although a message was left to return the call; the SRNA did not return the call. Interview with the Director of Nursing (DON) and the Administrator, on 12/13/18 at 5:00 PM, revealed they investigated the root cause of Resident #72's fall, and identified the resident would tell staff when he/she required the assistance of two (2) persons, and the resident would let staff know when he/she was too weak to transfer with just one (1) person. Further interview revealed Resident #72 was transferred with the assist of one (1) staff on 12/10/18 and sustained a fall. Additional interview revealed it was important staff followed the care plan to help ensure patient safety.

Based on observation, interview and record review, it was determined the facility failed to ensure staff involved in the care and management of the residents with urinary catheters, followed current accepted infection control standards of practice for one (1) of twenty-four (24) sampled residents, Resident #10. Observations on 10/31/17 revealed Resident #10's catheter bag and tubing to be on the floor for over an hour as staff members were observed walking up and down the unit hallway. The findings include: Review of the facility's policy, Standard Precautions revised 5/15 revealed Resident care equipment, such as catheters, should be handled in a manner that prevents skin and mucous membrane exposures, contamination of clothing, and transfer of microorganisms to residents and environments. Record review revealed the facility admitted Resident #10 on 10/28/17 with [DIAGNOSES REDACTED]. Further record review revealed a urinary catheter was placed on 10/28/17 for the [DIAGNOSES REDACTED].e. infection, trauma, obstruction, pain) through review date of 01/26/18 and interventions which included Catheter Care every shift and as needed, and keep catheter bag and tubing off the floor. Observation on 10/31/17 at 11:00 AM revealed Resident #10 was sitting in a recliner in his/her room with a urinary catheter tubing coming out of the pant leg from left leg, going under right leg. Further observation revealed the catheter bag was under the resident's right leg and hanging off the foot end of the recliner not secured. Urine was observed in the bag to be dark gold in color with sediment noted in bag. Observation on 10/31/17 at 11:30 AM revealed Resident #10 sitting in the recliner in room, catheter tubing coming out or pant leg from left leg going under right leg, catheter bag under right leg and hanging off the foot end of the recliner and the tubing was much closer to touching the floor. Observation on 10/31/17 from 11:45 AM to 11:50 AM revealed Resident #10 was sitting in the recliner in room, catheter tubing coming out or pant leg from left leg going under right leg, catheter bag under right leg and hanging off the foot end of the recliner and the tubing was touching the floor. Observation on 10/31/17 from 12:15 PM until 12:35 PM revealed Resident #10 was sitting in the recliner in room, catheter tubing coming out or pant leg from left leg going under right leg, catheter bag under right leg and hanging off foot end of the recliner and the tubing and bag was touching the floor. Observation on 10/31/17 at 12:50 PM revealed Resident #10 was sitting in the recliner in room, catheter tubing coming out or pant leg from left leg going under right leg, catheter bag under right leg and hanging off foot end of the recliner and touching the floor. Further observation revealed the Director of Nursing (DON) entered the room and picked the catheter bag up from floor and secured it to the pocket of the recliner on the left side of the recliner. Interview with the Director of Nursing (DON) on 10/31/17 at 12:55 PM, revealed the facility policy was for the urinary catheter to be below the bladder but not to be on the floor and not to be hanging in a manner that would cause tension on the catheter. She further stated the catheter bag nor tubing should not be on the floor for infection control. Further interview with the DON on 11/02/17 at 2:00 PM revealed it would be her expectation for staff to follow care plan regarding keeping catheter bags and tubing off the floor related to infection control issues. Interview with Assistant Director of Nursing (ADON), who was also in charge of the Infection Control Program for facility, on 11/02/17 at 2:00 PM revealed she had been employed by the facility for sixteen years. Further interview revealed it would be her expectation that staff would follow policy and not have catheter bags on floor so that germs could not enter the system or cause a different infection. She also stated staff was given inservices at orientation and periodically on infection control and catheter care and it would be her expectation for staff to follow procedure regarding catheters for the well being of the residents. Interview with the Administrator 11/02/17 at 3:00 PM, revealed it would be her expectation for staff to follow the care plan in regards to catheter care, keeping the catheter bag and tubing off the floor for infection control, to prevent infection to the resident or prevent the spread of infection.

Based observations, interview and record review, it was determined the facility failed to ensure a resident with a urinary catheter received the appropriate care and services to prevent infections to the extent possible by keeping the catheter anchored to prevent excessive tension on the catheter, which could lead to urethral tears or dislodging of the catheter, and securing the catheter to facilitate the flow of the catheter for one (1) of twenty-four (24) sampled residents, Resident #10. Observations on 10/31/17 revealed the resident's urinary catheter tubing was not secured to Resident #10's leg and the catheter bag and tubing were on the floor. The findings include: Review of the facility policy, Urinary Catheter Care revised 11/12, revealed tubing should be secured to the resident's leg to prevent tugging/pulling, the tubing should be frequently visualized to ensure proper placement and drainage. Record review revealed the facility admitted Resident #10 on 10/28/17 and a urinary catheter was placed on 10/29/174 for the [DIAGNOSES REDACTED].), Licensed Practical Nurses (LPN), and Registered Nurses (RN). Observation on 10/31/17 at 11:00 AM revealed Resident #10 was sitting in a recliner in his/her room with a urinary catheter tubing coming out of the pant leg from left leg, going under right leg. Further observation revealed the catheter bag was under the resident's right leg and hanging off the foot end of the recliner not secured. Urine was observed in the bag to be dark gold in color with sediment noted in bag. Observation on 10/31/17 at 11:30 AM revealed Resident #10 sitting in the recliner in room, catheter tubing coming out or pant leg from left leg going under right leg, catheter bag under right leg and hanging off the foot end of the recliner and the tubing was much closer to touching the floor. Observation on 10/31/17 from 11:45 AM to 11:50 AM revealed Resident #10 was sitting in the recliner in room, catheter tubing coming out or pant leg from left leg going under right leg, catheter bag under right leg and hanging off the foot end of the recliner and the tubing was touching the floor. Observation on 10/31/17 from 12:15 PM until 12:35 PM revealed Resident #10 was sitting in the recliner in room, catheter tubing coming out or pant leg from left leg going under right leg, catheter bag under right leg and hanging off foot end of the recliner and the tubing and bag was touching the floor. Observation on 10/31/17 at 12:50 PM revealed Resident #10 was sitting in the recliner in room, catheter tubing coming out or pant leg from left leg going under right leg, catheter bag under right leg and hanging off foot end of the recliner and touching the floor. Further observation revealed the Director of Nursing (DON) entered the room and picked the catheter bag up from floor and secured it to the pocket of the recliner on the left side of the recliner. Further observation revealed the catheter tubing was not secured to the resident's leg. Interview with the Director of Nursing (DON) on 10/31/17 at 12:55 PM, revealed she had been employed by the facility for twenty-three (23) years and stated the facility policy was for the catheter to be below the bladder but not to be on the floor and not to be hanging in a manner that would cause tension on the catheter. She further stated it should not be on the floor for infection control and not hanging in a way to cause tension so as not to pull out or harm the resident. Continued interview revealed the facility used stat locks or leg straps to secure the catheter to the resident's leg. The DON stated she was not sure if it was policy to secure the urinary catheter tubing to resident's leg or just good practice. Interview with RN #1 on 10/31/17 at 2:00 PM revealed she had been employed by the facility for fifteen (15) years. Further interview revealed the resident had been admitted on [DATE] and needed the urinary catheter related to [MEDICAL CONDITION]. Continued interview revealed she had been told by the DON that Resident #10 needed a stat lock put on to secure his/her catheter tubing to the leg. She stated there was not an order for [REDACTED]. Interview with Resident #10 on 11/02/17 at 1:00 PM revealed he/she had never asked the facility to not secure his/her catheter tubing to his/her leg with a leg strap or stat lock and he/she did not remember ever having one before the afternoon of 10/31/17. He/She stated, I depend on the staff to know how to take care of me and know what they are doing and how to take care of the catheter. Interview with SRNA #1, on 11/01/17 at 10:00 AM, revealed she had been employed by the facility for five (5) years. She further stated she knew urinary catheters were never supposed to be stored on the ground; however, sometimes they fell but she knew it was her responsibility to monitor her residents to make sure they were secured properly and attached in a manner to make sure they did not fall on the ground or hang in a way to cause undue tension on the resident. Continued interview revealed she did check to make sure catheters were secured to the resident's legs normally when she was getting the resident dressed; however, she did not check to see if Resident #10 had a stat lock or leg band on to secure the catheter tubing when getting the resident dressed on 10/31/17 and was unsure if he/she has had one since the urinary catheter was put in on 10/29/17. Interview with the Assistant Director of Nursing (ADON), who was also in charge of the Infection Control Program for the facility, on 11/02/17 at 2:00 PM revealed she had been employed by the facility for sixteen (16) years. Further interview revealed it would be her expectation that staff would follow policy and not have urinary catheter bags and tubing on floor so that germs could not enter the system or cause an infection. She also stated staff was given inservice training at orientation and periodically on infection control and urinary catheter care and it would be her expectation for staff to follow procedure regarding catheters for the wellbeing of the residents. Interview with the Administrator, on 11/02/17 at 3:00 PM revealed she had been employed with the facility for three (3) years. Continued interview revealed it would be her expectation for staff to follow the care plan in regards to catheter care, keeping the catheter bag and tubing off the floor for infection control, to prevent infection to the resident or prevent the spread of infection. She stated it would be her expectation for staff to follow the policy regarding using a leg strap or stat lock to secure the catheter tubing to the resident's leg to prevent harm to the resident, to prevent the catheter from being pulled out or tugging on the resident. She further stated it was important for the care plan to be followed because everyone was different and their needs were different and the care plan strives towards providing resident centered care to take care of the residents.

