Every finding on record at Hill Top House

The facility had a census of 21 residents. The sample included 12 residents and five nurse aides. Based on observation, record review, and interview, the facility failed to ensure three of the five staff members reviewed possessed the knowledge, skills, and competencies required for resident care needs. This placed the residents at risk of impaired care. Findings included: - Review of the training records and skills check for Certified Nurse Aide (CNA) O, P, and Q lacked evidence of the facility's procedure checklist related to the direct care of the residents. On 11/20/24 at 10:33 AM, Administrative Nurse D stated the facility had conducted a skills check-off the previous summer for the nursing staff, and not all employees attended. Administrative Nurse D stated the facility had not rescheduled or completed any further competencies for staff who did not attend. The facility's undated Required Training of Nurse Aides documented the facility would ensure that nurse aides demonstrate competency in skills and techniques necessary to care for residents as identified through resident assessments and described in the plan of care. The facility failed to ensure three of the five staff members reviewed possessed the knowledge, skills, and competencies required for resident care needs. This placed the residents at risk of impaired care.

The facility had a census of 21 residents. Based on record review and interview the facility failed to submit complete and accurate staffing information through Payroll Based Journal (PBJ) as required. This deficient practice placed the residents at risk for unidentified and ongoing inadequate nurse staffing. Findings included: - The PBJ report provided by the Centers for Medicare and Medicaid Service (CMS) for Fiscal Year (YR) 2023 Quarter (Q) 4 indicated the facility did not have licensed nurse coverage 24 hours a day, seven days a week on multiple days (five). A review of the facility's licensed nurse timesheet data for the dates listed on the PBJ revealed a licensed nurse was on duty 24 hours a day seven days a week. On 11/18/24 at 12:26 PM, Administrative Staff A reported the discrepancy may be related to the submission of licensed nurse break hours and this had been adjusted to capture all the hours licensed nurses worked. Administrative Staff D stated the facility had nurse coverage 24 hours a day. The facility's undated Mandatory Submission of Uniform Format Staffing Information (PBJ) policy documented the facility would electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contracted staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS. The facility failed to submit accurate PBJ data which placed the residents at risk for unidentified and ongoing inadequate staffing.

The facility had a census of 21 residents. Based on interviews and record review, the facility failed to implement a water management plan to mitigate risks for Legionella (a bacterium spread through the mist, such as from air-conditioning units for large buildings. Adults over the age of 50 and people with weak immune systems, chronic lung disease, or heavy tobacco use are most at risk of developing pneumonia caused by Legionella). The facility failed to maintain an antibiotic tracking system and did not review its infection control policies annually. This deficient practice placed the 21 residents of the facility at risk for infection. Findings included: - The facility printed out a log that included resident names, locations, and prescriptions. The prescriptions were dated from 9/30/22 to 10/02/24. The log revealed eight prescriptions for antibiotics in 2024 but indicated the infection being treated was unknown. The log lacked documentation of onset, symptoms, or cultures. The facility's Infection Control policy was last reviewed on 07/01/21 and the facility's Vaccine policy was 02/13/23. The facility had Appendix A for Identifying Buildings at Increased Risk which indicated the facility should have a water management program for the hot and cold-water distribution system. On 11/19/24 at 01:55 PM, Administrative Staff A verified the facility had not reviewed the infection control policies annually, and that it had been a couple of years since they did. Administrative Staff A verified the facility had not followed through with setting up a water management program to address Legionella risk. On 11/20/24 at 09:55 AM, Administrative Staff D, the certified Infection Preventionist, verified the facility had not tracked infections and did not have an ongoing monitoring process in place. She stated the staff discussed any current infections during the Quality Assessment and Assurance meetings. On 11/20/24 at 09:55 AM, Administrative Staff E stated she checked for patterns if more than one infection was going on at a time. The facility's Antibiotic Stewardship policy, dated 07/15/2021, stated the center would discuss antibiotic use and resistance data. Compliance with antibiotic use algorithms and results of provider feedback during QAPI. The policy stated the Infection Preventionist would monitor antibiotic stewardship activities through a review of provider orders, clinical documentation, and pharmacy and lab reports. The ICP would track antibiotic use and resistance patterns, provide education as needed, and alert the facility if certain antibiotic-resistant organisms were identified. The policy stated the facility would implement a standard assessment and communication tool for residents suspected of having an infection SBAR. The facility would monitor both antibiotic use practices and outcomes related to antibiotics in order to guide practice changes and track the impact of new interventions. Monitor if cultures were obtained before antibiotics were initiated and if antibiotics changed during the course of treatment. The facility's Infection Control Policy dated 07/01/2021, stated the facility would establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The facility's Legionella Risk Management policy stated the facility would ensure appropriate precautions for the control of Legionella bacteria were identified through a Legionella risk assessment process and appropriate control measures implemented to ensure, as reasonably practicable, the health, safety, and welfare of residents. The minimum standards to be met included: Legionella risk assessments, a description of the building water system, and an identification of where Legionella could grow and spread. An action plan for preventing or controlling the risk. Implementation, management, monitoring, and recording of precautions. The facility failed to implement a water management plan to mitigate risk for Legionella and failed to maintain an antibiotic tracking system and review infection control policies at least annually. This placed the 21 residents of the facility at increased risk for infection.

The facility had a census of 21 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to develop a baseline care plan within 48 hours of admission for Resident (R) 123. This placed the resident at risk for impaired care due to unidentified or uncommunicated care needs. Findings included: - R123's Electronic Medical Record (EMR) recorded diagnoses of diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), urinary incontinence, hypertension (high blood pressure), gastroesophageal reflux disease (GERD-backflow of stomach contents to the esophagus), nutritional deficiencies, anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), irritable bowel syndrome (IBS- abnormally increased motility of the small and large intestines), a history of transient ischemic attack (TIA- temporary episode of inadequate blood supply to the brain) and cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain) without residual deficits. The Entry Tracking Record Minimal Data Set (MDS) dated [DATE] recorded R123 admitted on [DATE] from home or the community. R123's clinical record lacked a baseline care plan from the admitted [DATE]. The Physician Order dated 11/08/24, directed staff to admit to the nursing home long-term care with diagnoses of diabetes, urinary incontinence, and a history of stroke. The Progress Note, dated 11/08/24 at 01:38 PM, documented R123's arrival at the facility via personal vehicle. Vital signs were obtained, and a family member assisted the resident with unpacking and getting the room situated as R123 wanted. On 11/19/24 at 12:23 PM, observation revealed staff escorted R123 to her room. R123 reported she did not feel well and was dizzy. Licensed Nurse (LN) G obtained vital signs and a blood sugar level. R123's blood sugar level was low. LN G reported that R123 had a history of low blood sugar levels since admission. On 11/19/20 at 01:00 PM, LN G reviewed R123's EMR and verified there was no baseline care plan. On 11/20/24 at 11:30 AM, Administrative Nurse D verified R123's EMR lacked a baseline care plan and said one should have been developed within 48 hours of admission. The facility's undated Interim Temporary Care Plans policy documented an interim plan of care is developed and initiated on admission to the facility. Continual evaluation of interim, temporary plans of care was completed by staff members caring for the elder. Revisions to the care plan will be ongoing and the current conditions, needs, and goals of the elder change. The facility failed to develop a baseline care plan within 48 hours of admission. This placed R123 at risk for impaired care due to unidentified and uncommunicated care needs.

The facility had a census of 21 residents. The sample included 12 residents with five reviewed for unnecessary drugs. Based on observation, interview, and record review the facility failed to obtain a stop date from the physician for the use of as-needed (PRN) lorazepam (antianxiety medication) for Resident (R) 9. This placed the resident at risk for complications related to psychotropic (alters mood or thought) medications and unnecessary medication. Findings included: - R9's Electronic Medical Record (EMR) documented diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), insomnia (inability to sleep), and dementia (a progressive mental disorder characterized by failing memory and confusion) with agitation (feeling of aggravation or restlessness brought on by a provocation or a medical condition). The Significant Change Minimum Data Set (MDS), dated [DATE], documented that R9 had short- and long-term memory problems with severely impaired cognition. The MDS documented R9 received hospice (end-of-life) services and did not receive antianxiety drugs. R9's Care Plan, dated 11/14/24, documented R9 had Alzheimer's dementia and anxiety. R9 could become agitated with care at times, including hitting and slapping. The care plan directed staff to provide opportunities for positive interaction and attention and directed staff to stop and talk with her when passing by, initiated 06/13/23. The plan directed staff to monitor behavior episodes, attempt to determine underlying causes, and document behavior and potential causes, initiated on 06/13/23 and revised on 10/25/23. The plan directed to administer psychotropic medications as ordered and monitor for side effects and effectiveness every shift initiated 06/13/23. The plan directed staff to discuss with the physician and family the ongoing need for the use of medication and review behaviors and interventions and alternate therapies attempted and their effectiveness as per facility policy, initiated on 06/13/23. Staff were to monitor, document, and report any adverse reactions to psychotropic medications, initiated on 06/13/23 and revised on 10/25/23. The Physician Order, dated 11/04/24, directed staff to administer lorazepam oral concentrate 0.25 milliliter (ml) every four hours as needed for agitation or restlessness. The order stated duration was indefinite. On 11/19/24 at 08:13 AM, observation revealed Certified Nurse Aide (CNA) M woke R9 and told R9 what she was doing. While CNA M provided incontinence care, R9 frowned but did not cry out. R9 made a small noise during the transfer from her bed to a wheelchair. CNA M stated that R9 used to become more upset when staff worked with her, but she had declined. On 11/19/24 at 01:58 PM, Licensed Nurse (LN) G stated R9 was more alert before her health declined and would become agitated with care, striking out at staff. LN G said staff monitored how many times each shift R9 had restlessness, agitation, and hitting. On 11/20/24 at 09:35 AM, Administrative Nurse D verified when a physician ordered PRN lorazepam, staff should obtain a specific stop date. The facility's Psychotropic Medication Use policy stated any resident admitted with a PRN psychoactive medication would have a 14-day stop date. Any psychotropic medication ordered by a physician as an emergency treatment for behaviors would have an automatic 72-hour stop date during which the physician and nursing staff would assess the potential root cause for the behaviors and interventions that may replace or be used as adjunct therapy for the behaviors. The physician's order must include a qualifying diagnosis and a list of specific targeted behaviors for which the staff would monitor. The attending physician must certify that a psychotropic medication was necessary to treat a specific condition or behavior. The facility failed to obtain a stop date from the physician for the use of PRN lorazepam for R9, placing the resident at risk for complications related to psychotropic medications and unnecessary medication.

