Every finding on record at Parkview Heights Nursing and Rehabilitation Center

Based on observation, interview, and record review, the facility failed to accurately complete the Minimum Data Set (MDS) for four residents: Resident (R) 3, R2, R14 and R30, related to anticoagulant medication (medication used to prevent clotting).Findings included:1. R3's Electronic Medical Record (EMR) recorded a Minimum Data Set (MDS), dated [DATE], which documented R3 received an anticoagulant medication (medication used to prevent clotting) during the assessment look-back period.R3's EMR under the Orders tab, revealed the following Physician's Order:Plavix (an antiplatelet medication), 75 milligrams, by mouth, every day, for a diagnosis of atherosclerosis arteries of extremities (when fatty plaque builds up in the arteries that supply blood to your limbs), ordered 01/19/19.2. R14's Electronic Medical Record (EMR) recorded a Minimum Data Set (MDS), dated [DATE], which recorded R14 received an anticoagulant medication (medication used to prevent clotting) during the assessment look-back period.R14's EMR under the Orders tab revealed the following Physician's Order:Plavix, 75 milligrams, by mouth, every day, for a diagnosis of 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), ordered 11/24/22.3. R30's EMR recorded a Minimum Data Set (MDS), dated [DATE], which recorded R30 received an anticoagulant medication (medication used to prevent clotting) during the assessment look-back period.R30's EMR under the Orders tab, revealed the following Physician's Order:Plavix, 75 milligrams, by mouth, every day, for a diagnosis of atherosclerotic heart disease (chronic inflammatory process where plaque builds up inside the arterial walls), ordered 04/24/25.4. R2's EMR recorded a admission MDS, dated [DATE], which recorded R2 received an anticoagulant medication during the assessment look-back period.R2's EMR under the Orders tab, revealed the following Physician's Order: Plavix 75 mg, by mouth, every day, for a diagnosis of atherosclerosis arteries of extremities, ordered 12/28/2025.On 05/21/26 at 12:26 PM, Licensed Registered Nurse (LRN/MDS) B confirmed she had coded the MDS incorrectly regarding the Plavix. LRN/MDS B confirmed Plavix was not an anticoagulant.On 05/21/26 at 02:09 PM, Administrative Nurse C stated it was the expectation for the MDSs to be completed accurately.The facility utilized the Resident Assessment Instrument for completion of accurate MDSs.

Based on observation, record review, and interview, the facility failed to ensure Resident (R) 7 received assistance with activities of daily living (ADL) of cleansing off her face. Findings included:- R7's Electronic Medical Record (EMR) revealed diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion) and weakness.R7's Significant Change Minimum Data Set (MDS), dated [DATE], documented R7 had a Brief Interview for Mental Status (BIMS) score of four, indicating severe cognitive impairment. R7 MDS revealed she had no behaviors and R7 required moderate assistance with personal hygiene. R7's Falls Care Area Assessment (CAA), dated 03/25/25, documented R7 required assistance with mobility and hygiene. R7's Care Plan, dated 10/11/23, instructed staff that R7 was dependent on staff for personal hygiene. R7's Physician Orders, documented Valtrex (is a prescription antiviral medication used to treat and manage viral infections like cold sores), give 1 gram, 1 tablet, by mouth three times a day for sore in mouth until 05/23/26, date ordered 05/19/26. On 05/19/26 at 10:12 AM, R7 was seated in a recliner in lounge area with her eyes closed and a brown colored film of dried food that looked like chocolate pudding noted on her lower lip. On 05/19/26 at 12:53 PM, R7 was seated in the recliner in lounge area with her eyes closed and a dry brown colored film noted on her lower lip.On 05/20/26 at 07:31 AM, R7 sat in her wheelchair at a table near the nurse station she reported she was ok, observed the dried on brown film on her lower lip she reported that she did not know what was wrong with her lip as she tried to wipe it off with a tissue and it did not wipe off.On 05/20/26 at 10:30 AM, staff assisted R7 from activities in her wheelchair to the lounge area. R7 sat there for a little while in her wheelchair. R7 self-propelled around independently, and staff brought her over to the table next to the nurse station and encouraged R7 to fold a basket of towels. She remained with the brown film on lower lip. On 05/21/26 at 08:10 AM, R7 was seated in the dining room with the dried brown film on her lower lip. On 05/21/26 at 08:38 AM, Certified Nurse Aide (CNA) H reported that he was told not to touch R7's mouth/lips as the brown film was dried blood. On 05/21/26 at 01:22 PM, Licensed Nurse (LN) F reported that the CNAs should wipe off R7's lips and the nurse should make sure they are doing that. LN F reported she was unsure what R7 had on her lip, that it was sore and it would bleed. On 05/21/26 at 12:50 PM, Administrative Nurse D revealed she was unsure why R7 was on Valtrex, she reported that she expected the staff to assist R7 with wiping off her lip. The facility's policy Activities of Daily Living (ADLs), dated 06/01/25, documented a resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.