Based on observation, interview and record review, it was determined the facility failed to provide or arrange services as outlined by the comprehensive care plan, for one (1) of twenty-four (24) residents, Resident #10. Observation of Resident #10 on 10/31/17 revealed the urinary catheter was not secured to the resident's leg and record review of the resident's care plan revealed Staff LPN, RN were to be educated on possible tugging/tension, pain, or injury that could result from not using leg strap, and encourage to use the leg strap. The findings include: Review of the facility's policy, Care Planning dated 10/17, revealed the facility will provide a resident centered care aiming to provide individualized Comprehensive/Interdisciplinary Care Plans for each resident. Review of the facility's policy, Urinary Catheter Care revised 11/12, revealed tubing should be secured to the resident's leg to prevent tugging/pulling, the tubing should be frequently visualized to ensure proper placement and drainage. Record review revealed the facility admitted Resident #10 on 10/28/17 and a catheter was placed on 10/28/17 for the [DIAGNOSES REDACTED].e. infection, trauma, obstruction, pain) through review date of 01/26/2018. Review of the interventions revealed and interventions for Catheter Care every shift and as needed; educate on possible tugging/tension, pain or injury that can result from not using leg strap and Encourage to use; and position catheter bag and tubing below the level of the bladder and off the floor with identified responsible employees SRNA, Licensed Practical Nurses, Registered Nurses. Observation on 10/31/17 at 11:00 AM revealed Resident #10 was sitting in a recliner in his/her room with a catheter tubing coming out of the pant leg from left leg, going under right leg. Further observation revealed the catheter bag was under the resident's right leg and hanging off the foot end of the recliner not secured. Urine was observed in the bag to be dark gold in color with sediment noted in bag. Observation on 10/31/17 at 11:30 AM revealed Resident #10 sitting in the recliner in room, catheter tubing coming out or pant leg from left leg going under right leg, catheter bag under right leg and hanging off the foot end of the recliner and the tubing was much closer to touching the floor. Observation on 10/31/17 from 11:45 AM to 11:50 AM revealed Resident #10 was sitting in the recliner in room, catheter tubing coming out or pant leg from left leg going under right leg, catheter bag under right leg and hanging off the foot end of the recliner and the tubing was touching the floor. Observation on 10/31/17 from 12:15 PM until 12:35 PM revealed Resident #10 was sitting in the recliner in room, catheter tubing coming out or pant leg from left leg going under right leg, catheter bag under right leg and hanging off foot end of the recliner and the tubing was touching the floor. Observation on 10/31/17 at 12:50 PM revealed Resident #10 was sitting in the recliner in room, catheter tubing coming out or pant leg from left leg going under right leg, catheter bag under right leg and hanging off foot end of the recliner and touching the floor. Further observation revealed the Director of Nursing (DON) entered the room and picked the catheter bag up from floor and secured it to the pocket of the recliner on the left side of the recliner. Further observation revealed the catheter tubing was not secured to the resident's leg. Interview with the DON on 10/31/17 at 12:55 PM, revealed she had been employed by the facility for twenty-three (23) years and stated the facility policy was for the catheter to be below the bladder but not to be on the floor and not to be hanging in a manner that would cause tension on the catheter. She further stated it should not be on the floor for infection control and not hanging in a way to cause tension so as not to pull out or harm the resident. Continued interview revealed the facility used stat locks or leg straps to secure the catheter to the residents' legs. Further interview revealed the facility would need a physician order [REDACTED]. Interview with Resident #10 on 11/02/17 at 1:00 PM revealed he/she had never asked the facility not to secure his/her catheter tubing to his/her leg with a leg strap or stat lock and he/she did not remember ever having one before the afternoon of 10/31/17. He/She stated, I depend on the staff to know how to take care of me and know what they are doing and how to take care of the catheter. Interview with the DON on 11/02/17 at 2:00 PM revealed it would be her expectation for staff to follow care plans regarding keeping catheter bags and tubing off the floor related to infection control issues. She stated she would also expect staff to follow care plans related to securing catheter tubing, however stated use of stat lock for Resident #10 was not added until 10/31/17, but said that encourage to use leg strap was on the care plan from the 10/29/17 care plan. Interview with Registered Nurse (RN) #1 on 10/31/17 at 2:00 PM revealed she had been employed by the facility for for fifteen (15) years. Continued interview revealed she had been told by the DON the resident needed a stat lock put on to secure his/her catheter. Further interview revealed the resident had been admitted on [DATE] and needed the catheter related to [MEDICAL CONDITION]. She stated there was not an order for [REDACTED].#1 did state it was important to follow care plan as it was the guide on how to care for the resident. Interview with State registered Nursing Assistant (SRNA) #1 on 11/01/17 at 10:00 AM, revealed she had been employed by the facility for five (5) years. She further stated she knew urinary catheters bags were never supposed to be stored on the ground; however, sometimes they fell but she knew it was her responsibility to monitor her residents to make sure they were secured properly and attached in a manner to make sure they did not fall on the ground or hang in a way to cause undue tension on the resident. Continued interview revealed she does check to make sure catheter tubing is secured to the resident's leg, normally when she was getting the resident dressed; however, she did not check to see if resident #10 had a stat lock or leg band to secure the catheter tubing on him/her when getting the resident dressed on 10/31/17 and was unsure if she had one since the catheter was put in on 10/29/17. SRNA #1 stated it was important for follow the care plan which guided the care for each residents. Interview with Assistant Director of Nursing (ADON), who was also in charge of the Infection Control Program for the facility, on 11/02/17 at 2:00 PM revealed she had been employed by the facility for sixteen (16) years. Further interview revealed it would be her expectation that staff would follow policy and not have catheter bags on the floor so that germs could not enter the system or cause a different infection. She also stated staff was given inservices at orientation and periodically on infection control and catheter care and it would be her expectation for staff to follow procedure regarding catheters for the well being of the residents. Interview with the Administrator on 11/02/17 at 3:00 PM revealed she had been employed with the facility for three (3) years. Continued interview revealed it would be her expectation for staff to follow the care plan in regards to catheter care, keeping the catheter bag off the floor for infection control, to prevent infection to the resident or prevent the spread of infection. It would be her expectation for staff to follow the policy regarding using a leg strap or stat lock to secure the catheter tubing to the resident's leg to prevent harm to the resident, to prevent the catheter from being pulled out or tugging on the resident. She further stated it was important for the care plans to be followed because everyone was different and their needs were different and the care plan was developed to provide resident centered care to take care of the resident.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to investigate the root cause of falls and/or modify interventions when necessary to prevent resident falls for nine (9) of twenty-four (24) sampled residents (Resident # 1, #3, #5, #7, #9, #10, #11, #16, and #19). The findings include: Review of the facility Health Care Management/Fall Management Policy, revised 08/15, revealed the facility would identify residents at risk for falls and implement fall reduction interventions to reduce the risk of falls and possible injury to the resident. After a fall occurred the nurse was to assess a resident for injury, assess the surroundings for potential clues as to what happened, where the resident was headed, who witnessed the event and what the resident was able to communicate. Per the Policy, interventions for injury and prevention of further incidents were to be put into place. The nurse was to complete complete the documentation related to the fall occurrence. The residents care plan was to be updated with new interventions for the prevention of a fall. The interdisciplinary Team (IDT) Fall Team, which included nursing, therapy, activities, and ancillary staff reviewed the fall occurrences and monitored the effectiveness of interventions. The Policy stated, the IDT implemented changes in the interventions of the nursing care plan to meet the changing needs of the resident. The findings include: 1. Review of Resident #1's clinical record revealed the facility admitted the resident on 10/31/14, with [DIAGNOSES REDACTED]. Review of the Significant Change Minimum Data Set (MDS) Assessment, dated 08/02/15, revealed the facility assessed Resident #1 having both short and long term memory loss. Further review of the MDS, revealed the resident was assessed as requiring extensive