The facility had a census of 21 residents. The sample included 12 residents with two reviewed for hospice services. Based on observation, interview, and record review the facility failed to ensure a communication process and collaboration between the hospice provider and the facility for Resident (R) 9 and R17 to coordinate hospice services provided including visit frequency and assessment, medications, and medical equipment. This placed the residents at risk of impaired end-of-life care. Findings included: - R9's Electronic Medical Record (EMR) documented diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), insomnia (inability to sleep), and dementia (a progressive mental disorder characterized by failing memory and confusion) with agitation (feeling of aggravation or restlessness brought on by a provocation or a medical condition). The Significant Change Minimum Data Set (MDS), dated [DATE], documented that R9 had short- and long-term memory problems with severely impaired cognition. The MDS documented R9 received hospice services. R9's Care Plan, dated 11/14/24, documented R9 had Alzheimer's dementia and anxiety. R9 could become agitated with care at times, including hitting and slapping. The care plan directed staff to provide opportunities for positive interaction and attention and directed staff to stop and talk with her when passing by, initiated 06/13/23. The plan directed staff to monitor behavior episodes attempt to determine underlying causes, and document behavior and potential causes, initiated on 06/13/23 and revised on 10/25/23. The plan directed to administer psychotropic medications as ordered and monitor for side effects and effectiveness every shift initiated 06/13/23. The plan directed staff to discuss with the physician and family the ongoing need for the use of medication and review behaviors and interventions and alternate therapies attempted and their effectiveness as per facility policy, initiated on 06/13/23. Staff were to monitor, document, and report any adverse reactions to psychotropic medications, initiated on 06/13/23 and revised on 10/25/23. The care plan directed staff to allow R9 time to answer questions and to verbalize feelings, perceptions, and fears daily. The care plan directed staff to consult with pastoral care or social services, initiated on 12/06/23. The care plan lacked any mention of hospice services. A review of R9's clinical record lacked information regarding hospice staff assessments, care, or visits. On 11/19/24 at 08:13 AM, observation revealed Certified Nurse Aide (CNA) M woke R9 and told R9 what she was doing. While CNA M provided incontinence care, R9 frowned but did not cry out. R9 made a small noise during the transfer from her bed to a wheelchair. CNA M stated that R9 used to become more upset when staff worked with her, but she had declined. On 11/19/24 at 11:37 AM, Certified Nurse Aide (CNA) N and CNA O stated the charge nurse usually let CNA staff know if a resident was on hospice. They reported there was a list in the shower room that documented who hospice was giving a shower or bath and when. They also stated that the residents on hospice got incontinence products from the hospice company. They stated that the hospice also provided equipment, like wheelchairs and oxygen. On 11/19/24 at 01:25 PM, CNA M verified that R9 received hospice services. CNA M said the hospice nurse visited weekly and the hospice aide came weekly to bathe R9. On 11/19/24 at 02:20 PM, Licensed Nurse (LN) G stated the last hospice care plan was dated 11/06/24 and verified the facility's care plan did not include any hospice information. She verified the facility did not receive hospice assessment findings or visit notes. The facility's Hospice Agreement, dated 05/15/18, was last signed on 05/01/20 by both parties. The nursing facility and Hospice shall each prepare and maintain complete and detailed clinical records concerning each residential hospice patient receiving facility and hospice services. Each clinical record shall completely and accurately document all services provided to and events concerning (including evaluations, treatments, progress notes, and physician orders for each hospice patient. The nursing facility and hospice shall each retain the records and the records shall be readily accessible and organized. to facilitate retrieval by either party. The facility failed to ensure a communication process and collaboration between the hospice provider and the facility for R9. This placed the resident at risk of impaired end-of-life care. 37450 - R17's Electronic Medical Record (EMR) included diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), restlessness and agitation (feeling of aggravation or restlessness brought on by a provocation or a medical condition), non-displaced fractures (broken bone) of the second cervical (neck/spine) vertebra, second and third thoracic (mid back area) vertebra (bone of the spinal column), first, third, and fourth lumbar (lower spine) vertebra, osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk) with a current pathological fracture (a break in a bone that is caused by an underlying disease), and nutritional deficiency. The Significant Change Minimum Data Set (MDS), dated [DATE], documented R17 had moderately impaired cognition. R17 required partial/moderate assistance with personal hygiene and upper body dressing, and substantial/extensive assistance with toileting, lower body dressing, bathing, bed mobility, and transfers; walking was not attempted due to medical condition or safety concerns. R17 was occasionally incontinent of urine. R17 received scheduled and as-needed pain medication for pain which was frequent and affected sleep and day-to-day activities. The MDS further documented that R17 received hospice services (specialized end-of-life care with a focus on comfort). R17's Care Plan dated 09/26/24, documented R17 received hospice care services. The care plan directed staff to adjust provisions of activities of daily living to compensate for the resident's changing abilities, assess and respect the resident's wishes, encourage support systems of family and friends, and keep the environment quiet and calm. The care plan further directed staff to observe R17 closely for signs of pain, administer pain medication, and work cooperatively with the hospice team to ensure the resident's, spiritual, emotional, intellectual, physical, and social needs were met. The care plan lacked specific information related to the hospice provider, services and equipment or medications that would be provided, and when to notify the hospice provider. The Hospice Order dated 09/18/24, documented R17's hospice provider, and diagnoses of CHF and fractures. R17 had her neck brace, and the hospice provider would provide pull-ups, a skilled nurse weekly, and a nurse aide two times a week. The orders included medications covered under R17's hospice benefit. The Progress Note dated 09/11/24 at 01:13 PM, documented R17's primary care practitioner asked staff to Please discuss comfort care and or hospice with R17's family and the charge nurse was to address R17's power of attorney about changes. The Progress Note dated 09/12/24 at 02:15 PM, documented the facility nurse spoke with R17's family and spouse about hospice care. The hospice social worker was in to meet with the family. The Progress Note dated 09/12/24 at 05:29 PM, documented the hospice nurse called to relay that as of 09/12/24, R17 was admitted to hospice. Upon review, R17's clinical record lacked evidence of the hospice assessment findings and hospice nurse visit notes. On 11/18/24 at 02:20 PM, observation revealed R17 sat in a recliner in her room with a family member next to her. R17 reported she was doing okay. R17 had the footrest elevated and a small, rolled blanket to the back of her neck. On 11/19/24 at 11:37 AM, Certified Nurse Aide (CNA) N reported staff received information from the charge nurse when a resident was receiving hospice services. CNA N stated the hospice provider would usually provide incontinent products, a wheelchair, and oxygen. CNA N stated the shower list had when a hospice aide would bathe the resident. On 11/19/24 at 03:31 PM, Licensed Nurse (LN) G reported the facility did not have a hospice book or chart for R17. LN G reported the facility staff signed the hospice staff's tablets confirming the hospice staff visit and that the hospice nurse and facility nurse verbally discussed the resident's condition. LN G was unable to find the hospice nurse documentation of assessments or ongoing collaboration in R17's EMR. LN G reported the hospice plan of care was sent to the facility via email every six months with the recertification of hospice services. On 11/20/24 at 10:33 AM, Administrative Nurse D verified the hospice provider should send notes from all visits made which should be scanned into the EMR. Administrative Nurse D reported the hospice provider had a change in computerized record keeping and was unaware the hospice provider had not been sending the information from the visits until recently. Administrative Nurse D said the facility had not followed up on receiving information from the hospice provider. The facility Hospice Agreement dated 05/15/2018, last signed 5/1/20 by both parties documented that the nursing facility and hospice shall each prepare and maintain complete and detailed clinical records concerning each residential hospice patient receiving facility and Hospice services. Each clinical record shall completely and accurately document all services provided to and events concerning (including evaluations, treatments, progress notes, and physician orders of each) hospice patient. The nursing facility and hospice provider shall each retain the records and the records shall be readily accessible and organized to facilitate retrieval by either party. The facility failed to collaborate care and services with R17's hospice provider, which placed R17 at risk of impaired end-of-life care.