Based on observation, interview, and record review, the facility failed to identify and implement resident-centered fall interventions for Resident (R) 7, R2, and R13 who were at risk for falls.Findings included:- R7's Electronic Medical Record (EMR) revealed diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion) and unsteadiness on feet. R7's Significant Change Minimum Data Set (MDS), dated [DATE], documented R7 had a Brief Interview for Mental Status (BIMS) score of four, indicating severe cognitive impairment. R7 required supervision and touching for transfers, standing, and walking 150 feet; no falls documented. R7's Falls Care Area Assessment (CAA), dated 03/25/25, documented R7 had experienced falls during the lookback window; fall on 03/14/26 resulted in an intra-thalamic bleed (thalamic hemorrhage is a type of stroke that occurs when a blood vessel ruptures within the thalamus) and three right side rib fractures (broken bone). R7 required assistance with mobility and hygiene, has poor safety awareness related to dementia and occasional incontinence of bowel and bladder. She was also prescribed medications that can increase risk of falls. R7's Care Plan, dated 10/01/24, instructed staff to provide call lights within reach and encourage the resident to use it for assistance as needed. R7 needed prompt responses for assistance. R7's Care Plan, dated 10/05/25, instructed staff to educate the resident on the controls of the new recliner and provide her reminders. R7's Care Plan, dated 03/22/26, instructed staff to provide toileting every two hours. R7's Care Plan, dated 03/27/26, documented the plan of care was reviewed and the resident assisted per the care plan in commons area for close observation and continue with current care plan in place. R7's Care Plan, dated 03/31/26, instructed staff to provide 30-minute checks when R7 sat in living room. R7's Care Plan, dated 04/01/26, instructed staff that R7 may rest in recliner in television lounge when feeling restless. R7's Care Plan, dated 04/15/26, documented the plan of care was reviewed in place; the resident was in the living room for close observation, seen by multiple staff five minutes prior to fall with the wheelchair next to the resident. Reinforce with resident to wait for staff assistance for tasks. R7's Care Plan, dated 05/03/26, instructed staff to ask R7 if she is tired, and would like to lay in a recliner or her bed, hourly. R7's Care Plan, dated 05/15/26, for fall on 05/07/26 staff to ensure recliner remote is placed in the pocket of the chair so resident cannot sit on it. R7's EMR under Assessments documented fall assessments, completed on 11/04/25, 12/06/25, 01/08/26, 01/13/26, 02/13/26, 03/15/26. 03/18/26, 03/23/26, 03/28/26, 04/16/26, 04/20/26, 05/03/26, and 05/08/26 R7 were a high risk for falls. R7's Progress Note, dated 11/03/25 at 07:37 AM, documented the resident fell on the way to the bathroom in room. A nurse assessed the resident and found no visualized injury. The resident made no complaints of pain. Review of facility's unwitnessed fall report, dated 11/05/25, documented that R7 was unsteady on her feet and ambulated in room frequently without walker, staff was to encourage R7 to use her walker when ambulating. R7 was alert with confusion and is an active exit seeker. R7's Progress Note, dated 01/08/26 at 05:01 AM, R7 ambulated in hallway with staff. Red in color spots noted on her pants. R7 had a skin tear to left knee, resident had reopened it when she fell again, and the resident did not report the fall at the time of the fall. Review of facility's unwitnessed fall report, dated 01/11/26, documented that R7 was independent in her room with all transfers, refused to use call light despite frequent reminders. Continue with current care plan. R7's Progress Note, dated 03/14/26 at 10:47 AM, documented R7 was found sitting on floor, leaning back against bed; her pants were down on her hips with laundry towels on her lap. Hematoma (collection of blood trapped in the tissues of the skin or in an organ, resulting from trauma) was noted on right side of forehead just above right eye. R7 reported she was at dresser and fell while turning around to move. She reports she hit her head on her floor and landed on her right side. Staff advised to send the resident to emergency room for evaluation due to blood thinner. Review of facility's unwitnessed fall report, dated 03/14/26, documented R7 was found on the floor next to her dresser with her pants not pulled up all the way, R7 was unsteady on her feet, turned and lost balance, fell and hit her head; fall intervention put in place, evening shift staff instructed to assist R7 with picking out her clothing for the next day. R7's Device Assessment on 03/18/26 at 11:28 AM documented a specialty chair was assessed and was being used by the resident; specialty chair used per recommendation for optimal positioning, safety, and pressure reduction. An ambulatory device of a cane or walker was assessed and was being used by resident. This device had been evaluated as assistance with ambulation. No injuries or adverse outcomes were noted due to the use of stated devices in facility. The resident continued to benefit from the use of stated devices in center. Devices were reassessed quarterly and as indicated with a change in resident condition. R7's Progress Note, dated 03/27/26 at 06:04 PM, noted R7 fell onto floor, trying to climb out of a reclined chair. She sustained a laceration noted to the right eyebrow, and an abrasion to the right elbow. The hospice nurse would come out to assess R7. Review of facility's unwitnessed fall report date 03/31/36 documented R7 was restless and unaware of safety needs; she did not put recliner foot down before she tried transfer self. Continue current plan of care. R7's Progress Note, dated 4/20/2026 at 04:22, noted R7 was in the recliner and attempted to get up to get out of chair to use the restroom. Staff witnessed R7 from across the living room during the incident. R7 attempted to get out of recliner while the footrest was up and fell over the footrest and rolled onto her right side on the floor. R7 obtained skin tears to her right elbow and both knees. Review of facility's witnessed fall report dated 04/20/26 documented a new intervention for staff to toilet the resident after lunch. R7's Progress Note, dated 05/07/2026 at 04:55 PM documented staff found R7 sitting on the floor in front of the recliner in the living room. The recliner was in the highest position when the resident was found. She stated I don't know what happened, with no signs of injury. Review of facility's unwitnessed fall report dated 05/15/26 documented R7 leaned on the remote for recliner and raised the recliner to the highest position. The intervention noted staff were educated to ensure the recliner remote was placed in the pocket of the chair so R7 would not sit on remote. R7's EMR lacked any further Device Assessment completed after any of her falls from the recliner. On 05/19/2026 at 10:12 AM R7 sat in a recliner in the lounge with her eyes closed. She had dried food on her lower lips. The recliner remote lay on the floor. On 05/19/26 at 03:00 PM R7 sat in the recliner in the lounge. R7 eyes were closed and the recliner remote lay on her chair on her left side near her hip. On 05/19/26 at 03:28 PM R7 attempted to get up from the recliner; staff intervened and assisted her up to her wheelchair. On 05/20/26 at 10:30 AM staff assisted R7 from activities in her wheelchair to the lounge area. R7 sat there for a little while in her wheelchair. R7 self-propelled around independently, and staff brought her over to the table next to the nurse station and encouraged R7 to fold a basket of towels. On 05/21/2026 at 07:52 AM R7 laid in bed. She reached up and pulled her light switch to her over bed light on. On 05/21/26 at 12:10 PM Certified Nurse Aide (CNA) M reported that if residents were to fall, staff would call the nurse over their microphone. CNA M reported there was usually an intervention completed right after a fall, and it was communicated during report. CNA M reported that the intervention was documented on the care plan, and the staff are trained to look at EMR on the Kardex for interventions. On 05/21/26 at 12:13 PM Licensed Nurse (LN) F reported that an intervention was discussed after a resident had a fall. LN F reported that Administrative Nurse D would update the care plan. LN F reported the staff would