assistance with bed mobility, transfers, and toileting. Review of Resident #1's Comprehensive Care Plan, dated 07/11/15, revealed the resident was at risk for falls related to side effects of medications, poor communication/comprehension, unaware of safety needs, incontinence, confusion, gait/balance problems, impaired cognition, impaired hearing, impaired mobility, impaired vision, and new environment. The goal stated the resident's risk of falls/injuries would be reduced through the review date of 11/02/15. The interventions included; encourage resident to lye down in bed between meals, nurse to assess pain level at bedtime and offer pain medication if needed, offer snack before bed, do not leave resident in room unattended while up in wheelchair, assist with transfer/mobility/repositioning/toileting as needed. Further interventions included ensuring the wheel chair was locked and the bed was stable prior to transferring, keep floors free from spills and/or clutter, adequate, glare-free light, call light within reach and encourage resident to use while in room, bed in low position, side rails as ordered, frequently used items within reach, monitor for side effects of medications, notify clinician/responsible party with any falls or changes, obtain and monitor labs/diagnostic tests as ordered, report results to clinician and follow up as indicated, offer and encourage rest periods. Continued interventions included; update family on any items needed (i.e. different shoes), Dycem/Posey Grip to wheel chair, low bed, pain medication or Tylenol to decrease pain related restlessness, routine /scheduled toileting, wears glasses, reduce clutter on the floor in the resident room, ensure clear path to toilet, proper fitting clothes to decrease potential tripping hazard, bed in low position, bed set to proper height to allow resident to safely get in/out of bed, floor mats to bedside, Pharmacy consult to evaluate medications, resident education of functional limitations, resident rest breaks and put resident to bed when fatigued. Review of the Fall Occurrence Form and the Nurse's Progress Notes for Resident #1, revealed the resident had fallen eighteen (18) times between since June 2015; however, there was no documented evidence eleven (11)of the falls were investigated to determine the root cause and appropriate interventions. Review of the Fall Occurrence Report for Resident #1 revealed he/she sustained a fall on 06/04/15 at 11:15 PM and was found on the mat by the bed lying on his/her right side with no injuries noted. The resident stated I just slid out, as revealed on the Fall Occurrence Report. There was no documented evidence a root cause analysis had been documented on the Fall Occurrence Report to reflect the reason for the fall. A new intervention for a bed and chair alarm was to be initiated as stated under the area marked new interventions on the Fall Occurrence Report. Review of the Interdisciplinary Team (IDT) Meeting Notes, dated 06/11/15, revealed all interventions were in place and were being used, resident still remains on Low Air Loss (LAL) mattress related to wounds on foot. Once wounds heal LAL will be removed, but team is inquiring about getting resident a lheal mattress (manufacturer name of mattress to assist in wound healing) However, there was no documented evidence the interventions for the bed and chair alarm or interventions to remove the LAL mattress once the resident's wound healed was added to the resident's Comprehensive Care Plan in order to prevent further falls. Review of the Fall Occurrence Report for Resident #1 revealed the resident had a fall on 06/15/15 at 03:30 PM, the resident was yelling for help, and the resident was found on the floor by the bed lying on his/her buttocks. Further review, revealed the resident was trying to take off his/her shorts and boots with no injuries noted. The Falls Occurrence Form stated, under the section marked new interventions, switch air mattress out for Iheal mattress. Review of the Interdisciplinary Team (IDT) Meeting Notes, dated 06/18/15, revealed new interventions placed after the fall included; mattress switched out to Iheal mattress. However, there was no documented evidence this intervention to prevent falls was transcribed to the resident's Comprehensive Care Plan in order to prevent further falls. Review of the Fall Occurrence Form for Resident #1 revealed the resident sustained [REDACTED]. Further review revealed the resident was on the floor beside the bed and verbalized I don't know when asked about the fall occurrence. The Form stated, no injuries noted. There was no documented evidence a root cause analysis had been documented on the Fall Occurrence Form to reflect the reason for the fall. A new intervention of changing bed to IHeal was revealed on the fall occurrence report. Review of the IDT Meeting Notes, dated 06/18/15 revealed all interventions were in place and were being used. Bed alarm in place. However, there was no documented evidence of interventions for the IHeal mattress or the bed alarm on the residents' Comprehensive Care Plan in order to prevent further falls. Review of the Fall Occurrence Form revealed Resident #1 had a fall on 07/08/15 at 12:05 AM. Per the Form, the resident was found lying on his/her right side, beside the bed with no injury noted. Further review, revealed the resident had increased anxiety related to a upper respiratory infection (URI) diagnosis. Per the Form, the resident stated, I wasn't doing anything. There was no documented evidence a root cause analysis had been documented on the Fall Occurrence Form to reflect the reason for the fall. A new intervention of initiating a turn schedule for this resident was documented on the Form. Review of the Interdisciplinary Team (IDT) Meeting Notes, dated 07/09/15 revealed the new interventions included low air loss mattress discontinued prior to fall and turn every two (2) hour schedule. However review of the resident's Comprehensive Care Plan revealed the CNCP was not revised to include this intervention for the turning schedule in order to prevent falls. Review of the Fall Occurrence Form revealed Resident #1 had a fall on 07/20/15 at 08:45 AM. The Form revealed the resident was found sitting on the floor mat next to the right side of the bed and stated he/she was trying to get up, when asked by staff why he/she fell . Per the Form, no injuries were noted. However, there was no evidence a root cause analysis had been documented on the Fall Occurrence Form to reflect the reason for the fall. In addition, there was no IDT meeting documented as being held after the resident's fall on 07/20/15, in order for the facility to discuss the fall and further investigate the need for further fall interventions to be added to the Care Plan. Review of the Fall Occurrence Form, revealed Resident #1 had a fall on 07/20/15 at 11:15 PM. Further review, revealed a staff member answered the call light and found the resident on his/her right side on the floor mat next to his/her bed and the resident was unable to give a statement due to confusion. Per the Form, no injuries were noted. However, there was no documented evidence a root cause analysis had been documented on the Fall Occurrence Form to reflect the reason for the fall. The new intervention was documented on the Fall Occurrence Form for staff to frequently reposition the resident in the chair/bed to decrease fatigue. Review of the Interdisciplinary Team (IDT) Meeting Notes, dated 07/23/15 revealed revealed all interventions were in place, and will continue to monitor and update interventions as needed. There was no documented evidence the interventions to frequently reposition the resident in the chair/bed to decrease fatigue was added to the resident's Comprehensive Care Plan in order to prevent further falls. Review of the Fall Occurrence Report dated 07/27/15 at 04:45 PM, revealed Resident #1 was found lying on the floor to the left side of the wheelchair and stated he/she did not know the reason for the fall occurrence, no injuries noted. There was no documented evidence a root cause analysis had been documented on the Fall Occurrence Form to reflect the reason for the fall. A new intervention of personalizing the resident's room to provide familiar surroundings to decrease anxiety was documented on the Form. However, there was no documented evidence of a IDT meeting for the residents' fall on 07/27/15 in order for the fall to be discussed and fully investigated as per policy. In addition, there was no documented evidence the resident's Comprehensive Care Plan was revised with this new intervention. Review of the Fall Occurrence Form, revealed Resident #1 had a fall on 08/14/15 at 03:25 PM, and was found on the floor mat on his/her buttocks beside the bed with no injuries noted. Per the Form, the resident had an acute illness. New interventions of frequently repositioning the resident in the chair/bed to decrease fatigue and reducing anxiety by providing diversion through comfort (snacks, music, weighted blanket, soft object) was documented on the Form. However, there was no documented evidence these interventions were added to the resident's Comprehensive Care Plan in order to prevent further falls. In addition, there was no documented evidence of a IDT meeting for the residents' fall on 08/14/15 at 03:25 PM as per policy. Review of the Nurse's Progress Notes, dated 08/22/15 at 12:20 AM, revealed Resident #1 sustained a fall. Further review revealed staff was called to the resident's room by an aide on the hall, and upon entering the room the resident was sitting upright on his/her buttocks on a fall mat with no injuries documented. There was no documented evidence of a Falls Occurrence Form or investigation to find the root cause for this fall. In addition, there was no documented