- Observation on 02/14/23 at 09:12 AM revealed Licensed Nurse (LN) G, Certified Medication Aide (CMA) M and Certified Nursing Assistant (CNA) N in the resident's room to provide R 12 morning cares CMA M raised the head of the bed and CNA N assisted her to pivot transfer from the bed. The resident's brief was wet and removed and staff sat the resident on the bedside commode. LN G held the back of the commode. Observation of the commode revealed the leg to the back rest of the commode. LN G held the back so it did not wobble or collapse while the resident used it. The back bar of the commode also had an area of rust approximately 4 inches long across the bar. On 02/14/23 at 09:15 AM, LN G stated she noticed commode lacked a wingnut the day before. LN G stated she reported the broken commode to Maintenance Staff U. LN G was unaware how long it had been broken. On 02/15/23 at 10:00 AM, Maintenance Staff U reported no one notified him of the condition of the commode. On 02/15/23 at 10:40 AM, Maintenance Staff U reported there was a commode with rusted legs and without a wingnut by the back door and he threw it out. On 02/16/23 at 10:50 AM, Administrative Nurse D reported staff should have removed the commode once staff determined the wingnut was not on. The facility lacked a policy for guidance of broken equipment. The facility failed to remove unsafe equipment (bedside commode) to prevent a possible injury to R 12 when staff used a rusted commode that lacked a securing/ bracing wingnut. 41302 The facility census totaled 24 residents with 12 in the sample that included four residents for accident hazards. Based on observation, interview, and record review, the facility failed to ensure the fall prevention interventions were implemented to prevent further falls for Resident (R) 28, R12, and R17. The staff left R28 in the dining room without a chair alarm in place, which resulted in a fall with a fracture of her right wrist and her right hip. The facility also failed to replace faulty equipment to prevent a possible fall for R12. Findings included: - R28's diagnoses from the Electronic Health Record (EHR) documented anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), dementia (progressive mental disorder characterized by failing memory, confusion), and major depressive disorder (major mood disorder). The 09/26/22 Admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of zero, indicating severe cognitive impairment. R28 had no falls since the prior assessment. The 12/27/22 Quarterly MDS documented a staff interview indicating R28 had severe cognitive impairment. The MDS further noted R28 had two or more non-injury falls since the prior assessment. The 12/27/22 Care Plan documented R28 was at risk for injuries related to multiple falls. R28 had an intervention from previous falls for staff to ensure her pressure alarm was in place and working. The staff were to check on R28, frequently. Review of the Fall Investigations and Nurse Notes dated 01/05/23, documented R28 fell , with fractures to her right hip and her right wrist. On 01/05/23, R28 was in the dining room following a meal and staff left her unattended and without her pressure alarm in place, for the meal, from 01:10 PM until her fall at 01:15 PM. R28 noted to have been up and ambulated around her table for three minutes before she fell . The interventions of the pressure alarm and frequent supervision were not observed. Staff notified Emergency Medical Services (EMS, a system that responds to emergencies in need of medical care) and R28 transported to the emergency room for further evaluation and treatment. Review of the Witness Statement dated 01/05/23, revealed Certified Medication Aide (CMA) R documented R28 was in the dining room following lunch, when she stood and rearranged the dirty dishes on the table. R28 stood at the table for about a minute before she stumbled and fell on to her right hip, as seen on the video camera. R28 fell when she was left unsupervised in the dining room, after eating, and without her chair alarm. Review of the Witness Statement dated 01/05/23, revealed Administrative Nurse E documented she entered the dining room from the kitchen, advised a Certified Nurse Aide (CNA) to get the charge nurse, the lift, and the vital sign machine. R28 was on the floor in a sitting position, next to her dining room chair. R28's right leg had external rotation and seemed shorter than her left leg. The staff notified 911(emergency call number). R28 fell because she was left alone in the dining room without her alarm, and she tried to stand and fell . Review of the Witness Statement dated 01/05/23, revealed CNA N documented she was down the hall making beds when staff came and told her R28 fell . CNA N went to the dining room and saw R28 sitting on the floor on her bottom. CNA N documented the last time she saw R28 was on 01/05/23 at 12:52 PM. CNA N documented R28 fell because she got up and lost her balance. Review of the Witness Statement dated 01/05/23, revealed CNA O documented a coworker told her R28 was sent to the hospital. The last time CNA O saw R28 was when she was being assisted down to the dining room. CNA O documented she was in another resident's room at the time of the fall. In CNA O's opinion, R28 fell because she did not have her alarm that she was supposed to, and she was left alone in the dining room for too long. Review of the Witness Statement dated 01/05/23, Licensed Nurse (LN) I documented on the day of the fall R28 did not have her alarm in place. When she entered the dining room, R28's right leg was noted with visible shortness and gross external rotation, also her right wrist was deformed, and she was guarding and holding it. The staff called 911, with EMS arriving, vital signs listed, local hospital notified of transport for x-rays and further treatment as needed. The staff notified family and administration of the incident. Review of the Witness Statement dated 01/05/23, revealed CNA P documented R28 was in the dining room eating. CNA P left and was coming back to walk R28 to the family room but before she got back, a staff member found R28 on the floor. R28 was cognitively impaired and attempted to clean the table. Review of the Witness Statement dated 01/05/23, CNA Q documented she found R28 sitting on the floor with CNA P. CNA Q heard on the communication device that they needed a lift, the nurse, and vital sign machine. CNA Q went to get the lift. CNA Q noted R28 fell because she did not have her alarm on, and no one was around to watch her. Review of Nurse Note dated 01/06/23, documented R28 transferred from one hospital to another hospital for surgical repair due to a fractured right wrist and a fractured right hip. On 02/15/23 at 09:29 AM, Administrative Nurse E reported when she walked out of the kitchen, she saw R28 on the floor with her legs out in front of her. Administrative Nurse E reported she observed R28's right wrist was deformed, and her right leg was rotated and appeared shorter than the other leg. She instructed the nurse to call for the EMS for transport while Administrative Nurse E sat with R28. On 02/15/23 at 09:36 AM, Certified Nurse Aide (CNA) N reported that she was working with an agency staff, who CNA N instructed to watch the dining room, while CNA N went down the hall to make beds. When CNA N returned, everyone was in the dining room because R28 fell . On 02/16/23 at 08:08 AM Licensed Nurse (LN) I reported on the day of the fall, she was called by staff to the dining room, multiple staff were in and out of the dining room and saw R28. R28 did not have her alarm in place. When she entered the dining room, she knew immediately that R28's hip was not positioned correctly, and she called EMS to transport R28. On 02/16/23 at 11:06 AM, Administrative Nurse D revealed she expected staff to implement a new intervention following a fall and for staff to follow those interventions. She confirmed that for R28's 01/05/23 fall, the interventions had not been followed. The facilities 07/12/18 High Fall Risk Protocol policy documented staff were to provide each resident with adequate supervision and assistive devices to prevent accidents. The facility failed to provide adequate supervision and assistance devices to prevent accidents, when R28 fell on [DATE] that resulted in a right wrist and right hip fracture.

The facility reported a census of 24 residents with 12 sampled. Based on interview and record review, the facility failed to review and revise the care plans for one Resident (R)17, regarding new interventions to prevent falls. Findings included: - Review of R17's diagnoses from the Electronic Health Record (EHR) documented repeated falls, weakness, amnesia (a dramatic form of memory loss) and Alzheimer's disease (a progressive dementia - loss of cognitive function such as thinking, remembering and reasoning). Review of R17's annual Minimum Data Set (MDS), dated [DATE], documented a brief interview for mental status (BIMS) of 12, indicating moderately impaired cognition. R17 required extensive assistance of two or more staff with transfers. Review of the Falls Care Area Assessment (CAA) dated 01/02/23, revealed that the resident was at increased risk for falls and injury due to impaired cognition, pain and numbness/weakness to all extremities. The care plan, dated, 02/11/22 revealed: A non-injury fall on 02/11/22, with the interventions for staff to remind the resident to use her call light and for staff to pick up dropped items from the floor. A non-injury fall on 04/02/22, with the intervention for staff to reeducate the resident to use a pendant to call for assistance. A non-injury fall on 04/29/22, with the intervention to place a floor mat next to the bed when the resident is in bed, to prevent rolling out of bed. A non-injury fall on 06/03/22, with the intervention for staff to assess for a concave mattress. A fall with minor injury on 07/06/22, with the intervention for staff to place a pressure monitor under the mat next to bed, and staff should apply non-skid socks. A non-injury, unwitnessed fall on 11/20/22, in the chapel bathroom, with intervention for staff to assist the resident to the bathroom every two hours and as needed. However, the facility lacked interventions for the non-injury fall on 12/08/22. Furthermore, the facility lacked interventions for a repeated fall with injury on 12/18/22. The Physician's orders lacked documentation of orders specific for fall prevention. Review of the resident's assessments revealed fall risk screenings, dated: On 10/20/22, with result of 65, indicating high risk for falling. On 12/18/22, with result of 75, indicating high risk for falling. On 12/27/22, with result of 75, indicating high risk for falling. On 01/02/23, with result of 65, indicating high risk for falling. On 02/16/23 at 09:30 AM, Certified Nurse Aide (CNA) N stated that R17 required a personal body alarm for her recliner and her wheelchair, but the resident learned how to disable the audible alarm alerts. Staff should attempt to keep the resident engaged in the common areas as much as possible so all staff can observe the resident, to prevent falls. On 02/16/23 at 10:06 AM, Licensed Nurse (LN) I reported R17 frequently forgot her limitations and she lacked the cognition to comprehend her limitations. Staff were to place a pressure sensor alarm on R17's recliner and wheelchair, along with a floor mat beside her bed for fall prevention. After a resident's fall, a licensed nurse on duty should implement an immediate intervention until the Interdisciplinary Team (IDT) would meet and develop a permanent intervention for the resident's care plan. On 02/16/23 at 10:13 AM, Administrative Nurse D reported she expected the licensed nurse on duty at the time of a fall was to implement an immediate intervention until the IDT could meet to create a permanent intervention and update the resident's care plan to prevent further falls. IDT meets at least once per week. On 02/16/23 at 11:14 AM, Administrative Nurse D confirmed the lack of new interventions on the care plan after the falls on 12/08/22 and 12/18/22. The 01/23/17 facility's policy for Fall Prevention Protocol documented that the IDT would develop a plan for services and other interventions to reduce the elder's risk for falls. The facility failed to review and revise this resident's care plan related to falls.