discuss an intervention change verbally during report so the staff would know. LN F revealed usually we would change an intervention for a fall. On 05/21/2026 at 02:09 PM, Administrative Nurse C stated R7 had the right to fall, and 30-minute checks would ensure the staff saw R7 at least every 30 minutes to ensure her safety. Administrative Nurse C reported that intervention one on one for R7 was not documented in EMR, and the staff know they have to complete the one on one when R7 was restless. Administrative Nurse C had no reply when asked how a resident with a BIMS of 4 could remember when reminded to call for assistance, use her walker or wait for assistance. Administrative Nurse C reported that a device assessment was completed for residents with a lift chair. The facility policy for Incidents and Accidents, revised 06/01/2025, included: The facility shall ensure appropriate and immediate interventions are implemented to prevent reoccurrences and improve the management of resident care. - R2's Electronic Medical Record (EMR) revealed diagnoses of vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by decreased blood flow to the brain), and weakness and unsteadiness on feet. R2's admission Change Minimum Data Set, (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of seven, indicating severely impaired cognition. R2's MDS revealed he required maximal assistance with transfers, and he was non-ambulatory. R2 was independent with wheelchair mobility. R7's MDS revealed he had falls before he was admitted in the last 2-6 months prior to admission but no falls since he was admitted . R2's Falls Care Area Assessment (CAA), dated 01/15/26, documented R2 was admitted from a rehabilitation hospital with reports of falls on provided documentation. His fall score of 65 reflected a high risk for falls related to history of falls, diagnoses, and weakness, and the BIMS of seven reflected severe cognitive impairment, with poor safety awareness. Staff will anticipate R2's needs in minimizing risk of falls. R2's Care Plan, dated 12/28/25, instructed staff to have call light is within reach and encourage me to use it for assistance as needed. I need prompt responses to all requests for assistance. R2's Care Plan, date initiated 01/11/26, instructed staff to have R2 on close observation related to known wandering behaviors and known poor sleep habits. Continue with current POC in place. R2's Care Plan, date initiated 01/23/26, instructed staff to keep wheelchair pedals in bag on back of wheelchair and not on the side of the wheelchair to reduce another fidget and getting caught on items when self-propelling. R2's Care Plan, date initiated 01/25/26, instructed staff to provide one on one observation overnight when R2 was awake. R2's Care Plan, date initiated 02/24/26, instructed staff to assist R2 with toileting around 03:00 to 04:00 PM. R2's EMR under Assessments documented fall assessments, completed on 01/08/26, 01/11/26, 01/23/26, 02/18/26, 03/04/26, and 04/05/26 R2 were a high risk for falls. R2's Progress Note, dated 01/06/26 at 01:38 PM, documented R2 was admitted to the facility. R2's Device Assessment, on 01/07/26 at 08:13 AM documented a specialty chair was assessed and was being used by the resident. Specialty chair used per recommendation for optimal positioning, safety, and pressure reduction. An ambulatory device of a cane or walker was assessed and was being used by resident. This device had been evaluated as assistance with ambulation. No injuries or adverse outcomes were noted due to the use of stated devices in facility. The resident continued to benefit from the use of stated devices in center. Devices were reassessed quarterly and as indicated with a change in residents' condition. R2's Progress Note, dated 01/10/2026 at 05:10 AM, documented R2 was lying in recliner in living area, staff had just assisted R2 to the bathroom, R2 scooted self to the end of the footrest, chair tipped, and resident fell out of recliner onto floor, onto his right side of his face on the floor. R2 received a skin tear to the right elbow, left thumb, abrasion to right eye. Review of facility's unwitnessed fall report dated 01/11/26 documented R2 does not sleep well and required constant staff supervision for safety; R2 sleeps in recliner in living room; Continue with current care plan. R2's Progress Note, dated 01/23/2026 12:13 AM, documented R2 was in recliner with legs elevated, eyes were closed. The staff observed him in recliner while the staff walked past to go check on another resident. Staff called on walkie that R2 was on the floor, no noted injuries. R2 is a one on one, as R2 does not sleep well, resident tries to get out of recliner, when he wakes up. R2 is alert to self only. R2 forgets he cannot stand or ambulate by himself. Review of facility's unwitnessed fall report dated 01/25/26 R2 is a one-on-one observation overnight when awake. On 05/20/26 at 10:39 AM Certified Nurse Aide (CNA) M and CNA O assisted R2 to his wheelchair they used a gait belt and communicated well with R2. He had difficulty standing up well and kept his knees bent. CNA O propelled R2 in his wheelchair down the hallway to his room approximately 75 feet. No foot pedals were placed on the wheelchair, and his feet hit the floor three times once with a jerking motion of the wheelchair, while she propelled him down the hallway after the third time R2's foot hit the floor CNA O told the resident to keep his feet up. CNA M and CNA O assisted R2 to the toilet and he struggled to stand up well for the staff. CNA M and CNA O completed hands on care and assisted R2 up from the toilet, he struggled to stand, knees were bent, and he had a hard time holding onto the bar on the wall. CNA O reported that she had to bear full weight with the transfer. R2 family member was in the room during care and reported that he had done much better with standing in the past. On 05/20/26 at 01:25 PM R2 sat in his wheelchair self-propelling around in the TV lounge area. On 05/20/26 at 03:30 PM R2 sat in his wheelchair with his feet propped up on a chair and had his eyes closed. On 05/21/26 at 10:38 AM Certified Medication Aide (CMA) I propelled R2 out of his room in his wheelchair and pushed R2 in his wheelchair from his room to nurse station approximately 75 feet with no foot pedals on the wheelchair. On 05/21/26 at 10:40 AM CMA I reported that R2 could not use foot pedals as he had received a bad skin tear on his left leg when he was transferred to the wheelchair, and the foot pedal latch was then covered with a pool noodle cover. CNA H reported that R2 was able to keep his feet up by himself. On 05/21/2026 10:42 AM Licensed Nurse (LN) F reported that R2 should probably use foot pedals when being transported in the wheelchair by the staff. LN F reported that foot pedals are left in the bag hung off the back of a resident's wheelchair when they propel themselves. On 05/21/2026 at 02:09 PM, Administrative Nurse C stated R2 had the right to fall, Administrative Nurse C reported that intervention one on one for R2 was not documented in EMR, that the staff know they must complete the one on one when R2 was awake. Administrative Nurse C reported that a device assessment was completed for residents with a lift chair. The facility policy for Incidents and Accidents, revised 06/01/2025, included: The facility shall ensure appropriate and immediate interventions are implemented to prevent reoccurrences and improve the management of resident care. - R13's Electronic Medical Record (EMR) documented a diagnosis of dementia (a progressive mental disorder characterized by failing memory and confusion). R13's Annual Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of four, indicating severe cognitive impairment. She required partial to moderate staff assistance with standing from a sitting position and used a walker and a wheelchair for mobility. She had one fall with injury (except major) since the prior assessment. R13's Fall Care Area Assessment (CAA), dated 11/27/2025, documented R13 had one fall resulting in a minor injury during the lookback assessment period. R13's Quarterly MDS, dated [DATE], documented she had a BIMS score of three, indicating severe cognitive impairment. She was dependent on staff with standing from a sitting position and used a walker and a wheelchair for mobility. She had one fall with injury since the prior assessment. R13's Care Plan, revised 05/01/26, included staff instruction that