evidence the IDT met to discuss this fall and no documented evidence of new interventions to prevent further falls. Review of Nurse's Progress Notes dated 08/26/15 at 03:30 AM, revealed Resident #1 was on the floor mat on his/her right side, with legs outstretched, and his/her back against the bed with no injuries documented. The Note stated, a new intervention of initiating a toileting program would be initiated. However, the resident's Comprehensive Nursing Care Plan, revealed an intervention of routine/scheduled toileting. The Care Plan was not revised with additional interventions on initiating a toileting program. In addition, there was no documented evidence of a Fall Occurrence Form or fall investigation in order to find the root cause of the fall. Also, there was no documented evidence of a IDT Meeting to discuss this fall as per policy. Review of the Nurse's Progress Notes, dated 09/03/15 at 06:45 PM, revealed Resident #1 was found sitting on his/her buttocks on the floor with his/her left arm resting on top of the mattress. He/she was facing the head of the bed. Further review revealed the a staff member stated he/she had just been propelling self down the hallway towards the window at the end of the hallway, and earlier he/she was wanting the curtains closed in his/her room. Further review revealed there was no injuries noted. There was no documented evidence of a Fall Occurrence Form or fall investigation in order to find the root cause of the fall. Also, there was no documented evidence of a IDT Meeting to discuss this fall as per policy and no documented evidence of new interventions added to the Comprehensive Care Plan to prevent further falls. Review of the Nurse's Progress Notes dated 09/08/15 at 07:50 PM, revealed Resident #1 was found on his/her buttocks on the floor at the bedside with his/her right arm resting on the low bed mattress, facing the foot of the bed. Continued review revealed there was no injuries documented and the new intervention was for staff to encourage the resident to use turning pillows to assist in prevention of rolling out of the bed to assist with a stop. There was no documented evidence of a Fall Occurrence Form or fall investigation in order to find the root cause of the fall. Also, there was no documented evidence of a IDT Meeting to discuss this fall as per policy and no documented evidence of new interventions added to the Comprehensive Care Plan to prevent further falls. Review of the Nurse's Progress Notes, dated 09/12/15 at 06:21 PM, revealed Resident #1 was found sitting on his/her buttocks on the floor mat to the left of the bed facing the window, with his/her legs folded out towards the register. There was no injuries documented. Further review of the Notes, revealed, staff were to be educated to be aware of the resident's needs and were to do more frequent checks. A Note dated 9/17/15, labelled un-witnessed, revealed there was an IDT meeting on 9/17/15 regarding the resident's fall that occurred on 9/12/15. However, there was no further information related to the IDT Meeting and what was discussed. There was no documented evidence of a Fall Occurrence Form or fall investigation in order to find the root cause of the fall. Also, there was no documented evidence of new interventions added to the Comprehensive Care Plan to prevent further falls. 2. Review of Resident #7's medical record, revealed the facility admitted the resident on 11/25/14, with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) Assessment, dated 12/07/14, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) of fifteen (15) out of fifteen (15), indicating the resident was cognitively intact. Per the MDS, the facility further assessed the resident as having no prior history of falls before admission. Continued review of the MDS, revealed the facility assessed Resident #7 as requiring assist of one (1) staff for transfers, ambulation, mobility and toilet use. Review of the Quarterly MDS Assessment, dated 08/26/15, revealed the facility assessed the resident as having a BIMS of a thirteen (13) out of fifteen (15), indicating the resident had moderate cognitive impairment. Further review of the MDS, revealed the facility assessed the resident as requiring the assist of two (2) staff for transfers and toilet use. Review of the Comprehensive Care Plan, dated 11/25/14, revealed Resident #7 was at risk for falls related to medication side effects, incontinence, gait, balance problems, impaired mobility and being in a new environment. The goal stated the resident's risk of falls/injuries would be reduced. Further review, revealed the interventions included; encourage the resident to stay out of his/her room when up in the wheel chair/Broda chair, the resident was not to be left alone unattended in the room while in the wheel chair/Broda chair, the resident was to be assisted back to bed after meals, a stop sign was to be placed in the resident's doorway to prevent others from entering the room, the resident was to be assisted to the Broda chair; however, if anxious, going to beauty shop or leaving the facility, the resident was to be in a wheel chair, wheel chair in the posterior tilt position, assist with transfers/mobility/repositioning/toileting, floors were to be free from spills and/or clutter; adequate and glare free lighting, call bell within reach and staff were to encourage the resident to use the call bell, side rails as ordered, frequently used items within reach, monitor blood pressure with any complaint of dizziness or loss of balance, monitor for side effects of medications, obtain and monitor labs and diagnostic tests as ordered and report results to the clinician and responsible party, use assistive devices to transfer and ambulate as needed, administer pain medications as needed and prescribed, pain medication to be administered more routinely to promote decreased pain and restlessness, proper footwear in place to allow stability when standing, anti-rollback device to the wheel chair, rest breaks when fatigued, a reacher, proper fitting clothes to decrease potential of tripping hazard, reposition the resident in the chair/bed to decrease fatigue, bed to proper height, floor mats to the bedside, a bed/chair alarm, pharmacy consult and Physical Therapy/Occupational Therapy to evaluation and treat as ordered to promote improved stability. Review of the Fall Occurrence Form and the Nurse's Progress Notes for Resident #7, revealed the resident had fallen twenty-six (26) times between December 2014 and September 2015; however, there was no documented evidence five (5) of the falls were investigated to determine the root cause and appropriate interventions. Additionally, review of two (2) investigation revealed, the new interventions documented to be implemented as a result of the fall, should have been implemented prior to the fall. Review of Resident #7's Nurse's Progress Note, dated 01/10/15 at 11:15 AM, revealed visitors notified the nurse, Resident #7 was leaning in the trash can with his/her alarm sounding. Resident #7 was found by the nurse with his/her head in the trash can and was leaning on his/her knees. The chair alarm was sounding. Resident #7 was assessed with [REDACTED]. Per the Nurse's Note, the fall was possibly caused by a Urinary Tract Infection from one month previous; however, there was no documented evidence a fall investigation was conducted to determine the root cause and appropriate interventions. Review of a Nurse's Progress Note, dated 01/20/15 at 4:24 PM revealed Resident #7 was lying on the floor face down and curled up between the hallway and the resident's room. Resident #7 was assessed and no injuries were noted. Per the Nurse's Note, the fall was possibly caused by the Urinary Tract Infection from the previous month; however, there was no documented evidence a fall investigation was conducted to determine the root cause and appropriate interventions. Review of a Nurse's Progress Note, dated 04/20/15 at 6:26 PM, revealed Resident #7 was observed to fall in the dining room trying to reach for cookies at another table. Resident #7 was assessed and no injuries were noted. The Physician and family were notified. Per the Note, no new interventions were implemented; however, there was no documented evidence a fall investigation was conducted to determine the root cause and appropriate interventions. Review of Nurse's Progress Note, dated 08/31/15 at 6:24 PM, revealed Resident #7 was found in the shower room on the 2100 hallway sitting up next to the shower stall in front of his/her Broda Chair. Resident #7 was assessed and no injuries were noted. However, there was no documented evidence the facility conducted a fall investigation to determine the root cause or appropriate interventions. Review of a Nurse's Progress Note, dated 09/20/15 at 6:59 PM, revealed Resident #7 was found sitting in the doorway of the 2100 hall rest room. The wheel chair was located inside the rest room and the door was open. Resident #7 was found lying on his/her right side. The resident was assessed with [REDACTED]. Review of the Fall Occurrence Form, dated 07/05/15 at 4:30 PM, revealed Resident #7 was found on the floor beside the bed on his/her buttocks. Interventions in place were regular schedule toileting, bed lowest position, floor mats, reacher, pain medication to decrease restlessness, routine rest breaks, and personalized room to provide familiar surroundings to decrease anxiety. Resident #7 was assessed and no injuries were noted. Further review of the Fall Occurrence Form, revealed a new intervention for the pain medication Tylenol to be administered more routinely to promote decreased pain and restlessness; however, review of the Comprehensive Care Plan revealed, this was an intervention that was already initiated and should have been implemented on 11/25/14. Review of the Fall Occurrence Form, dated 07/31/15 at 04:30 AM, revealed Resident #7 reported to the nurse's station and stated he/she had fallen in his/her room. The resident reported he/she fell to his/her knees at the foot of the bed and waited until he/she got some strength back to get up. Resident #7 was trying to get his/her glasses on the nightstand when his/her legs gave out. The resident was assessed and no injuries were noted. Interventions in place prior to the fall were the bed in the lowest position, and non-skid rugs. Per the occurrence form, a new intervention was implemented as routine toileting; however, review of the Comprehensive Care Plan, this intervention was initiated and implemented on 11/25/14. Interview on 10/08/15 at 11:10 AM with Certified Nursing Assistant (CNA) #5 revealed Resident #7 would fall and try to get up, but his/her legs were weak. CNA #5 stated, Resident #7 required checks more often when he/she was in his/her room. Interview on 10/08/15 at 11:20 AM, with CNA #4, revealed Resident #7 had limited insight and safety awareness into what he/she could do and Resident #7 would continue to exhibit behaviors even after being redirected. Interview on 10/08/15 at 11:05 AM, with Registered Nurse (RN) #3, revealed staff were doing all they could to assist Resident #7, interventions were in place and they did not know what new interventions could be implemented. 