The facility census totaled 21 residents, with three residents reviewed for elopement risk. Based on observation, interview, and record review the facility failed to provide adequate supervision for Resident (R) 1, with a history of exit seeking behaviors (including removing a window screen in October of 2021) and who exited the facility through a window on 04/15/22 at approximately 08:25PM. The facility staff did not know of this until two off duty facility staff members called the facility and reported the resident was at the local convenience store (located six minutes north of the facility and within 500 feet of a major US Highway) and the resident was found scared and tearful. This failure placed R1 in immediate jeopardy. Findings included: - R1's diagnoses from the 09/14/21 Physician's Orders in the Electronic Medical Record (EMR) revealed dementia (progressive mental disorder characterized by failing memory, confusion) without behaviors. The 09/21/21 Admission Minimum Data Set (MDS) revealed a brief interview for mental status (BIMS) of four, indicating severe cognitive impairment. Wandering occurred one to three days of the seven-day look back period. The resident was independent with ambulation. The 09/21/21 Cognitive and Behavioral Care Area Assessment (CAA) documented that R1 had a diagnosis of dementia with a BIMS indicating severe cognitive impairment. R1 exhibited wandering behavior at night. The 03/23/22 Modification of Quarterly MDS revealed a BIMS of five, indicating severe cognitive impairment. There were no other changes from the previous MDS. The 04/06/22 Care Plan documented R1 ambulated independently. Staff should distract R1 from wandering by offering pleasant diversions, structured activities, food, conversation, and television. On 04/15/22, staff updated R1's care plan to include 15-minute safety checks and to have a Wanderguard (bracelet that sets off an alarm when residents wearing one attempt to exit the building without an escort) placed on the left ankle. The Physician Orders documented the following orders: On 03/23/22, check the placement of the Wanderguard and ensure the red-light blinks. The provider discontinued (stopped) the order the same day. On 04/16/22, Ensure the Wanderguard worked by checking for a blinking red light, twice daily. Behavior Notes written by staff throughout 10/08/21 documented R1 becoming increasingly confused and irritated with staff, telling staff he was leaving by breaking windows and actively exit seeking by attempting to open facility doors and setting off door alarms, as well as removing the screen from his room window. Staff placed a Wanderguard which caused R1 to become more agitated and verbally aggressive with staff. R1 went to the kitchen asking for a knife to remove the Wanderguard. Administrative Staff A and Administrative Nurse B removed the Wanderguard due to threatening behavior and staff initiated 15-minute checks. The 10/12/21 Wandering Risk Scale assessment documented R1 was a high risk for elopement, due to removing a window screen in a room and exit seeking. The 12/21/21 Wandering Risk Scale assessment documented R1 was a high risk for elopement, due to continued wandering of the facility in the evening and discussing his desire to leave the facility by climbing out the window. The assessment documented that R1 wore a Wanderguard on his ankle. The 03/23/21 Wandering Risk Scale assessment documented R1 was a high risk for elopement, due to his attempts to leave the facility by pushing on the front door and setting off the alarm, as well as his continued discussion about wanting to leave the facility. The assessment documented that R1 wore a Wanderguard on his ankle. Behaviors Notes written by staff between 04/05/22 and 04/12/22 documented R1 attempted to exit the building through doors and attempted to remove the screen from a bedroom. R1 shook the doors and set off the alarms. R1 was also found in the soiled utility room on one occasion and demanded staff get out when staff attempted to redirect him out of the room. On 04/21/22 at 12:00PM, the surveyor and Administrative Nurse C walked the route most likely taken by R1 on 04/15/22 for the elopement. Behind the facility was a dirt field and gravel roads surrounded the other three sides of the facility. There was no traffic present throughout the walk through. The convenience store was located at the end of the main gravel road, a six-minute walk from the facility. On 04/21/22 at 12:23PM, an observation of R1 revealed a Wanderguard on the left ankle. R1 was pleasant and talked with staff in the hallway as he walked toward the dining room for lunch. R1 wore shoes and clothing was appropriate for the weather. Interview on 04/21/22 at 09:00AM with Administrative Staff A revealed Administrative Nurse B reviewed the surveillance camera to see what happened. R1 was seen going into a vacant resident room and did not come out. They discovered that R1 opened the window in the room and went out through it. R1 was found at the local convenience store and was brought back to the facility by staff. R1 was afraid that he would be in trouble with the facility staff. Prior to the elopement, R1 refused to wear a Wanderguard, but upon returning to the facility, R1 agreed to the Wanderguard for safety. Administrative Staff A stated that the window screens were screwed in and the window knobs were removed from each window to help prevent R1 and other residents from exiting the facility via the window. Interview on 04/21/22 at 09:31AM with Administrative Nurse C revealed that when R1 admitted to the facility as an elopement risk and staff placed a Wanderguard on R1. R1 had a meltdown and tried to cut the device off with a knife. Staff removed the Wanderguard the same day and staff initiated 15-minute safety checks for four or five days. After the elopement on 04/15/22, R1 agreed to wear a Wanderguard on his ankle for safety. Administrative Nurse C stated that R1 was found at the local convenience store by Certified Nurse Aide (CNA) G and Dietary Aide H. Administrative Nurse B went to the convenience store and drive R1 back to the facility. Staff placed on R1 on 15-minute safety checks upon arrival and he remained on them since his return. The night of 04/15/22, the weather was breezy with temperatures in the 60s and no severe [NAME]. Interview on 04/21/22 at 02:47PM with CNA E, revealed staff checked R1's Wanderguard daily for placement and ensured it worked properly. R1 has not tried to remove the Wanderguard since having it placed on 04/15/22. CNA E stated that R1 tried to elope at least once per shift when she worked, but was only successful once on 04/15/22. Interview on 04/21/22 at 04:18PM with Licensed Nurse (LN) D, revealed R1 was on 15-minute safety checks since his elopement, but she tried to keep R1 with her for one-to-one visual monitoring while she worked. R1 had a history of sun downing (condition where a person tends to become confused or disoriented toward the end of the day). She offered R1 a Pepsi or beer in the evening and it would occasionally calm him down. LN D stated that R1 had a Wanderguard upon admission, but it caused him to have behaviors and staff removed the device. After the elopement, staff placed a Wanderguard for safety. LN D stated that R1 would exit seek frequently, but staff easily redirected him by talking about his family. Interview on 04/25/22 at 09:29AM with Dietary Aide H, revealed she was unaware that R1 left the facility until she walked into the convenience store and found R1 inside the store on 04/15/22 around 09:00PM. It was dark outside, and the traffic was slow and mostly empty of cars on the roads. Dietary Aide H stated that R1 said he walked out of the facility and could not get back in, so he walked to the convenience store. R1 did not have any injuries and did not appear to be scared. Dietary Aide H stated that CNA G notified the facility that R1 was at the convenience store and that Administrative Nurse B arrived shortly to drive R1 back to the facility. Interview on 04/25/22 at 10:25AM with CNA F, revealed she was working at the facility the evening of 04/15/22. When R1 returned to the facility, staff checked his vital signs and assessed for injuries. R1's vital signs were normal, and he did not have any injuries. CNA F stated she did not know if R1 had a Wanderguard in place at the time of the elopement. When R1 returned to the facility, staff placed a Wanderguard to his ankle and staff checked the device daily. Interview on 04/25/22 at 10:32AM with Administrative Nurse B, revealed she received a call from LN I stating R1 was at the local convenience store. Administrative Nurse B told LN I to notify Administrative Staff A [who immediately went to the facility]. Administrative Nurse B got to the convenience store one-minute later and found Dietary Aide H and CNA G waiting with R1. R1 told Administrative Nurse B that he had been looking for her and that he wanted to go home. Once in Administrative Nurse B's truck, R1 cried and asked her not to tell anyone about what happened. Administrative Nurse B discussed safety with R1 on the drive back to the facility. R1 said he wanted to go for a walk outside and got locked out. Administrative Nurse B stated that when staff placed a Wanderguard on R1 in the past, he became upset and it was ultimately removed with family approval. Upon R1's return to the facility, staff discussed the Wanderguard with R1 and he agreed to have one placed on his ankle. Staff assessed the resident for injuries and checked his vital signs. Administrative Staff A reviewed surveillance footage to determine how R1 eloped without the door alarms being triggered. R1 was seen wandering around the facility talking to both staff and residents and ended up in a vacant room and did not come back out. Administrative Nurse B and Administrative Staff A determined R1 exited the facility through a window and asked staff working to check all windows in the facility for evidence. The window screen was found outside the window in the grass and the window open. Staff initiated on 15-minute safety checks and placed all other residents at risk for elopement on hourly checks. The 03/2020 Elopement Risk Policy documented that staff were always to monitor resident's whereabouts including monitoring of responses/reactions to events/activity in surroundings at time of aimless wandering and report behaviors to supervisor immediately. The failure to provide R1 with adequate supervision, allowed R1 to leave the facility through a window and walk approximately six minutes to the local convenience store. This placed R1 in immediate jeopardy. On 04/20/22 the facility completed the following corrections: 1. The facility immediately initiated 15-minute safety checks for R1 and hourly rounding on all elopement risk residents. 2. All residents at risk for elopement were reevaluated and assessments were updated. 3. A wander guard was placed on R1's left ankle. 4. All window screens were screwed in place and the window cranks were removed from all windows. 5. The facility identified the need for staff education on the elopement policy, drills and plan of action and completed an in-service on 04/20/22 with all facility staff. All staff members not in attendance must complete education with either Administrative Nurse B or Administrative Nurse C prior to working the floor of their next shift. 6. Elopement drills were completed and are on going with staff. 7. A Performance Improvement Plan (PIP) committee was created for elopement prevention and response. This deficient practice was cited as past non-compliance.