she was at risk for falls. Staff were to keep a sign on her bedside table to remind her to call for assistance when she needed to get up and to do hourly rounds to ensure her safety. R13's EMR under the Assessments tab, revealed a fall assessment which placed her at a low risk for falls on 04/19/2026. Further fall assessments, dated 02/23/2026, 01/27/2026, 11/13/2025, and 08/23/2025, placed R13 at a high risk for falls. A Fall Report, dated 04/18/2026, provided by the facility documented R13 had an unwitnessed fall in her room at approximately 02:45 PM. Staff discovered R13 on her back on the floor of her room. R13 was able to move all extremities per normal, and her vital signs (VS) were within normal limits (WNL). Staff assisted her up from the floor and assisted her to sit in her recliner. Staff implemented a fall intervention for staff to do hourly rounds to ensure R13's safety. A Fall Report, dated 01/17/2026, provided by the facility documented R13 had an unwitnessed fall in her room at 08:00 PM. Staff discovered R13 on her back on the floor of her room in front of her recliner. She was able to move all extremities per normal, and her VS were WNL. Staff assisted her up from the floor and assisted her to sit in her recliner. Staff implemented a fall intervention to place a sign on her bedside table reminding her to call staff for assistance before getting up on her own. On 05/19/2026 at 10:35 AM, R13 sat in her recliner in her room. Her call light rested on the floor next to her chair and her bedside table lacked a sign reminding her to call for staff if she needed assistance getting up. On 05/20/2026 at 10:45 AM, R13 sat in her recliner in her room. Her call light rested on the floor next to her chair and her bedside table lacked a sign reminding her to call for staff if she needed assistance getting up. On 05/20/2026 at 01:52 PM, Certified Nurse Aide (CNA) J stated R13 was confused and requires staff assistance with most of her ADLs. CNA J was unaware of fall interventions for R13 but stated she should have her call light within reach when she was in her recliner. On 05/29/2026 at 01:52 PM, CNA H stated R13 was able to walk at times but required staff assistance. CNA H confirmed R13's bedside table lacked a sign reminding her to call for staff if she needed assistance getting up. CNA H stated R13 should have her call light when she was in her room and stated he was unaware of her fall interventions. On 05/20/2026 at 09:37 AM, Licensed Practical Nurse (LPN) E stated staff were to implement a new fall intervention following each fall. The intervention would then be added to the care plan and communicated to the staff. On 05/21/2026 at 02:09 PM, Administrative Nurse C stated the resident had the right to fall. Hourly rounds would ensure the staff saw R13 at least every one hour to ensure her safety. Administrative Nurse C stated she would expect staff to ensure a sign was on R13's bedside table to remind her to call for assistance when she needed to get up. The facility policy for Incidents and Accidents, revised 06/01/2025, included: The facility shall ensure appropriate and immediate interventions are implemented to prevent reoccurrences and improve the management of resident care.

Based on observation, interview, and record review, the facility failed to ensure Resident (R)2 received the necessary nutritional support when staff failed to provide a breakfast meal for several days in May 2026. Findings include:- R2's Electronic Medical Record (EMR) revealed diagnoses of vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by decreased blood flow to the brain) and dysphagia (swallowing difficulty). R2's admission Change Minimum Data Set, (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of seven, indicating severely impaired cognition. R2's MDS revealed he required touching assistance for eating; he had no weight loss and was on a therapeutic diet.R2's Nutritional Status Care Area Assessment (CAA), dated 01/15/26, documented R2 was participating in speech therapy services at a skilled level of care due to dysphagia. R2 received a regular diet of mech soft texture and thin consistency. R2 typically eats 76-100% of meals and snacks. Chart review reflects a stable weight of approximately 130 pounds. Staff would monitor and document oral intake and nutritional changes. Any changes will be addressed with the dietician and physician. R2's Care Plan, dated 12/28/25, staff instructed R2 required supervision or touching assistance when eating. R2's Care Plan, dated 02/03/26, staff were instructed to weigh R2 at the same time of day and record: weekly and as needed with bath scale. Staff were instructed to notify Registered Dietician (RD) and provider of weight loss greater than five pounds (Lbs.). R2's Care Plan, dated 02/04/26, staff were instructed to monitor/record/report to R2's provider as needed signs or symptoms of malnutrition, muscle waste, significant weight loss: greater than 5% in one month, greater than 7.5% in three months, and greater than 10% in six months. Consultant Staff U (RD) to evaluate and make diet change recommendations as needed. R2's Physician Orders, documented regular diet, mechanical soft consistency, and thin liquid consistency, and double protein at meals for wound healing, date ordered 12/30/25.R2's Physician Orders, documented weights weekly with bath days Tuesday or Thursday eveningone time a day, date ordered 12/30/25. R2's Weights, reviewed 04/11/26 through 05/13/26 documented in EMR documented:04/11/26 at 01:28 PM weighed 137.5 Lbs.04/15/26 at 01:50 PM weighed 138.1 Lbs.04/18/26 at 01:57 PM weighed 139.5 Lbs.04/22/26 at 01:41 PM weighed 138.9 Lbs.04/29/26 at 08:51 AM weighed 132.0 Lbs.05/06/26 at 01:22 PM weighed 130.0 Lbs.05/09/26 at 01:56 PM weighed 132.6 Lbs.05/13/26 at 01:42 PM weighed 126.6 Lbs.R2's Registered Dietician Note, dated 05/04/26 03:43 weight on 04/2926 of 132 Lbs. was an unplanned seven Lbs. weight loss in one week. Does not trigger for significant weight loss. R2 is sleeping more and thus not eating as well. Discussed this with interdisciplinary team today. Provider notification would be prepared today notifying him of weight loss. R2 started on 15 milligrams of Remeron (an antidepressant a class of medications used to treat mood disorders) for mood disorder. Remeron can have side effects of increasing appetite. R2's Registered Dietician Note, dated 05/19/26 at 04:02 PM documented, weight on 05/13/26 of 127 Lbs. was a significant, unplanned 8% & 7.5% weight loss in one and three months. R2 continued to sleep throughout the day, thereby making it difficult to eat. Recommend discontinue the double portion entree' due to not eating well. The past week, on average, consumed 33% of his meals. Start an 8-ounce house supplement at bedtime today. R2's Nutrition Amount Eaten, documented in tasks on EMR reviewed from 05/03/26 through 05/21/26 revealed for breakfast meal intake documented on 05/03/26, 05/10/26, 05/13/26, and 05/14/26 lacked a breakfast meal percentage. The breakfast meal intake documented the resident unavailable on 05/04/26, 05/11/26, 05/15/26, 05/20/26 and 05/21/26. The breakfast meal intake documented the resident refused on 05/08/26, and 05/18/26. On 05/20/26 at 07:32 AM R2 was seated in the recliner in the television lounge his eyes were closed, and his upper denture was very dry and stuck to his upper lip. On 05/20/26 at 09:05 AM R2 remained in the recliner in lounge with eyes closed and dry denture remained stuck to his upper lip place. R2 was not observed in the dining room. Resident sat in the recliner under direct observation from 09:05 AM through 10:39 AM. Certified Nurse Aide (CNA) M and CNA O assisted R2 for AM care in his room. On 05/20/26 at 10:50 AM CNA O reported that R2 had just woken up and did not have breakfast. On 05/20/26 at 11:00 AM No breakfast was observed given to R2. After AM care on 05/20/26 he was assisted back into his recliner by CNA M and CNA O. On 05/20/26 at 12:00 PM R2 was in the dining room with his family drinking fluids. At 12:30 PM R2's family member reported that he was so much more awake and ate some of his lunch. On 05/20/26 at 01:25 PM R2 was seated in his wheelchair self-propelling around in the TV lounge area. On 05/20/26 at 03:30 PM R2 sat in his wheelchair with his feet propped up on a chair and had his eyes closed. On 05/21/26 at 07:35 AM R2 was seated in the recliner in the TV lounge with his eyes closed and his dry upper denture