3. Review of the clinical record for Resident #3 revealed the facility admitted the resident on 12/01/14 with [DIAGNOSES REDACTED]. Review of the Significant Change Minimum Data Set (MDS) Assessment, dated 01/14/15, and the Quarterly MDS Assessment, dated 10/05/15, revealed the facility assessed Resident #3, as being severely cognitively impaired. In addition, review of both MDS Assessments, revealed the resident was assessed as requiring extensive assistance with transfers and bed mobility. Review of Resident #3's Comprehensive Plan of Care, dated 12/02/14, revealed the resident was at risk for falls related to poor communication/comprehension, a history of falls, incontinence, confusion, impaired cognition, and impaired balance. The goal stated the resident's risk of falls and injuries would be reduced. The interventions included; rest breaks, put resident to bed when fatigued, proper footwear, proper fitting clothes to decrease tripping hazards, reposition to decrease fatigue, anxiety reduction through diversion; snacks, music, weighted blanket, approach from the front to prevent from being startled, bed in low position, floor mats to bedside, and bed and chair alarm. Review of the Fall Occurrence Form and the Nurse's Progress Notes for Resident #3 fell three (3) times since May 2015; however, there was no documented evidence the three (3) falls were investigated to determine the root cause and appropriate interventions. Additionally, review of one (1) investigation revealed, the new interventions documented to be implemented as a result of the fall, should have been implemented prior to the fall. Review of the Fall Occurrence Form, revealed the resident sustained [REDACTED]. There was no documented evidence a root cause analysis had been documented on the Fall Occurrence Form to reflect the reason for the fall. The Falls Occurrence Report stated under the area marked new interventions, maintain current interventions. Review of the Interdisciplinary Team (IDT) Meeting Notes revealed the team met on 05/07/15 and new interventions placed after the fall included; walk resident and provide toileting assistance when anxious and offer medication as need for anxiousness and restlessness. However, there was no documented evidence the Care Plan was revised to include these interventions to prevent falls. Review of the Fall Occurrence Form, revealed the resident sustained [REDACTED]. There was no documented evidence a root cause analysis had been documented on the Fall Occurrence Form to reflect the reason for the fall. The Falls Occurrence Report stated under the area marked new interventions, rest breaks and anxiety reduction; however, review of the Care Plan revealed these interventions were added to the Care Plan on 12/02/14. Review of a Nurse's Progress Note, dated 10/04/15 at 4:56 AM, revealed on 10/04/15 at 3:15 AM, Resident #3's chair rolled out from under him/her and the resident fell to the floor. However, there was no documented evidence of the root cause of the fall. Continued review of the Note, revealed a new intervention for non skid socks at all times. However, there was no documented evidence the Care Plan was revised to include this intervention. Also, as of 10/08/15, there was no documented evidence the (IDT) met to review the cause of the fall to in order to prevent further falls with additional fall interventions. 4. Review of the clinical record for Resident #16 revealed the facility admitted the resident on 12/31/10 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 08/25/15, revealed the facility assessed Resident #16, as being moderately cognitively impaired. Further review of the MDS, revealed the facility assessed the resident as requiring extensive assistance with transfers and bed mobility. Review of Resident #16's Comprehensive Plan of Care, revised 09/15/14, revealed the resident was at risk for falls related to a history of falls, incontinence, Arthritis, impaired hearing and impaired mobility. The goal stated falls/injuries would be reduced. There was several interventions including; toilet right after each meal and offer toileting every two (2) hours, assist with transfers, mobility, repositioning, toileting as needed, and ensure the wheelchair was locked and the bed was stable before transferring. Review of the Fall Occurrence Form and the Nurse's Progress Notes for Resident 16 revealed the resident had fallen one (1) time in the past six (6) months; however, there was no documented evidence the falls was investigated to determine the root cause and appropriate interventions. Review of the Fall Occurrence Form, revealed the resident sustained [REDACTED]. However, there was no documented evidence the root cause of the fall was identified on the Falls Occurrence Report. Also, there was no documented evidence of new interventions to prevent further falls on the Falls Occurrence Report. Review of the IDT Meeting Notes dated 06/25/15, revealed new interventions to be put in place as a result of this fall, included encouraging and reminding the resident to utilize the call light and ask for assistance, and ensure the resident had proper foot wear before transferring. However, there was no documented evidence the Care Plan was revised to include these interventions to prevent further falls until 09/15/15, over two (2) months later. 5. Review of Resident # 5's medical record, revealed the facility admitted the resident on 2/13/14, with [DIAGNOSES REDACTED]. Further [DIAGNOSES REDACTED]. Review of Resident #5's Minimum Data Set (MDS) Assessment, dated 08/23/15, revealed the facility assessed the resident as having a Brief interview of Mental Status (BIMS of a fourteen (14) out of fifteen (15) indicating the resident was cognitively intact. Further review revealed the facility assessed the resident as requiring extensive assistance with one person to transfer. Review of Resident #5's Comprehensive Plan of Care, dated 09/22/14, revealed the resident was at risk for falls related to side effects of medications, poor communication/comprehension, history of falls, unaware of safety needs, incontinence, gait/balance problems, impaired cognition, and impaired mobility. The following interventions were initiated on 09/22/14; assist with transfers, mobility, repositioning, and toileting as needed, ensure the wheelchair was locked and bed was stable prior to transferring; keep floors free from spills and or clutter, adequate glare-free light, call light within reach and encourage resident to use call light while in room, bed in low position, side rails as ordered, frequently used items within reach; monitor blood pressure with any complaint of dizziness or loss of balance; monitor side effects of medications; notify Clinician/Responsible Party with any falls or changes, obtain and monitor labs/diagnostic tests as ordered and use assistive devices to transfer/ambulate as needed. On 08/20/15 an intervention for floor mats to bedside was initiated. Review of the Fall Occurrence Form for a fall which occurred on 08/14/15 at 5:30 AM, revealed the resident was found sitting on his/her buttocks on the floor next to the bed. Per the Form, the resident stated he/she woke up sitting on the floor on his/her buttocks, denied hitting his/her head, and denied pain. Per the Form a new nursing intervention for Posey grips to the side rails was documented; however, there was no documented evidence the intervention was documented on the Care Plan. Further review revealed the care plan was not updated until 08/20/15, six (6) days later, with the intervention for floor mats to the bedside to prevent further falls. Review of the Fall Occurrence Form, for a fall which occurred on 09/23/15 at 11:56 AM, revealed Resident #5