The facility reported a census of 26 residents. Based on interview and record review the facility failed to address staffing in the Facility Assessment to document resources required to provide necessary care to the residents in regard to staffing across all shifts. This failure had the ability to affect all resident care in the facility. Findings included: - Review of the undated Facility Assessment documented no determination of facility staffing. Interview with Administrative Staff A on 08/02/21 at 01:10 PM revealed the facility assessment did not have a breakdown of how staffing was determined. Administrative Staff A stated she had not completed the facility assessment since last year. Interview with Administrative Nurse B on 08/02/21 at 01:55PM revealed she made the schedule for the nursing staff and the facility determined staffing based on the acuity of the residents. Review of the undated Facility Assessment Policy stated the facility assessment was the foundation to determine staffing levels and competencies to include an evaluation of the overall number of facility staff needed to ensure sufficient number of qualified staff were available to meet the needs of the residents. The facility failed to address staffing in the Facility Assessment to document resources required to provide necessary care to the residents in regard to staffing across all shifts. This failure had the ability to affect all resident care in the facility.

The facility reported a census of 26 residents. Based on observation, interview, and record review, the facility failed to provide the residents with a way to file a grievances anonymously. Findings included: - During the initial tour of the facility on 07/27/21 at 10:00 AM, there were no grievance forms or a way to submit those forms anonymously noted in the facility. On 07/28/21 at 02:01 PM, Resident (R) 14 stated they did not have forms to fill out for a grievance during the resident council meeting. On 07/28/21 at 02:21 PM, Activity Staff D stated they did not have forms to fill out for grievances, that the residents would tell the staff what the issue was and that the residents could call the Ombudsman with any concerns. On 08/02/21 at 12:12 PM, Activity staff D stated she had not developed a procedure for residents to file an anonymous grievance. On 08/02/21 at 05:00 PM, Administrative Staff A stated she did not know they needed an anonymous way to file a grievance. Review of the facility's undated Complaints or Grievances policy documented that each resident may voice grievances to administrative staff or outside representatives of their choice, free from interference, coercion, discrimination, or reprisal. The facility failed to allow residents to exercise their right to file a grievance, including the right to file an anonymous grievance, without interference, coercion, discrimination, or reprisal.

The facility reported a census of 26 residents, with 12 sampled, including one for dignity. Based on observation, interview, and record review, the facility failed to provide quality dignified care for Resident (R) 25 by allowing his fingernails to be overgrown with a dark substance under them after he requested staff trim them. Findings include: - Review of R25's Signed Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission Minimal Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of five, indicating severely impaired cognition. R25 required the assistance of one staff member for personal hygiene. Review of the ADL Function/ Rehabilitation Potential Care Area Assessment (CAA) dated 07/06/21 documented staff will care plan to maintain the current level of functioning, risk factors were current disease processes. Review of the Care Plan dated 07/06/21 documented R25 required physical assistance of one staff with bathing/showering, and staff were to check nail length and trim and clean on bath day, and as necessary, and report any changes to the nurse. Review of the Electronic Health Record (EHR) under the Task tab for the CNA's, lacked information regarding bathing or nail care. On 07/27/21 at 01:58 PM, an observation of R25's fingernails revealed they were of uneven lengths and had a dark substance under them. On 07/28/21 at 09:28 AM observed R25 sat in his wheelchair in the commons area with fingernails uneven and had a dark substance under his fingernails. On 07/28/21 at 01:05 PM, R25 sat in the dining room, fingernails were still not cut or cleaned, and R25 asked if the surveyor could cut them for him. On 07/29/21 at 09:55 AM, R25 was in the commons room attending an activity and observation revealed his fingernails continued with the dark color substance under the nails, and nails were of uneven lengths. On 08/02/21 at 09:19 AM, R25 sat in the common area, nails continued to have dark substance under them and differing lengths. He stated he would not mind them being trimmed but was tired of asking for it. On 07/28/21 at 01:30 PM, Certified Nurse Aide (CNA) E stated R25 received his baths at night, day shift would brush his teeth, but staff performed nail care on his bath days. CNA E said, to find the last time his nails received care, you would look in the EHR under task, and the last task information would document that information. On 07/29/21 at 10:20 AM, CNA F revealed R25 mainly required assistance with toileting, dressing, and used a slide board to transfer. On his bath days, they would check his nails, and with being a diabetic, a CNA could not trim his nails for him, but they could clean them. CNA F stated there were forms with the bathing that they would fill out and that it had skin and nail assessment on it. If the resident had diabetes, they would inform the nurse that his nails needed trimmed. On 08/02/21 at 10:20 AM, Licensed Nurse (LN) C stated if the residents had diabetes, it would be the nurse's responsibility to trim or cut the finger and toenails. LN C stated she was unaware of R25's need for nail care but would make time to accomplish this task. On 08/02/21 at 12:06 PM, Administrative Staff B stated nails for diabetic residents were cleaned by the nurses, and she expected the nurses to keep up on diabetic resident's toe and fingernail trimming or cutting. She expected the CNAs to let the nurse know if a resident required nail care. Review of the facility's undated Right to Dignity policy documented the facility would groom the elder as they wished, including nail care. The facility failed to maintain R25's dignity by allowing his nails to become overgrown and have a dark substance under them.

The facility reported a census of 26 residents, with 12 included in the sample, including one for respiratory care. Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for Resident (R) 12 which included oxygen use and care. Findings Include: - Review of R12's Electronic Health Record (EHR) dated 06/11/21 documented the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) of 14, indicating intact cognition. R12 utilized oxygen (O2) therapy. Review of the Quarterly MDS dated [DATE] documented a BIMS of 13, indicating intact cognition and he utilized O2. Review of the Care Plan dated 03/30/21 lacked documentation for the care and maintenance of R12's oxygen. On 07/29/21 at 02:18 PM, R12 participated in an activity in the dining room. The staff brought an oxygen concentrator to the dining room for R12's use. On 08/02/21at 09:45 AM, R12 sat in a recliner in his room with O2 via nasal cannula in place. R12 stated he used O2 all the time. The humidifying bottle lack a date of last change. On 07/28/21 at 01:43 PM, Certified Nursing Aide (CNA) E stated R12 used the O2 in the afternoon for his shortness of breath, like having an activity in the dining room. He used the O2 before walking to the dining room. On 07/29/21 at 10:15 AM, CNA F stated R12 was independent during the day, but towards evenings he would need a little bit of help, and he used O2 as needed. On 08/02/21 at 10:30 AM, Licensed Nurse (LN) C stated the oxygen use should be noted on the care plan for each resident using oxygen. On 08/02/21 at 12:04 PM Administrative Nurse B stated she believed the care of oxygen delivery items should be included on the care plan, when asked about oxygen use and care. The facility did not provide a policy regarding care plans, as requested on 08/02/21 at 01:04 PM. The facility failed to develop and implement a comprehensive person-centered care plan for R12 to include oxygen use and care.

The facility reported a census of 26 residents, with 12 sampled, including one for discharge to the community. Based on interview and record review, the facility failed to complete a discharge summary to include the recapitulation of Resident (R) 28's stay. Findings included: - A review of the Minimum Data Set (MDS) documented R28 admitted on [DATE] and discharged on [DATE], with no MDS completed. Review of the Electronic Health Records (EHR) Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued review of the EHR revealed no discharge papers, including a recapitulation of stay, located within R28's record. Interview with Social Services Director (SSD) D on 07/29/21 at 08:20AM stated she did not complete a recapitulation of the stay and that it was the nurses' responsibility to do this. Interview with Administrative Nurse B on 08/02/21 at 11:54 AM confirmed the facility lacked a completed recapitulation of R28's stay. Review of the undated Admission, Transfer and Discharge Policy documented the facility staff documented in the clinical record discharge information provided to the resident including a summary of the care, treatment and services provided and progress reached toward goals. The facility failed to appropriately document the discharge summary, including the recapitulation of stay for R28.