hung out of his mouth. On 05/21/26 at 08:51 AM R2 remained in his recliner as above and he had not been offered breakfast. On 05/21/26 at 09:30 AM CNA H reported that R2 would sometimes get up for breakfast, but he stays up late he does not get up for breakfast if he was sleeping that was the family request. CNA H reported that R2 should be getting him up soon and there was breakfast saved for him. On 05/21/26 at 10:38 AM Certified Medication Aide (CMA) I propelled R2 out of his room in his wheelchair and pushed R2 in his wheelchair from his room to nurse station approximately 75 feet with no foot pedals on the wheelchair. On 05/21/26 at 10:43 AM CAN H Provided R2 with a cup of coffee and no breakfast at the table near the nurse station. On 05/21/26 at 10:58 AM Licensed Nurse (LN) F and CNA H weighed R2 on chair scale in spa room, weight of 123.6. On 05/21/26 at 11:05 AM LN F reported that R2 had lost three Lbs., and she would let the charge nurse know. LN F reported that R2 should have been given breakfast. On 05/21/26 at 11:30 AM Dietary Staff P reported that she was involved with weight loss, and Consultant Staff U (RD) had been at the facility for the past two days. Administrative Staff A was also present and reported that the family did not want him woken up to eat and that is charted in the progress notes. Dietary Staff P reported that Consultant Staff P made a recommendation for a house shake on 05/19/26. Dietary Staff P revealed that R2 should have been offered something to eat when he is woken up and was not aware that he had missed meals. On 05/21/26 at 12:27 PM Consultant Staff P revealed that R2 had been sleepy and had started to have a weight loss. She expected the staff to offer R2 something to eat if it was not too close to the lunch meal that was served at 11:30 AM. She reported that R2 started on Remeron on 05/04/26 and that it should help his appetite. On 05/21/26 at 12:50 PM Administrative Staff A gave me the tasks nutrition documentation and some progress notes about R2's weight loss. She reported she could not locate progress notes in EMR before 05/19/26 of the family requests not to wake R2 up for meals. The facility's policy Frequency of Meals dated 01/25/26, documented the facility would ensure that each resident receives at least three meals daily without extensive time lapses between meals.

Based on record and interview, the facility failed to ensure all residents were free from significant medication errors when a staff member administered 30 units of insulin to Resident (R)13, who was not a diabetic.Findings included: - R13's Electronic Medical Record (EMR) documented a diagnosis of dementia (a progressive mental disorder characterized by failing memory and confusion).R13's Annual Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of four, indicating severe cognitive impairment. She did not have a diagnosis of diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin) and did not receive insulin during the seven-day lookback period.R13's Cognitive Loss/Dementia Care Area Assessment, dated 11/27/25, documented R13 had severe cognitive limitations.R13's Quarterly MDS, dated [DATE], documented she had a BIMS score of three, indicating severe cognitive impairment. She did not receive insulin during the lookback period.R13's Care Plan, revised 05/01/26, instructed staff to administer her medications, as ordered.R13's EMR under the Progress Notes tab, dated 05/06/26, documented Licensed Practical Nurse (LPN) G administered 30 units of Lantus insulin (a long-acting insulin used to control high blood sugar (BS) to R13, who was not diabetic, into her left upper arm. LPN G immediately noticed she had administered the insulin to the wrong resident and notified the on-call physician. R13's BS at the time of the insulin administration was 162 milligrams per deciliter (mg/dL). The on-call physician ordered BS to be taken every hour for four hours and if BS were stable to take BS every two hours. If R13's BS went below 70 ml/dL, staff were to administer Glucagon (a hormone produced by the pancreas that raises blood sugar levels) and send her to the emergency room. R13's BS remained stable throughout the night with the lowest BS reading 115 ml/dL at 03:45 AM; the facility staff continued to obtain R13's BS until 10:45 AM when the physician stated the resident was stable and they could stop.On 05/21/2026, LPN G stated she had administered the insulin to the wrong resident and immediately notified the on-call physician. The resident had no negative outcome from the medication error and R13's BS did not go below 70 ml/dL. LPN G stated she monitored R13 throughout the night.On 05/21/2026 at 02:09 PM, Administrative Nurse C stated it was the expectation for the staff to administer medications, as ordered.The facility policy for Medication Administration, revised 04/01/2026, included: Medications are to be administered, as ordered, by the physician.

Based on observation, interview, and record review, the facility failed to ensure staff provided cognitively impaired Resident (R) 7 with her prescribed nectar thickened (liquid with slightly higher viscosity that pour easily but leave a coating on the glass or spoon, they slow down the swallowing process to prevent fluids from entering the lungs) liquids. Findings included:- R7's Electronic Medical Record (EMR) revealed diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion) and weakness.R7's Significant Change Minimum Data Set (MDS), dated [DATE], documented R7 had a Brief Interview for Mental Status (BIMS) score of four, indicating severe cognitive impairment. R7's MDS revealed she was independent with eating. R7's Nutritional Status Care Area Assessment, dated 03/25/25, documented R7 had a prescribed regular diet of regular texture and thin liquids. Consumes 76-100% of meals and snacks of most meals but eating has become more sporadic. Resident has selected hospice care; therefore, comfort eating is encouraged. R7's Care Plan, dated 09/25/25, documented staff to serve diet as ordered, monitor intake and record. Staff to monitor nutritional status. R7's Care Plan, dated 05/19/26, lacked documentation that R7 had nectar thickened liquids ordered. R7's Physician Orders, documented provide regular diet mechanical soft texture (a modified diet that consists of soft, easy-to-chew foods that require minimal chewing), nectar consistency, serve food on red plate; ground meat with gravy, date ordered 05/06/26. R7's Dietary Note, dated 05/04/26 at 12:43 PM, documented nursing reported R7 was having trouble with swallowing liquids, and nursing staff would like her to receive slightly thickened liquids; however, point click care only has nectar thick liquids available as a diet option. Facility will update care plan.On 05/20/26 at 07:31 AM, Certified Nurse Aide (CNA) O assisted R7 to the dining room in her wheelchair. R7 was assisted to her table and where she was seated observed a glass of apple juice and orange juice both glasses approximately 120 milliliters (ml.) of regular thin liquid.On 05/20/26 at 08:37 AM, R7 was served breakfast and did not try to feed herself. CNA O sat down to assist her to eat. R7 had drank a full glass of orange juice and approximately 100 ml of apple juice from 07:33 AM till 08:30 AM and an unknown staff member brought her over another glass of orange juice and sat that in front of her. R7 refused to eat despite encouragement. CNA O gave R7 some coffee and R7 reported there it is and then R7 started to eat the food offered to her only a few bites. Noted that R7 had regular thin orange juice in her cup and apple juice. CNA O confirmed that the juices were not nectar thick and reported that she did not give R7 the juice and had not seen R7 drinking those juices before she sat down, she reported that R7 was nectar thick liquids only and did not know who gave her regular thin juices. CNA O reported that R7's coffee was nectar thick as she made it for her.On 05/21/26 at 08:10 AM R7 was seated in the dining room with regular thin water approximately 240 ml in front of her.On 05/21/26 at 08:12 AM Certified Medication Aide (CMA) I pushed the cup of water away from R7's reach. On 05/21/26 08:12 AM Dietary Staff Q reported that she passed the water this morning and the residents don't always stay seated in the same spot, she reported that R7 was on nectar thick liquid and poured her a cup of nectar thick liquid, she reported she worked yesterday and could not recall giving R7 any juices. On 05/21/26 08:16 AM Dietary Staff P (Certified Dietary Manager) reported that the staff normally pass the water before the residents come into the dining room. She reported that R7 does not usually get juice because she liked coffee. Dietary Staff P reported that the staff know that she is on nectar thick liquids and did not know who or why someone would give R7 juice yesterday and expected the correct fluids to be passed. 