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to review and revise the Comprehensive Plans of Care after residents sustained falls for eight (8) out of twenty-four (24) sampled residents (Resident #1, #3, #5, #9, #10, #11, #16, and #19). The findings include: Review of the Care Spring (Highland Spring) Health Care management policy for Care Plans, dated 07/15, revealed it was the policy of the facility to provide Comprehensive/Interdisciplinary Care Plans for each resident. Continued review revealed, Care Plans were to be unique and patient specific. Per the policy, a Care Plan was developed to identify strengths or possible barriers to guide the resident in reaching their maximum functional level - while encompassing a holistic approach including medical, nursing, psycho-social, nutritional, activities, therapy, spiritual and educational intervention. Care Plans were updated following the Resident Assessment Instrument (RAI) manual. 1. Review of Resident #1's clinical record revealed the facility admitted the resident on 10/31/14, with [DIAGNOSES REDACTED]. Review of the Significant Change Minimum Data Set (MDS) Assessment, dated 08/02/15, revealed the facility assessed Resident #1 having both short and long term memory loss. Further review of the MDS, revealed the resident was assessed as requiring extensive of two (2) staff for bed mobility, transfers and toileting. Review of Resident #1's Comprehensive Plan of Care, dated 07/11/15, revealed the resident was at risk for falls related to side effects of medications, poor communication/comprehension, unaware of safety needs, incontinence, confusion, gait/balance problems, impaired cognition, impaired hearing, impaired mobility, impaired vision, and new environment. The goal stated Resident #1's risk of falls/injuries would be reduced through the review date of 11/02/15. There were several interventions including; encourage resident to lye down in bed between meals, nurse to assess pain level at bedtime and offer pain medication if needed, offer snack before bed, do not leave resident in room unattended while up in wheelchair, assist with transfer/mobility/repositioning/toileting as needed. Continued interventions included ensuring the wheel chair was locked and the bed was stable prior to transferring, keep floors free from spills and/or clutter, adequate, glare-free light, call light within reach and encourage resident to use while in room, bed in low position, side rails as ordered, frequently used items within reach, monitor for side effects of medications, notify clinician/responsible party with any falls or changes, obtain and monitor labs/diagnostic tests as ordered, report results to clinician and follow up as indicated, offer and encourage rest periods. Further interventions included; update family on any items needed (i.e. different shoes), Dycem/Posey Grip to wheel chair, low bed, pain medication or Tylenol to decrease pain related restlessness, routine /scheduled toileting, wears glasses, reduce clutter on the floor in the resident room, ensure clear path to toilet, proper fitting clothes to decrease potential tripping hazard, bed in low position, bed set to proper height to allow resident to safely get in/out of bed, floor mats to bedside, Pharmacy consult to evaluate medications, resident education of functional limitations, resident rest breaks and put resident to bed when fatigued. Review of the facility's Fall Occurrence Form and the Nurse's Progress Notes for Resident #1 revealed he/she sustained eighteen (18) falls since June 2015. Review of the Fall Occurrence Report for Resident #1 revealed the resident sustained [REDACTED]. Further review, revealed the resident stated I just slid out. There was no documented evidence of a root cause analysis documented on the Fall Occurrence Report to reflect the reason for the fall. A new intervention for a bed and chair alarm was to be initiated as stated under the area marked new interventions per the Fall Occurrence Report. Review of the Interdisciplinary Team (IDT) Meeting Notes, dated 06/11/15, revealed all interventions were in place and were being used, resident still remains on Low Air Loss (LAL) mattress related to wounds on foot. Once wounds heal LAL will be removed, but team is inquiring about getting resident a lheal mattress (manufacturer name of mattress to assist in wound healing) However, there was no documented evidence the Comprehensive Care Plan was revised with the interventions for the bed and chair alarm or interventions to remove the LAL mattress once the resident's wound healed. Review of the Fall Occurrence Report for Resident #1 revealed the resident sustained [REDACTED]. Further review, revealed Resident #1 was trying to take off his/her shorts and boots with no injuries noted. The Falls Occurrence Form revealed, under the section marked new interventions, switch air mattress out for Iheal mattress. Review of the Interdisciplinary Team (IDT) Meeting Notes, dated 06/18/15 revealed the new intervention placed after the fall was to switch the for a Iheal mattress. However, there was no documented evidence the Comprehensive Care Plan was revised related to this intervention. Review of the Fall Occurrence Form for Resident #1 revealed the resident fell on [DATE] at 05:00 PM. Further review revealed the resident was on the floor beside the bed and stated I don't know when asked about the fall occurrence. The Form stated, no injuries were noted. A new intervention to change the bed to an IHeal mattress was noted on the Form. Review of the IDT Meeting dated 06/18/15, revealed the team met and all interventions were in place and were being used including the bed alarm. However, there was no documented evidence the Comprehensive Care Plan was revised to included the interventions for the IHeal mattress or the bed alarm. Review of the Fall Occurrence Form revealed Resident #1 sustained a fall on 07/08/15 at 12:05 AM. Per the Form, the resident was found lying on his/her right side, beside the bed and no injuries were noted. Further review, revealed the resident had increased anxiety related to a upper respiratory infection (URI). Per the Form, the resident verbalized, I wasn't doing anything. Per the Form, there was a new intervention of initiating a turn schedule. Review of the Interdisciplinary Team (IDT) Meeting Notes, dated 07/09/15 revealed new interventions included low air loss mattress discontinued prior to fall and turn every two (2) hour schedule. However there was no documented evidence the Comprehensive Care Plan was revised to include the intervention for the turning schedule. Review of the Fall Occurrence Form revealed Resident #1 sustained a fall on 07/20/15 at 08:45 AM. The Form stated the resident was found sitting on the floor mat next to the right side of the bed and he/she was trying to get up, when asked by staff why he/she fell . Per the Form, the resident sustained [REDACTED]. Review of the Fall Occurrence Form revealed Resident #1 sustained a fall on 07/20/15 at 11:15 PM. Further review, revealed a staff member answered the call light and found the resident on his/her right side on the floor mat next to his/her bed and the resident was unable to give a statement due to confusion. Per the Form, the resident sustained [REDACTED]. However, there was no documented evidence the interventions to frequently reposition the resident in the chair/bed to decrease fatigue was added to the resident's Comprehensive Care Plan in order to prevent further falls. Review of the Fall Occurrence Report dated 07/27/15 at 04:45 PM, revealed Resident #1 was found lying on the floor to the left side of the wheelchair and the resident stated he/she did not know the reason for fall occurrence, no injuries noted for this fall occurrence. A new intervention of personalizing the resident's room to provide familiar surroundings to decrease anxiety was documented on the Form. However, there was no documented evidence the resident's Comprehensive Care Plan was revised with this new intervention. Review of the Fall Occurrence Form, revealed Resident #1 had a fall on 08/14/15 at 03:25 PM, and was found on the floor mat on his/her buttocks beside the his/her bed with no injuries noted. New interventions for frequently repositioning the resident in the chair/bed to decrease fatigue, and reducing anxiety by providing diversion through comfort (snacks, music, weighted blanket, soft object) was documented on the Form. However, there was no documented evidence the Comprehensive Care Plan was revised with these fall interventions. Review of the Nurses' Progress Notes, dated 08/22/15 at 12:20 AM, revealed Resident #1 sustained a fall, staff was called to the resident's room by an aide on the hall, and upon entering the room the resident was sitting upright on his/her buttocks on a fall mat with no injuries documented. There was no documented evidence of a Falls Occurrence Form or investigation and there was no documented evidence the Comprehensive Nursing Care Plan was revised with new interventions to prevent further falls. Review of Nurse's Progress Notes dated 08/26/15 at 03:30 AM, revealed Resident #1 was on the floor mat on his/her right side, with legs outstretched, with his/her back against the bed and no injuries were documented. The Note further stated, a new intervention of initiating a toileting program would be initiated. However, the Comprehensive Care Plan, revealed an intervention of routine/scheduled toileting. There was no documented evidence the Care Plan was revised with additional interventions on initiating a toileting program. Review of the Nurse's Progress Notes, dated 09/03/15 at 06:45 PM, revealed Resident #1 was found sitting on his/her buttocks on the floor with his/her left arm resting on top of the mattress. Per the note, the resident was facing the head of the bed. Further review revealed a staff member has seen the resident propelling self down the hallway towards the window at the end of the hallway, and earlier he/she was wanting the curtains closed in his/her room. Further review revealed Resident #1 had no injuries. There was no documented evidence of a Fall Occurrence Form or fall investigation no documented evidence the Comprehensive Care was revised to prevent further falls. Review of the Nurses' Progress Notes dated 09/08/15 at 07:50 PM, revealed Resident #1 was found on his/her buttocks on the floor at the bedside with his/her right arm resting on the low bed mattress, facing the foot of his/her bed. Further review revealed there was no injuries documented and the new intervention was for staff to encourage the resident to use turning pillows to assist in prevention of rolling out of the bed to assist with a stop. There was no documented evidence of a Fall Occurrence Form or fall investigation and no documented evidence the Comprehensive Care Plan was revised with new interventions to prevent further falls. Review of the Nurse's Progress Notes, dated 09/12/15 at 06:21 PM, revealed Resident #1 was found sitting on his/her buttocks on the floor mat to the left of the bed facing the window, with his/her legs folded out towards and there was no injuries documented. Further review of the Notes, revealed, staff were to be educated to be aware of Resident #1's needs and were to do more frequent checks. There was no documented evidence of a Fall Occurrence Form or fall investigation and no documented evidence the Comprehensive Care Plan was revised to prevent further falls. 