The facility reported a census of 26 residents, with 12 sampled, including one for respiratory care. Based on observation, interview, and record review, the facility failed to provide respiratory care consistent with professional standards of practice for Resident (R) 12. - Findings Include: Review of Resident (R) 12's Electronic Health Record (EHR) dated 06/11/21 documented the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) of 14, indicating intact cognition. Staff had identified R12 as utilizing oxygen (O2) therapy. Review of the Quarterly MDS dated [DATE] documented a BIMS of 13, indicating intact cognition. Staff had identified R12 used oxygen. Review of the Care Plan dated 03/30/21 lacked documentation for the care and maintenance of R12's oxygen. Review of Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review on 08/02/21 at 10:30 AM of Licensed Nursing (LN) and Certified Nursing Aide (CNA) tasks in EHR lacked documentation of oxygen tubing changes. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 07/29/21 at 02:18 PM, R12 was participating in an activity in the dining room. Staff brought an oxygen concentrator to the dining room for R12 to use. On 08/02/21at 09:45 AM, R12 was sitting in a recliner in his room with oxygen via nasal cannula in place. R12 stated he uses oxygen all the time. Oxygen tubing and humidifying bottle lack date of last change. On 07/28/21 at 01:43 PM, CNA E stated that R12 used the oxygen in the afternoon for his shortness of breath, like having an activity in the dining room. He would use the oxygen before walking to the dining room. They believed the LN staff were responsible for changing the oxygen tubing and maintain the humidifier. On 07/29/21 at 10:15 AM, CNA F stated R12 was independent during the day, but towards evenings he would need a little bit of help, and he was on oxygen as needed. CNA F stated she thought the tubing was changed every 30 days by the nurse. On 08/02/21 at 10:30 AM, LN C stated that oxygen tubing and humidifier bottles were to be changed and dated. She believed LN staff would document on the Treatment Administration Record (TAR) on the night shift. However, she was unsure if they were all changed at once or scheduled individually. On 08/02/21 at 12:04 PM Administrative Nurse B stated the LN staff were to change the tubing and humidifier bottles weekly by the night nurse and documented it on tasks. Administrative Nurse B stated she believed the care of such things should have been care planned. She would expect that facility staff change the tubing and humidifier weekly, document the changes, and label the tubing and humifider. She confirmed there were no orders for the care of oxygen supplies for R12. The facility did not provide a policy, as requested on 08/02/21 at 01:04 PM. The facility failed to provide respiratory care consistent with professional standards of practice for R12.

The facility reported a census of 26 residents. Based on interview and record review, the facility failed to ensure the staff person designated as the Infection Preventionist (IP) who was responsible for the facility's Infection Prevention and Control Program (IPCP) completed the specialized training in infection prevention and control. Findings included: - On 08/02/21 at 02:30 PM, Administrative Nurse B revealed that she was responsible for the Infection Prevention and Control Program (IPCP), and she lacked certification as an Infection Preventionist (IP). Furthermore, she revealed the facility lacked a certified IP. Review of the undated Job Description-Infection Preventionist documented that the person in this role was to possess current, specialized training and certification in Infection Control (CIC) in an approved course. The facility failed to ensure the person designated as the IP completed the required certification.

The facility census totaled 21 residents, with four residents identified as having the COVID-19 virus. Based on observation, interview, and record review, the facility failed to ensure Resident (R)1, R2, and R3's rooms were labeled adequately to identify which residents were on transmission-based precautions (infection control practices and procedures to prevent cross-contamination) for COVID-19. Findings included: - Observation on 11/09/20 at 11:00 AM revealed R1 was in her room. On the exterior of the door hung one yellow personal protective gown, and a box of gloves sat on the handrail located next to the door. The door, and area surrounding R1's room, lacked any identification of what type of personal protective equipment (PPE) staff needed in order to enter R1's room. Observation on 11/09/20 at 11:13 AM revealed R3 and R4 in their respective rooms. Both rooms lacked any signage/guidance to staff regarding what PPE was required to enter the residents' rooms. There was no PPE located readily available outside of either room. Interview with Certified Nursing Aide (CNA) B on 11/09/20 at 10:03 AM revealed she believed residents with stop signs on the doors were the residents requiring precautions, also any with yellow gowns hanging on the door. CNA B could verbally report that R1, R2, R3, and R4 did require the use of a gown, in addition to the face shield and face mask she already had in place, to enter their rooms. An interview with CNA C on 11/09/20 at 11:03 AM revealed residents on transmission-based precautions had a stop sign on their door, and she would also find which residents required the precautions during the verbal report. Interview with Licensed Nursing (LN) D on 11/09/20 at 10:16 AM revealed she wrote a list for each department as to which residents were on transmission-based precautions daily. Interview with Administrative Nursing staff A on 11/09/20 at 10:15 AM revealed when the resident's tested positive over the weekend, she had forgotten about placing the precaution signage up to notify all staff. Review of an un-dated facility policy entitled Novel Coronavirus (2019-nCoV)(COVID-19) revealed the facility would implement transmission-based precautions, including signage, when a resident tested positive for COVID-19 or had an undiagnosed respiratory infection. Trash bins would be positioned near the exit doors inside the resident's rooms to allow for the disposal of used PPE. Resident doors would remain closed at all times, and the facility would designate a specific area for infected residents or a specific hallway. The facility failed to ensure that all staff knew R1, R3, and R4 were on transmission-based protocol (which required PPE before entering their room), by failing to post adequate signage outside of the resident's rooms.

The facility totaled 27 residents with three residents sampled for elopement (an incident in which a cognitively impaired resident with poor or impaired decision-making ability/safety awareness leaves the facility without the knowledge of staff). Based on observation, interview, and record review the facility failed to ensure resident (R)1 did not leave the facility without staff knowledge for 57 minutes. Findings included: - Review of Medication Review Sheet, signed by physician on 12/05/19, revealed R1's [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of seven, indicating severe cognitive impairment. He had no documented episodes of wandering during the seven-day review period and he was independent for locomotion on/off the unit. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 10/09/19, reported R1 had impaired short- and long-term memory. Review of the Quarterly MDS, dated [DATE], reported a BIMS of 10, indicating moderate cognitive impairment. There were no documented episodes of wandering during the seven-day review period and he required supervision of one staff member for locomotion on unit and was independent for locomotion off the unit. R1's Care Plan advised staff on 07/22/18 to monitor his location every 30 minutes during the day hours and every hour during the night. Staff were to document wandering behavior and attempt diversional interventions in the behavior log. The Care Plan revision on 05/23/19 included guidance that he believed he could live at home independently and his family believed he required 24-hour supervision due to his history of wandering, confusion, and lack of safety awareness. On 10/24/19, staff were advised he had a Wanderguard (bracelet that sets off an alarm when residents wearing one attempt to exit the building without an escort) which he wore in his pant pockets and staff were to check the location twice a day. A Wandering Risk Scale completed by the facility on 01/08/20 indicated the resident as a high risk to wander. Review of a Behavior Note, dated 02/02/20, revealed R1 talked with his roommate and stated they were living in a prison because they were trying to get out to go to town and they were advised they had to have someone go with them. Review of a Behavior Note, dated 02/02/20, revealed the resident spoke with the unidentified licensed nursing (LN) staff about his finances. During the conversation, he reported feeling like he was in prison and how he would like to get his own apartment. The unidentified LN staff asked the resident if it would help him feel better if he was routinely taken downtown every now and again. The resident reported Someone would still have to go with me, I would still be supervised. I just want to be able to go do stuff on my own without supervision. If I feel like going and sitting at the park, I could go sit at the park. The unidentified LN staff did send a fax to the resident's physician about possible depression and awaited a response. Review of Incident Note, dated 02/08/20, revealed the resident was upset during the morning and then after lunch, he was seen in the front lobby putting in the code to the keypad. He was redirected at that time. About 01:10 PM staff reported they were unable to locate R1 and staff began looking but were unsuccessful. The staff then searched the grounds and found R1 walking towards the facility at the northeast corner. His vital signs were within normal limits and he appeared without distress or signs of injury. R1 denied falling, shortness of breath, or pain. Review of the facility's provided investigation revealed on 02/08/20 at 12:26 PM certified nursing staff (CNA) A witnessed R1 at the front door entering the code on the keypad. CNA A redirected him back to the family room and then, per video surveillance, R1 exited the front door at 12:35 PM. He was found 57 minutes later approximately 50 yards from the front door. The facility staff did not know if the resident left the facility grounds. The Wanderguard device was in a drawer in his room and the staff assigned to perform the 30-minute checks were assisting another resident. Review of Witness Statement, dated 02/08/20, from licensed nurse (LN) [NAME] revealed the resident was wound up all morning regarding some family concerns. While LN [NAME] was providing care to R4, CNA A reported she had witnessed R1 pushing the code into the lobby door keypad but she was able to redirect him. After finishing with R4, LN [NAME] advised staff she was taking a 20-minute food break. Upon her return, she provided care to R5 and at approximately 01:25 PM, CNA A reported they could not locate R1. LN [NAME] had CNA A start checking the grounds. LN [NAME] wrote the staff found R1 with his coat, shoes, khaki pants, and a T-Shirt on and with no shortness of breath noted. Interview with CNA A on 02/11/20 at 10:31 AM revealed she last saw the resident approximately 10-15 minutes prior to him leaving and he was in the process of entering 44 into the keypad. She reported the code at that time as 4488* to open the door, prior the code change on 02/08/20. CNA A could redirect him to the activity room but as she was on her way to speak to LN E, she noted the resident coming out of the room, then redirected himself back into the room. She reported the resident was upset about cough drops and so she advised the nurse about the resident entering part of the code and his desire for cough drops. She then next saw R1 approximately 5-10 minutes after the missing resident code announcement and found him outside on the front sidewalk. CNA A reported R1 did not appear in any distress or display any signs of shortness of air. During an interview with Administrative Staff B on 02/11/20 at 02:26 PM she revealed there was the belief LN [NAME] should have delayed her break until LN [NAME] ensured maintenance were contacted to change the code for the keypad and assigned a staff member to stay with the resident at all times until the code change occurred. Review of the policy entitled Elopement Policy, dated 09/2016, revealed an elopement bracelet would be placed on every resident at risk for elopement. The facility failed to implement immediate interventions after witnessing R1's attempt to enter the code to the front door which allowed R1 to elope and remain out of the facility unaccounted for 57 minutes.