05/21/2026 8:20 AM CMA I reported that she noted that R7 had the regular thin water in front of her and pushed the water away from R7 out of her reach. CMA I reported she made R7 her nectar thick coffee then. The facility's policy Therapeutic Diet Orders dated 06/01/26 documented the facility provides all residents with foods in the appropriate form and/or the appropriate nutritive content as prescribed by a physician, and/or assessed by the interdisciplinary team to support the resident's treatment/plan of care, in accordance with his/her goals and preferences. Mechanically altered diet is one in which the texture or consistency of food is altered to facilitate oral intake. Examples include soft solids, pureed foods, ground meat, and thickened liquids. Dietary and nursing staff are responsible for providing therapeutic diets in the appropriate form.

Based on interviews, observation, and record review, the facility failed to utilize Enhanced Barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms which employ targeted gown and glove use during high contact care) when providing direct care to a Resident (R) 7 with open wounds to her knees. Additionally, the facility failed to ensure adequate hand hygiene during a dressing change for R7 and perineal care for R2. The facility failed to properly transport clean personal linens.Findings included:1. On 05/19/26 at 03:32 PM Certified Nurse Aide (CNA) L and CNA N applied gloves, neither CNA performed hand hygiene, nor did they apply any other personal protective equipment (PPE- gowns, face shields and/or eyeglasses/goggles, and gloves) before they assisted R7 to the bathroom and transferred her to the toilet. R7 had a dressing on each of her knees. CNA N removed R7's soiled brief. CNA L then removed her gloves without performing hand hygiene and tried to find R7 a different pair of shoes to wear in her closet. CNA L then applied her gloves without performing hand hygiene. CNA L and CNA N assisted R7 to her feet, CNA L cleansed R7 and CNA L and CNA N pulled up her pants and assisted R7 to her wheelchair. CNA L and CNA N removed their gloves without performing hand hygiene. CNA N removed the gait belt from R7, and CNA L placed the gait belt on her own waist and then both CNA L and CNA N performed hand hygiene. On 05/19/26 03:55 PM CNA L reported that she did not know that R7 was on EBP. CNA L reported that R7 did have open wounds on her knees. CNA L reported that the sticker on the resident's door name tag with the three blue swirling arrows that make a circle meant EBP and confirmed R7 had that sticker on R7's door name tag. CNA L reported that she did not wash her hands when she removed the old ones and should have performed better hand hygiene. On 05/19/26 at 04:00 PM CNA N reported that she did not know that R7 was on EBP. CNA N the sticker on the resident's door name tag with the three blue swirling arrows that make a circle meant EBP and confirmed R7 had that sticker on R7's door name tag and reported she did not notice that on her door tag. CNA N reported she should have performed hand hygiene before hands on care and after she removed her gloves.2. On 05/19/26 at 03:44 PM Licensed Nurse E sanitized her hands and applied gloves and a gown as she entered R7's room. LN E removed the R7's dressing from her right knee, the left knee dressing had rolled off as she pulled up the R7's pant leg. LN E cleansed both knees open areas, LN E removed her gloves and tried to find another pair of gloves in her pocket, CNA L handed LN L a pair of gloves, no hand hygiene was performed. LN E applied the pair of gloves and finished the dressing change.On 05/19/26 at 03:51 PM LN E reported that she did not think to perform hand hygiene when she removed her gloves before applying new ones. LN E reported that R7 was on EBP and that all staff should wear PPE gowns and gloves when they assist R7 with hands on care. 3. On 05/20/26 at 10:39 AM CNA M sanitized her hands applied gloves and gown as she entered R2's room. CNA O applied gloves and gown as she entered R2's room with no hand hygiene performed. CNA M used her gloved hands to open drawers, cupboards and closet doors looking for briefs and wipes. CNA O removed R2's soiled brief, CNA M and CNA O assisted R2 with change of clothes. CNA O removed her gloves without performing hand hygiene and applied new gloves. CNA O attempted to remove R2's upper denture and R2 refused to give them to her. CNA M and CNA O assisted R2 up from the toilet, he struggled to stand, knees were bent, and he had a hard time holding onto the grab-bar on the wall. CNA M cleansed R2 and pulled up his brief and clothes and assisted R2 to his wheelchair. On 05/20/26 at 02:06 PM CNA O reported that she did not realize that she did not wash her hands before she performed care, and that she should have washed her hands when she removed her gloves each time and before applying new gloves.On 05/20/26 at 02:06 PM CNA M reported that she should not have used her gloved hands to look for items in R2's room and that she should have washed her hands when she removed her gloves each time and before applying new gloves.4. On 05/20/26 at 11:03 AM observed Laundry Staff R delivered personal clothes to the residents' rooms in the 100 hallways, The linen cart was not covered as Laundry Staff R moved the linen cart down the hallway from room to room, Laundry Staff R also was observed pulling the clothes off the rack in hangers and hugging the clothes against her uniform.On 05/20/26 at 11:10 AM Laundry Staff R reported that she would keep the linen cart uncovered while she delivered down the entire hallway. Laundry Staff R reported she did not realize that she hugged the clothes against her uniform. 5. On 05/20/26 at 11:16 AM LN K prepared R14's insulin in the nurse station. LN K picked up a washcloth off the floor that R7 had dropped on the floor and R7 attempted to reach for the washcloth on the floor. LN K entered R14's room without performing hand hygiene before she applied gloves and administered the insulin to R14. 6. On 05/20/26 at 11:39 AM LN K prepared R22's insulin in the nurse station. LN K put a pair of gloves, alcohol prep, and insulin pen into her pocket. LN K entered the dining room and propelled R22's wheelchair out to the hallway. LN K pulled the gloves, alcohol prep and insulin pen out of her pocket without performing hand hygiene before she applied her gloves and administered the insulin to R22.On 05/20/26 at 03:25 PM LN K reported that she should have performed hand hygiene after she picked up the towel off the floor before she placed her gloves to administer R14's insulin and she should have performed hand hygiene after she moved R22 into the hallway. On 05/21/26 at 09:50 AM Administrative Staff A reported that the linen should be covered when delivered down the hallways and the clothes/linen should not be hugged by staff. On 05/21/26 at 12:50 PM Administrative Nurse D (Infection Preventionist) revealed she expected staff to wear appropriate PPE when providing direct care for residents on EBP. Additionally, she expected the staff to use clean gloves when providing care. Administrative Nurse D revealed she expected staff to perform hand hygiene before providing care and perform hand hygiene after staff removed gloves before they apply new gloves. The facility's policy Enhanced Barrier Precautions, dated 04/01/26, documented PPE for enhanced barrier precautions is only necessary when performing high-contact care activities. High-contact resident care activities include transferring, providing hygiene, changing briefs or assisting with toileting, and wound care: any skin opening requiring a dressing. The facility's policy Infection Prevention and Control Program, dated 02/15/26, documented hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures; laundry and direct care staff shall handle, store, process, and transport linens to prevent spread of infection; clean linen shall be delivered to resident care units on covered linen carts with covers down.