2. Review of the medical record for Resident #3 revealed the facility admitted the resident on 12/01/14 with [DIAGNOSES REDACTED]. Review of the Significant Change Minimum Data Set (MDS) Assessment, dated 01/14/15, and the Quarterly MDS Assessment, dated 10/05/15, revealed the facility assessed Resident #3, as being severely cognitively impaired. In addition, review of both MDS's revealed the resident was assessed as requiring extensive assistance with transfers and bed mobility. Review of Resident #3's Comprehensive Care Plan, dated 12/02/14, revealed the resident was at risk for falls related to poor communication/comprehension, a history of falls, incontinence, confusion, impaired cognition, and impaired balance. The goal stated the resident's risk of falls and injuries would be reduced. There was several interventions including; rest breaks, assist resident to bed when fatigued, proper footwear, reposition to decrease fatigue, anxiety reduction through diversion; snacks music weighted blanket, approach from the front to prevent from being startled, bed in low position, floor mats to bedside, and bed and chair alarm. Review of the Fall Occurrence Form, revealed Resident #3 sustained a fall on 05/01/15 at 12:00 Noon, and was noted to be lying by his/her Broda chair in the living room with no injuries noted. There was no documented evidence a root cause analysis had been documented on the Fall Occurrence Form related to the reason for the fall, and under the section marked new interventions, the Form stated, maintain current interventions. Review of the Interdisciplinary Team (IDT) Meeting Notes, dated 05/07/15, revealed new interventions placed after the fall included; walk resident and provide toileting assistance when anxious and offer medication as need for anxiousness and restlessness. However, review of the Care Plan revealed there was no documented evidence of a revision to include these interventions. Review of the Fall Occurrence Form, revealed Resident #3 sustained a fall on 06/07/15 at 10:20 PM, and was observed by staff climbing over the Broda chair and landing on his/her knees with no injuries. There was no documented evidence a root cause analysis had been documented on the Fall Occurrence Form to reflect the reason for the fall. The Falls Occurrence Report stated under the area marked new interventions, rest breaks and anxiety reduction. However, review of the Care Plan revealed these were not new interventions and these interventions were added to the Care Plan on 12/02/14. Review of a Nurse's Progress Note, dated 10/04/15 at 4:56 AM, revealed on 10/04/15 at 3:15 AM, Resident #3's chair rolled out from under him/her and the resident fell to the floor. There was no documented evidence of the root cause of the fall in the Note. Further review of the Note, revealed a new intervention for the resident to wear non skid socks at all times. However, there was no documented evidence the Care Plan was revised to include this intervention. Also, as of 10/08/15, there was no documented evidence the (IDT) met to review the cause of the fall to in order to review for additional interventions needed to prevent falls and further update the Care Plan. 3. Review of the medical record for Resident #16 revealed the facility admitted the resident on 12/31/10 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 08/25/15, revealed the facility assessed the resident as moderately cognitively impaired. Further review of the MDS, revealed the facility assessed the resident as requiring extensive assistance with transfers and bed mobility. Review of Resident #16's Comprehensive Care Plan, revised 09/15/14, revealed the resident was at risk for falls related to having a history of falls, incontinence, Arthritis, impaired hearing and impaired mobility. The goal stated falls/injuries would be reduced. There was several interventions including; toilet right after each meal, offer toileting every two (2) hours, assist with transfers, mobility, repositioning, toileting as needed, and ensure wheelchair was locked and bed stable before transferring. Review of the Fall Occurrence Form, revealed Resident #16 sustained a fall on 06/19/15/ at 11:10 and was initially found on the floor in his/her room lying on her/her left side with no injuries. There was no documented evidence the root cause of this fall was identified on the Falls Occurrence Report. Additionally, there was no documented evidence of new interventions to prevent further falls on the Falls Occurrence Report. Review of the IDT Meeting Notes dated 06/25/15, revealed new interventions to be put in place as a result of the fall, included encouraging and reminding the resident to utilize the call light and ask for assistance, and ensuring the resident was wearing proper foot wear before transferring. However, there was no documented evidence the Care Plan was revised to include these interventions until 09/15/15, which was over two (2) months later. 4. Review of the medical record for Resident #19 revealed the facility admitted the resident on 05/01/14 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 08/25/15, revealed the facility assessed the resident as being moderately cognitively impaired. Further review, revealed the facility assessed Resident #19 as requiring extensive assistance with transfers and bed mobility. Review of the Comprehensive Care Plan dated 09/30/14, revealed Resident #19 was at risk for falls related to side effects of medication, incontinence, confusion, gait/balance problems, impaired mobility and [MEDICAL CONDITION]. The goal stated the resident's risk of falls and injuries would be reduced. There were several interventions including; non skid socks at all times when not wearing shoes, and assist with transfers, mobility, repositioning and toileting as needed. Review of the Fall Occurrence Form, revealed Resident #19 sustained a fall on 08/18/15 at Midnight and was found by the Aide sitting on the floor in his/her room with no injuries. Per the Form, Resident #19 said he/she was attempting to go to the bathroom; however, there was no documented evidenced on the Form related to new interventions to prevent further falls. Review of the IDT Meeting Notes, dated 08/20/15, revealed new orders were noted for Physical Therapy to evaluate the resident three (3) to five (5) times weekly for therapeutic exercise and gait training. However, there was no documented evidence the Care Plan was revised with this new intervention. 5. Review of Resident #5's medical record revealed the facility admitted the resident on 02/13/14 with [DIAGNOSES REDACTED]. Review of Resident #5's Minimum Data Set (MDS) Assessment, dated 08/23/15, revealed he/she scored a fourteen (14) out of fifteen (15) on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. Continued review revealed, Resident #5 required extensive assistance of one (1) staff to transfer. Review of Resident #5's Comprehensive Plan of Care, initiated 09/22/14, revealed the resident was at risk for falls related to side effects of medications, poor communication/comprehension, history of falls, unaware of safety needs, incontinence, gait/balance problems, impaired cognition, and impaired mobility. Continued review of the Comprehensive Care Plan revealed, interventions were initiated on 09/22/14 to include: staff to assist with transfers, mobility, repositioning, and toileting as needed; ensure wheelchair was locked and bed was stable prior to transferring; keep floors free from spills and or clutter; adequate and glare-free light; call light within reach and encourage the resident to use the call light while in room; bed in the low position, side rails as ordered, frequently used items within reach; monitor blood pressure with any complaint of dizziness or loss of balance; monitor side effects of medications; notify Clinician/Responsible party with any falls or changes; obtain and monitor labs/diagnostic tests as ordered with results reported to the clinician and follow up as indicated; offer and encourage rest periods; update family on any items needed, use assistive devices to transfer/ambulate as needed. Further review revealed, on 08/20/15 an intervention of floor mats to the resident's bedside was initiated. Review of the Fall Occurrence Form for a fall, which occurred on 08/14/15 at 5:30 AM, revealed the resident was found sitting on his/her buttocks on the floor next to the bed. Per the Form, the resident stated he/she woke up sitting on the floor on his/her buttocks, denied hitting his/her head and denied pain. A new nursing intervention of Posey grips to the side rails was documented as initiated on the Form; however, there was no documented evidence the Comprehensive Care Plan was updated to include this intervention. Additionally, there was no documented evidence the Comprehensive Care Plan was updated or revised until 08/20/15, with the intervention of the floor mats to the resident's bedside. Review of the Fall Occurrence Form revealed the resident sustained [REDACTED]. Per the Form, the resident stated he/she rolled out of bed. Resident #5 was assessed as a non-injury fall and notification was made to the clinician and family. However, review of the Comprehensive Care Plan revealed no updates or revisions were documented. Interview on 08/08/15 at 4:30 PM, with Registered Nurse (RN) #2, the Unit Manager for the unit where Resident #5 resided, revealed all staff were responsible for updating the Care Plans, including the Unit Manager. Further interview revealed the IDT team reviewed the falls once a week and updated the Care Plans as needed. 