The facility census reported a census of 23 residents with 12 residents in the sample. Based on observation, interview, and record review the facility failed to implement interventions ordered by the physician and recommended by the wound nurse to use a neck pillow and relieve pressure for 1 of 2 residents (#15) reviewed for pressure ulcers. As a result resident #15 developed a 2nd deep tissue injury to his/her left ear. Findings included: - Review of the significant change minimum data set ((MDS) dated [DATE] revealed a brief interview for mental status (BIMS) score of 2 indicating severely impaired cognition. The resident had a risk for pressure ulcers and one unstageable pressure ulcer the time of the assessment. He/she had no pressure ulcers on the prior assessment, received a turning and repositioning program and had pressure reducing devices for his/her chair and bed. Review of the quarterly MDS dated [DATE] revealed the resident's cognition did not change from the 10/6/16 MDS. He/she remained at risk for pressure ulcers, had no unhealed pressure ulcers, and used pressure reducing devices for his/her bed and chair. Review of care area assessments (CAAs) dated 10/6/16 revealed the following: Pressure Ulcer: The resident had an unstageable (full thickness tissue loss in which the base of the ulcer is covered by slough (dead tissue, usually cream or yellow in color) and/or eschar (dead tissue) in the wound bed) pressure ulcer on his/her right heel and received hospice services. He/she required extensive assistance of two staff for bed mobility and had a risk for further skin breakdown. He/she used a pressure reduction mattress. Nutritional status: The resident received a regular diet and had an unstageable pressure ulcer on his/her right heel. He/she had maintained his/her weight and received Hospice services. Review of the Braden Assessment (a scale used to predict pressure ulcer risk) revealed: 1/16/17: The resident had a Braden score of 14 indicating he/she had a moderate risk of developing pressure ulcers. Review of the resident's care plan revealed: 2//15/17 Staff needed to turn the resident every 2 hours. 2/16/17 The charge nurse needed to perform a weekly skin integrity check on Fridays. 2/18/17: The wound nurse needed to document every week about any areas of skin breakdown and include the width, length, depth, and type of tissue, exudate (a mass of cells and fluid that has seeped out of blood vessels or an organ, especially in inflammation) and any changes. The care plan lacked information about whether or not the resident had any pressure related wound and also lacked wound nurse recommendations and physician orders to use a neck pillow and booties keep pressure off the resident's skin. Review of the Nutrition Dietary notes revealed: 2/7/17 Staff needed to offer the resident high calorie, nutrient dense foods and snacks. Review of the signed physician orders dated 3/14/17 revealed: 11/5/16: The resident received a regular diet, regular texture, and regular consistency. 9/21/16 Staff needed to use booties and pillows to ensure the resident had no pressure on his/her skin. 2/21/17 Staff needed to offer the resident a high calorie snack twice daily. Review of the weekly skin integrity record dated 2/10/17 revealed the resident had scattered [MEDICAL CONDITION] but no pressure related wounds. Review of the weekly skin integrity record revealed on 2/17/17 the resident had no pressure related wounds. On 3/17/17 the resident had bruised areas on his/her right and left ears. Review of the weekly wound assessment record revealed: 2/23/17: The resident had a newly developed STDI (suspected deep tissue injury) on his/her right ear antihelix (a part of the visible ear) acquired on 2/22/17 while he/she resided in the facility. The STDI had a dark purple/blue color without drainage. The peri-wound tissue had a pink color, intact skin and no inflammation. The resident's wound measured 35 millimeters (mm) long and 17 mm wide and the treatment focus included relieving pressure through use of a neck pillow and keeping the resident positioned off of his/her ear until the pressure injury healed. 3/3/17: The wound on the resident's right ear antihelix had improved to a dark red with some purple color and no longer deep black and blue. The wound had no drainage and pale colored peri-wound tissue. The resident's wound measured 35 mm (millimeters) long x 25 mm (millimeters) wide. Preventive measures included using a neck pillow to relieve pressure, an air mattress, and keeping the resident off his/her side while in bed. 3/10/17: The wound on the resident's right ear antihelix he/she acquired on 2/22/17 continued to improve with [MEDICATION NAME] tissue (tissue made up of densely packed cells that rest on a basement membrane to act as a covering or lining) present, no drainage, intact peri-wound skin that was pink in color. The resident's wound measured 15 mm long x 7 mm wide and treatment included using a neck pillow while in bed and to keep pressure off his/her ear. On 3/17/17 The STDI located on the resident's right ear antihelix on 2/22/17 had intact skin and was a pink color. A newly developed STDI was discovered on the resident's left ear antihelix. The second STDI was a black/deep purple color, had intact skin without drainage and measured 30 mm long x width 20 mm wide. Treatment and preventive measures for the resident's two STDIs included relieving pressure to the resident's ears while he/she lay in bed, use a neck pillow and an air mattress. Review of the nurse fax communication record revealed staff contacted the physician on 3/17/17 regarding the resident had developed a new deep tissue pressure ulcer to his/her left ear that measured 3 cm (centimeters) x 2 cm (centimeters). The physician responded to treat by keeping pressure off of the area. An observation on 3/21/17 at 4:43 PM revealed direct care staff E and direct care staff F entered the resident's room. Staff E removed the resident's socks to reveal his/her heels. The resident lay on an air mattress and did not have skin breakdown on his/her heels. The resident was not wearing heel protection boots according to physician orders dated 11/5/16. An observation on 3/22/17 at 1:16 PM revealed the resident lay on his/her left side with his/her head on a regular pillow. Subsequent observations on 3/22/17 revealed staff did not reposition the resident at 1:30 PM and 1:45 PM. At 1:58 PM the resident continued to lay on his/her left side with his/her head resting on a regular pillow. Observations at 2:15 PM, 2:30 PM, 2:45 PM, 3:00 PM and 3:15 PM revealed the resident had not changed his/her position. At 3:22 PM a hospice staff entered the resident's room and changed the resident's position. The resident lay on his/her left ear on a regular pillow between 1:16 PM and 3:22 PM (two hours six minutes) before non-facility staff arrived to bathe and reposition him/her. During an interview on 3/21/17 at 4:11 PM direct care staff E reported the resident had a pressure ulcer that was a little spot staff found when they got him/her up in the morning about 3 weeks ago after he/she laid on his/her pillow. Staff E stated the resident had a neck pillow now to keep his/her ears off the regular pillow so he/she would not have pressure on his/her ears and staff needed to turn him/her every two hours when he/she lay in bed. Staff E stated the resident had a history of [REDACTED]. The resident did not resist when staff placed the neck pillow under his/her neck or repositioned him/her. According to orders the resident also should have been wearing his/her booties at all times. During an interview on 3/22/17 at 8:35 AM direct care staff D reported staff placed a neck pillow under the resident's neck when he/she lay in bed to keep pressure off his/her ears. During an interview on 3/22/17 at 5:06 PM direct care staff E reported the resident should not lay on his/her ear and should have laid on his/her neck pillow instead of a regular pillow when staff put the resident in bed. During an interview on 3/22/17 at 5:16 PM licensed staff B reported when staff rolled the resident on his/her side staff needed to check his/her ears to ensure the resident's ears were not folded back. Staff stated staff used a neck pillow to keep pressure off the resident's ears and it needed to be used all the time when he/she lay in bed and if someone put the resident to bed without his/her neck pillow the licensed staff needed to remind the direct care staff to use it. During an interview on 3/23/17 at 9:22 AM administrative nursing staff A reported staff should change the resident's position every two hours and should use the resident's neck pillow to keep pressure off his/her ears and staff should check the resident every two hours to ensure he/she did not lay on his/her ears. During an interview on 3/27/17 at 9:20 AM physician extender staff Q reported the deep tissue injury on the resident's left ear might have been prevented by keeping pressure off the resident's ear. Review of the facility policy Pressure Ulcer Treatment and Prevention Protocol updated on 1/20/17 revealed pressure ulcers shall receive appropriate monitoring and treatment to promote healing. The treatment plan will be initiated under a physician order and staff will follow the treatment procedure appropriate to the wound. The facility failed to implement interventions ordered by the physician and recommended by the wound nurse to use a neck pillow and keep pressure off resident #15's ears. As a result of these failures resident #15 developed a 2nd deep tissue injury located on his/her left ear.