Based on interview and record review the facility failed to offer and provide or obtain an informed declination for the COVID-19 vaccine (a vaccine designed to prevent highly contagious respiratory virus) for Resident (R) 2. Additionally, the facility failed to maintain staff documentation of screening, education, offering, and current COVID-19 vaccination status. Findings included:1. R2's Electronic Medical Record (EMR) lacked documentation of a COVID-19 vaccine being offered since 2022.On 05/21/26 at 12:50 PM, Administrative Nurse D (Infection Preventiveness) reported that the facility does not maintain staff documentation of screening, education, offering, and current COVID-19 vaccination status, and that if a staff member was ill then they are told to go to their provider and to let the facility know. The facility's policy Infection Prevention and Control Program, dated 02/15/26, documented COVID-19 Immunization:Residents and staff will be offered the COVID-19 vaccines when vaccine supplies are available to the facility. If COVID-19 vaccination requires multiple doses, the resident, resident representative, or staff member is provided with current information regarding those additional doses, including any changes in the benefits or risks and potential side effects, associated with the COVID-19 vaccine, before requesting consent for administration of any additional doses. Residents or resident representatives will have the opportunity to accept or refuse a COVID-19 vaccination, and change their decision based on current guidance. Staff will have the opportunity to receive the COVID-19 vaccination or apply for a religious or medical exemption to the vaccine for facility consideration as per current Equal Employment Opportunity Commission (EEOC is an independent federal agency established by the Civil Rights Act of 1964 guidelines), state requirements, and/or facility policy. The facility will maintain documentation related to staff COVID-19 vaccination that includes at a minimum, the following:That staff were provided education regarding the benefits and potential risks associated with COVID-19 vaccine; Staff were offered the COVID-19 vaccine or information on obtaining COVID-19 vaccine.

The facility reported a census of 35 residents. Based on interview and record review, the facility failed to electronically submit to Centers for Medicare and Medicaid Services (CMS) with complete and accurate direct staffing information, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS (i.e. Payroll Base Journal (PBJ), related to licensed nursing staffing information, when the facility failed to accurately report 24 hour per day Licensed Nurse coverage on eight dates between 04/01/23 and 06/30/23 and five dates between 10/01/23 and 12/31/23. Findings Included: - Review of the Payroll Base Journal (PBJ) Staffing Data Report for fiscal year (FY),Quarter 3 2023 (April 1- June 2023) revealed lack of License Nurse (LN) for 24 hours/seven days a week 24 hour/day on the following dates: On 05/06, Saturday (SA), On 05/07, Sunday (SU), On 05/21, SU, On 06/10, SA, On 06/11. SU, On 06/24, SA, On 06/25, SU, Review of the PBJ for FY, Quarter 1, 2024 (October 1-December 1), revealed the following infraction dates the facility failed to have Licensed Nursing Coverage 24 hours/day included: On 11/11, SA, On 11/25, SA, On 12/08, Firday (FR), On 12/16, SA, On 12/19, Tuesday (TU), Interview, on 08/12/24 at 08:45 AM, with Administrative Staff A stated it was possible the information regarding licensed nurse hours had not been submitted accurately to reflect the actual hours worked by licensed nurses. The facility policy Payroll Based Journal dated 01/01/24, instructed staff to electronically submit timely to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS. The facility failed to electronically submit to Centers for Medicare and Medicaid Services (CMS) with complete and accurate direct staffing information, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS (i.e., Payroll Base Journal (PBJ), related to licensed nursing staffing information when the facility failed to accurately report 24 hour per day Licensed Nurse coverage on eight dates between 04/01/23 and 06/30/23 and five dates between 10/01/23 and 12/31/23.