6. Review of Resident #10's medical record revealed the facility admitted the resident on 09/08/14 with [DIAGNOSES REDACTED]. Review of the Minimum Data Set ( MDS) Assessment, dated 08/04/15 revealed, the facility assessed the resident as having a Brief Interview of Mental Status (BIMS) score of nine (9) out of fifteen (15). Further review, revealed the facility assessed the resident as requiring extensive assistance of two (2) staff during transfers to the Broda chair. Review of Resident #10's Comprehensive Care Plan, initiated on 08/28/15, revealed the resident was at risk for falls related to gait/balance problems and a [MEDICAL CONDITION] disorder. The following interventions were initiated on 07/28/15 ; nonskid mat in front of toilet in bathroom, non-skid mat on the right side of the bed, assist with transfers, mobility, repositioning, toileting as needed ,keep floors free from spills and or clutter, adequate, glare free light, call light within reach and encourage resident to use while in room, bed in low position, side rails as ordered, frequently used items within reach; monitor blood pressure with any complaint of dizziness or loss of balance; monitor for side effects of medications, notify clinician/responsible party with any falls or changes, obtain and monitor labs/diagnostic tests as ordered, report results to clinician and follow up as indicated, offer and encourage rest periods, update family on any items needed, use assistive devices to transfer/ambulate as needed, Dycem Posey grip to wheelchair, proper footwear in place to allow stability when standing, non-skid socks, to wear glasses, resident uses reacher to allow them to grasp objects out of their arm's length, resident rest breaks, and put resident to bed when fatigued Review of the Fall Occurrence Form for Resident #10 revealed on 06/13/15 at 7:30 AM, the resident was yelling from the room, and was found in the prone position next to the bed with an abrasion to the left eye, and a hematoma to the left forehead. The resident was assessed by the nurse, and the physician and family were notified. The resident was transferred to the local emergency room for evaluation and treatment. Review of the IDT meeting held on 06/18/15, five (5) days after the fall, revealed new interventions which were to be put in place as a result of the fall included; re-educating and reminding the resident to use the call light for assistance, and ensure the resident has a reacher to reach for objects easier. However, review of the Care Plan revealed no revision or update related to the injury related fall which occurred on 06/13/15. Review of the Fall Occurrence Form for Resident #10 revealed the resident sustained [REDACTED]. Per the Form, the nurse heard the resident calling out for help from his/her room. The resident was found sitting on the floor in from of his/her chair located in the corner of her room. Resident #10 stated he/she was trying to get up from her chair. Review of the IDT Meeting, held on 07/23/15 at 6:33 AM, seven (7) days after the fall, revealed the following interventions to put in place as a result of the fall; re-educate and remind the resident to use call light for assistance, and replace the posey grip in the recliner. However, review of the Care Plan revealed there was no revision for the interventions until 07/28/15, twelve (12) days after the fall occurred. 7. Review of Resident #9's medical record revealed the facility admitted the resident on 02/15/15 with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) Assessment, dated 09/23/14, revealed the facility assessed Resident #9 as having a Brief Interview for Mental Status (BIMS) of twelve (12) out of fifteen (15) indicating moderate cognitive impairment. Review of the Quarterly MDS Assessment, dated 08/19/15, revealed the facility assessed Resident #9, as having a BIMS of eleven (11), indicating moderate cognitive impairment. Further review revealed the facility assessed the resident as requiring limited assist of one (1) for bed mobility, ambulation, transfers and toileting as always incontinent of bowel and bladder. Review of Resident #9's Comprehensive Care Plan, dated 09/29/14, revealed the resident was at risk for falls related to side effects of medication, history of falls, incontinence, confusion, gait/balance problems, psychoactive drug use, non compliant with alarms, impaired cognition, [MEDICAL CONDITION], impaired mobility, impaired vision, and unassisted transfers. The goal stated the resident's risk of falls/injuries would be reduced. There was several interventions including; wheelchair cushion, assist with transfers/mobility/repositioning/toileting as needed, ensure wheelchair was locked and bed was stable prior to transferring, keep floors free from spills and/or clutter; adequate glare-free light; call light within reach and encourage resident to use while in room, bed in low position; side rails as ordered, frequently used items in reach, monitor blood pressure with any complaint of dizziness or loss of balance, monitor for side effects of medicine, offer and encourage rest periods, use assistive devices to transfer/ambulate as needed, Dycem/Posey Grip to wheelchair cushion, proper footwear in place to allow stability when standing, anti roll-back to wheelchair, reduce clutter on the floor in the resident room, and ensure clear path to toilet. Review of the Fall Occurrence Form, dated 05/27/15 at 12:30 AM, revealed Resident #9 was observed walking up the 1300 hall yelling I'm dying help me then he/she sat down on the floor. Per the Form, the resident stated he/she was looking for their mom. No injuries noted. Further review revealed the new intervention on the Falls Occurrence Report was to educate Resident #9 on using call light when needing assistance. However, review of the Care Plan revealed the Care Plan was not revised to include the new intervention to educate the resident to use the call light. There was no Interdisciplinary Team (IDT) Meeting Notes to review related to this fall. Review of the Fall Occurrence Form, dated 06/12/15 at 2:50 PM, revealed Resident #9 was found in room lying supine on the floor with no injuries noted. The resident stated he/she was reaching for the curling iron and fell out of bed. Further review of the Form, revealed a new intervention for the resident to wear proper foot wear to promote stability when standing, and longer oxygen tubing. However, review of the Care Plan revealed the intervention for proper footwear was initiated on 02/19/15, and there was no documented evidence the Care Plan was revised for the new intervention for longer oxygen tubing. There was no IDT Meeting Notes to review related to this fall. There was no documented evidence the Care Plan was revised after this fall in order to prevent further falls. Review of the Fall Occurrence Form, dated 06/20/15 at 11:20 AM, revealed Resident #9 was found sitting on his/her buttocks on the floor in front of his/her wheelchair, with no injuries noted. The resident stated he/she was trying to hang his/her jacket up and slid from the wheelchair. Per the Falls Occurrence Form, the new intervention was to educate Resident #9 on his/her functional limitations. Review of the IDT Meeting Notes for this fall revealed intervention of resident education to request staff assistance for needs. However, there was no documented evidence the Care Plan was revised related to this intervention. Review of the Fall Occurrence Form, dated 06/28/15 at 11:20 AM, revealed Resident #9 was found sitting on buttocks on the floor in front of bedroom door, at the closet door, and no injuries were noted. The resident stated he/she was trying to get clothes out of the closet. The residents wheelchair was sitting on the other side of the room and the alarm was not functioning. Per the Falls Occurrence Form, the new intervention was for the chair alarm pad/box to be changed. Review of the IDT Meeting Notes, dated 07/02/15, revealed the resident was to be educated on the importance of using the call light to request assistance for transfers. However, review of the Care Plan, revealed the no revision for interventions to change the chair alarm pad/box and educate the resident on the call light Review of the Fall Occurrence Form, dated 07/22/15 at 10:30 AM, revealed Resident #9 was found sitting on his/her buttocks on the floor in front of the wheelchair in the resident's room, no injuries were noted. The resident stated he/she was getting up to get his/her drink. Per the Form, the new intervention was to reduce clutter in the room, finger foods/snacks offered, and educate the resident on his/her functional limitations. Review of the IDT Meeting Notes for this fall revealed new interventions to to educate Resident #9 to utilize the call light to ask for assistance if unable to reach something and wait for staff to assist, and ensure call light and personal items were within reach. However, review of the Care Plan revealed no documented evidence of revisions for the new interventions to to reduce clutter in the room,