The facility census totaled 28 residents. Based on interview and deficiencies cited, the facility failed to develop and implement an effective system of monitoring action plans through the Quality Assessment and Assurance program to ensure deficient practices cited on the resurvey were corrected. This had the potential to affect 28 residents residing in the facility. Findings included: - Based on interview on 5/24/17 at 2:50 p.m. the facility failed to care plan specific targeted behaviors and interventions to treat the behaviors for residents receiving antipsychotic medications. See F-329. - Based on interview on 5/24/17 at 2:50 p.m. the facility failed to follow the consulting pharmacist recommendations to place specific targeted behaviors and interventions on resident care plans for the use of [MEDICAL CONDITION] medications. See F428. Review of the undated facility policy named Quality Assurance Performance Improvement Policy (QAPI) revealed the facility would ensure all staff consistently developed processes and systems to provide safe, effective, and optimal care and services to the resident who resided at the facility. The goals of the QAPI process of the facility included incorporating quality process assessment, evaluation and improvement planning for all systems and sustaining of improvement in quality within the organization. The facility failed to develop and implement an effective system of monitoring action plans to correct deficient practice cited during the resurvey through the Quality Assessment and Assurance program.

The facility reported a census of 26 residents with 3 residents sampled and 3 residents reviewed for falls. Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent accidents for 1 of the 3 sampled residents, as staff failed to implement appropriate interventions to prevent a fall and the resident sustained [REDACTED]. (#1) Findings included: - Resident #1's [DATE] physician's orders [REDACTED]. blood pressure), CHF (congestive heart failure, or a condition when the heart output presented as low and the body became congested with fluid), and COPD (chronic obstructive pulmonary disease, or a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). Resident #1's physician's orders [REDACTED]. Resident #1's [DATE] Annual MDS (Minimum Data Set) Assessment reported moderately impaired cognition and fluctuating cognitive signs including inattention, disorganized thinking, and psychomotor retardation. The MDS reported that the resident rejected care from staff 4 to 6 days of the observation period. The MDS reported the resident needed limited assistance of 1 staff for bed mobility, transfers, and walking in his/her room and the corridor, needed extensive assistance of 1 staff for toilet use, and used a walker for mobility. The MDS reported the resident experienced frequent incontinence in which a toileting trial resulted in decreased wetness, but currently had no toileting program. The MDS reported the resident experienced 2 falls without injuries since the previous assessment and the resident received diuretic medications 7 of the 7 observation days. Resident #1's [DATE] Falls CAA (Care Area Assessment) Summary reported the resident posed as a high risk for falling due to a [DIAGNOSES REDACTED]. Resident #1's [DATE] Fall Risk Assessment instructed staff that residents with a score of 10 or greater presented as a high risk for falls and listed resident #1's score as "25". Resident #1's [DATE] care plan revealed "I am weak and need more care than I have in the past, I have difficulty with my memory, and Parkinson's disease slowed my body down and my mind. My goal is to keep Parkinson's managed and to slow down the progression so that I can remain as independent as possible. Bending over is difficult." The care plan indicated that 1 staff assisted the resident to ambulate with the use of a walker. The care plan indicated "I often get up and go and don't ask for help so remind me often to wait for help. I have a pressure alarm so that when I get up, staff will know. I am able to turn it off at times, so try placing it out of my reach. I take (a diuretic) daily for CHF. Please give me (the diuretic) near the end of my meal times so I have time to get the bathroom when the medication starts working and I do not rush to the bathroom which makes me a higher risk for falls. I am a higher fall risk as Parkinson's disease effects my mobility and it is getting difficult for me to get up and down, turn, or go through doorways. I have a slow gait and shuffle my feet, so make sure I wear non-skid shoes or slippers and keep my pathway clear, leave the bathroom light or a night light on during the night, and keep items within my reach." The nursing care plan lacked direction to staff regarding the resident ' s toileting needs. Resident #1's "Summary of Falls and Interventions" included falls on the following dates with injuries and/or interventions initiated after each fall: * [DATE], no time listed, fall occurred in room: "was in bed, rolled over to get call light on recliner and rolled out of bed. Resident had requested call light be on (his/her) recliner, recliner will be scooted closer to bed" * [DATE] at 7:15 a.m., fall occurred in his/her room beside bathroom door: "tabs unit placed, resident reminded again to use call light" * [DATE] at 1:30 p.m., fall occurred in his/her room: "chair alarm applied, used with tabs unit also. Resident again reminded to use call light" * [DATE] at 3:45 a.m., fall occurred in his/her room: "re-enforced use of call light, walker and waiting for assistance" * [DATE] at 8:10 p.m., fall occurred in his/her room: "double check pressure alarm (resident taken to hospital via EMS" Review of resident #1's nursing notes on [DATE] at 8:10 p.m., the charge nurse responded to resident #1's room after calls from the direct care staff and found the resident on the floor laying on his/her left side. The nurses' notes reported no alarms sounded in the resident's room "so the resident turned it off". The nurses' notes revealed the charge nurse assessed the resident for injuries, noted the resident complained of left hip/side pain, and transported the resident to local emergency room at 8:20 p.m. after notifying the emergency room physician and the resident's family. The nurses' notes reported that the local hospital called at 10:45 p.m. to report the resident broke his/her left hip. A summary of the incident by Administrative Nursing Staff B revealed on "[DATE] at 8:10 p.m., the resident was found on the floor by staff as they entered the room, and the alarm was not sounding. The resident has in the past shut alarm off, (his/her family member) informed nursing during care plan (meeting) on [DATE] that (the resident) instructed (him/her) how to shut off pressure alarms. The resident complained of left sided pain on assessment and could not straighten the leg comfortably. EMS (emergency medical services) was called and transported the resident to the hospital. " The facility's investigation for the resident ' s fall on [DATE] stated that "prior to this incident, staff attempted to walk with the resident at all times to prevent falls. (The resident) used to use a "TAB" alarm (an alarm box with a string attached to clothing) and a seat alarm, but (he/she) removed TAB alarm frequently. (Direct Care Staff G) stated (he/she) witnessed (resident #1) turning the seat alarm control switch 'off' on several occasions. After he/she had assisted him/her and made sure it was "on", the resident was reminded to use the call light for assistance and (his/her) seat alarm sounded frequently in the resident room, dining room, and the solarium with immediate staff response". Review of the local ER (emergency room ) untimed [DATE] records revealed resident #1 reported he/she fell that evening while walking and slipped on his/her socks. The ER record reported the resident complained of left leg pain described as "shooting and cramping" and tenderness when staff lightly touched his/her left hip area. Review of the local ER [DATE] transfer form revealed a [DIAGNOSES REDACTED]. The ER transfer form reported the resident departed at midnight on [DATE] and transported by the local ambulance to higher level of care hospital for possible left hip surgical repair. During an observation and initial tour with Administrative Nursing Staff B on [DATE] at 9:13 a.m., Staff B identified the room resident #1 resided in prior to his/her death on [DATE]. The resident resided in a room near the nursing station and adjacent to Staff B's office. The resident's room presented as free of clutter and his/her belongings remained in the room. During an interview on [DATE] at 1:27 p.m., Direct Care Staff D reported that resident #1 needed "constant" monitoring as the resident experienced confusion and repeatedly got up without assistance to use the toilet, check on his/her spouse/roommate, and to check his/her in-room refrigerator. Staff D reported resident #1 presented as a high fall risk as he/she experienced shortness of breath, needed oxygen, and experienced dizziness at times after getting up and walking around. Staff D reported that the resident disliked staff assisting him/her with cares and often became angry when staff tried to anticipate his/her needs. Staff D reported that staff utilized pressure alarms when the resident sat in a chair or laid in bed and the resident had enough cognition awareness at times to turn the alarms off. During an interview on [DATE] at 3:45 p.m., Direct Care Staff E reported that resident #1 had a history of [REDACTED]. Staff E reported that staff checked on him/her frequently stating the resident got up without assistance repeatedly. Staff E reported resident #1's fall prevention interventions included non-skid shoes or slippers, check on his/her room every time that staff walked near his/her room, and use of pressure alarms in the bed and chair. Staff E reported that staff checked to make sure that alarms functioned as resident #1 at times turned the alarms off. During an interview on [DATE] at 11:59 a.m., Licensed Nursing Staff F reported staff moved the resident closer to the nursing station, attempted to use motion sensor alarms without success, and the primary physician changed his/her diuretic medication dosages and times to prevent further falls. Staff F reported an awareness that resident #1 knew how to turn off the pressure alarms. Staff F reported that after staff became aware of this, the facility changed resident #1's pressure alarm to a box with a hidden on/off switch to make deactivation more difficult for resident #1 and place the box out of his/her reach. Staff F stated the resident "must have finally found the switch". Staff F verified the use of a pressure alarm for resident #1 as a non-appropriate intervention to prevent further falls. During an interview on [DATE] at 8:24 a.m., Physician C reported that resident #1 presented with enough decision making skills to turn off a pressure alarm if the control box to the alarm remained close to him/her. Physician C reported that if staff placed the control box out of the resident's reach, including "behind the resident's chair, "the resident had more difficulty reaching the box" but had the capacity to get up independently at times. The facility failed to provide adequate supervision to prevent accidents for resident #1, as staff failed to implement appropriate interventions to prevent falls for this cognitively impaired resident with a history of falls and the resident sustained [REDACTED].