The facility reported a census of 35 residents with 14 residents selected for review. Based on observation, interview and record review, the facility failed to complete and analysis of findings for the Minimum Data Set (MDS), triggered Care Area Assessments (CAA) to complete a comprehensive assessment and develop a care plan for four of the 14 residents selected for review. This included Resident(R) 15, for Delirium; Cognitive Loss/Dementia, Psychotropic Drug Use and Pain, R 14 for Delirium, Cognitive Loss/Dementia, Psychotropic Drug Use, Psychosocial Well-Being, Pain, Mood State, Falls, Urinary Incontinence and Indwelling Catheter, R31 for Cognitive Loss/Dementia, Mood State, Psychotropic Drug Use, and Behavioral Symptoms and R8 for Urinary Incontinence and Indwelling Catheter, ADL (Activity of Daily Living) Functional/Rehabilitation Potential, Pain, and Return to Community to develop 'Comprehensive Care Plans as required. This deficient practice had the potential to lead to uncommunicated care needs. Findings included: - Review of Resident (R)31's medical record revealed diagnoses that included mild cognitive impairment, anxiety, major depressive disorder (major mood disorder), psychosis (any major mental disorder characterized by a gross impairment in reality testing), insomnia (inability to sleep), and dementia (progressive mental disorder characterized by failing memory, confusion) with behavioral disturbance. The Significant Change Minimum Data Set (MDS), dated [DATE], assessed the resident with severely impaired cognitive function, continuous inattention, altered level of consciousness. The resident received antipsychotic (class of medications used to treat psychosis and other mental emotional conditions), antianxiety (class of medications that calm and relax people with excessive anxiety, nervousness, or tension), antidepressant (class of medications used to treat mood disorders and relieve symptoms of depression), anticoagulant (medication use to prevent blood clots) and opioid (a class of medications used to treat pain), medications. The resident displayed nonverbal sounds and facial expressions of pain. The resident received no scheduled pain medications but did receive as needed pain medications and nonmedicinal interventions for pain. The Care Area Assessment (CAA), dated 07/25/24, was not developed for the MDS triggered areas of Cognitive Loss/Dementia, Mood State, Psychotropic Drug Use, and Behavioral Symptoms. On 08/13/24 at 12:57 PM, Administrative Nurse E stated she indicated on the CAA to care plan the area but did not develop the specific care area assessment for the triggered areas. The facility utilized the Resident Assessment Instrument (RAI) in completion of the MDS. The facility failed to develop the MDS triggered CAAs to complete a comprehensive assessment for this resident to develop a comprehensive care plan as required. This deficient practice had the potential to lead to uncommunicated care needs. - Review of Resident (R)8's medical record, revealed diagnoses included neurogenic dysfunction of the urinary bladder caused by a lesion of the nervous system, bladder with chronic urinary retention, hemiplegia (paralysis of one side of the body), and hemiparesis (muscular weakness of one half of the body). The Admission Minimum Data Set (MDS) dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of 14, which indicated normal cognitive function. The resident had an indwelling urinary catheter (insertion of a catheter into the bladder to drain the urine into a collection bag). The resident received scheduled and as needed pain medication and desired to return home. The Care Area Assessment (CAA), dated 07/28/24, for the MDS triggered areas of Urinary Incontinence and Indwelling Catheter, ADL (Activity of Daily Living) Functional/Rehabilitation Potential, Pain, and Return to Community were not developed. On 08/13/24 at 12:57 PM, Administrative Nurse E stated she indicated on the CAA to care plan the area, but did not develop the specific care area assessment for the triggered areas. The facility utilized the Resident Assessment Instrument (RAI) in completion of the MDS. The facility failed to develop the MDS triggered CAAs to complete a comprehensive assessment for this resident to develop a comprehensive care plan as required. This deficient practice had the potential to lead to uncommunicated care needs. 34056 - Review of Resident (R)15's electronic medical record (EMR), revealed a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion). The Significant Change Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of five, indicating severe cognitive impairment. She required supervision to touching assistance with chair to bed to chair transfers and had no limitation in functional range of motion (ROM). The following Care Area Assessments (CAA)s, dated 01/04/24, triggered but lacked an analysis of findings: Delirium, Cognitive Loss/Dementia, Psychotropic Drug Use and Pain. The care plan, revised 05/29/24, instructed staff the resident required substantial assistance of two staff for transfers and staff were to encourage the resident to wear non-skid footwear. Staff were to monitor the resident for pain and administer pain medications, as ordered. Staff were instructed to ask the resident yes or no questions and allow her plenty of time to complete her daily tasks. The care plan listed the black box warnings (BBW-the highest safety-related warning that medications can have assigned by the Food and Drug Administration (FDA) the staff were to monitor for due to the resident's use of psychotropic medications. Review of the resident's EMR from 07/16/24 through 08/13/24, revealed the resident required substantial/maximal to dependent assistance of two staff for all transfers. On 08/14/24 at 08:15 AM, Administrative Nurse D stated it was the expectation for the triggered CAAs to include an analysis of findings. The facility utilized the Resident Assessment Instrument (RAI) in the completion of MDSs. The facility failed to accurately complete the Significant Change MDS Care Area Assessments for this dependent resident. This deficient practice had the potential to lead to uncommunicated needs. - Review of Resident (R)4's electronic medical record (EMR), revealed a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion). The Significant Change Minimum Data Set (MDS), dated [DATE], documented the staff assessment for cognition revealed severe impairment. The resident required substantial/maximal assistance of staff for transfers and had no limitation in functional range of motion (ROM). The following Care Area Assessments (CAA)s, dated 02/29/24, triggered but lacked an analysis of findings: Delirium, Cognitive Loss/Dementia, Psychotropic Drug Use, Psychosocial Well-Being, Pain, Mood State, Falls and Urinary Incontinence and Indwelling Catheter. The care plan, revised 07/23/24, instructed staff the resident required substantial assistance of two staff for transfers and staff were to ensure the resident wore non-skid footwear. The care plan listed the black box warnings (BBW-the highest safety-related warning that medications can have assigned by the Food and Drug Administration (FDA) the staff were to monitor for due to the resident's use of psychotropic medications. The resident had a diagnosis of dementia and staff were instructed allow the resident adequate time to respond to questions. Staff were to monitor for pain and administer pain medications, as ordered. Staff were to check and change the resident due to urinary and bowel incontinence. Review of the resident's EMR, from 07/15/24 through 08/12/24, documented the resident required substantial/maximal to dependent assistance of two staff with transfers. On 08/12/24 at 10:09 AM, Certified Nurse Aides (CNA)O and CNA Q transferred the resident from her bed to her specialized wheelchair with extensive assistance. The resident lacked non-skid footwear, was unable to bear weight and her feet slid on the floor during the transfer. The staff failed to use a gait belt (a device put on a patient who has mobility issues, by a caregiver prior to that caregiver moving the patient). On 08/14/24 at 08:15 AM, Administrative Nurse D stated it was the expectation for the triggered CAAs to include an analysis of findings. The facility utilized the Resident Assessment Instrument (RAI) in the completion of MDSs. The facility failed to accurately complete the Significant Change MDS for this dependent resident. This deficient practice had the potential to lead to uncommunicated needs.

The facility reported a census of 35 residents with 14 residents sampled, including two residents reviewed for respiratory services. Based on observation, record review, and interview, the facility failed to complete a comprehensive care plan for one Resident (R)33, regarding the use of a Continuous Positive Airway Pressure (CPAP-a non-invasive positive airway pressure) for one Resident (R)33. Findings included: - Review of Resident (R) 33's electronic medical record (EMR) revealed a diagnosis of sleep apnea (a sleep disorder characterized by periods without respirations). The Modification of Admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The resident did not utilize a Continuous Positive Airway Pressure (CPAP-a non-invasive positive airway pressure). The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 07/08/24, did not trigger. The care plan, revised 07/12/24, lacked staff instruction on the use and care of the resident's CPAP. Review of the resident's EMR lacked a physician's order and indication for the CPAP. On 08/12/24 at 09:30 AM, the resident sat in the recliner in her room. Her CPAP mask was inside a plastic bag on the table next to her recliner. The mask contained a dried white substance and remained connected to the hose of the machine. On 08/14/24 at 07:37 AM, the resident sat in the recliner in her room. Her CPAP mask was inside a plastic bag on the table next to her recliner. The mask contained a dried white substance and remained connected to the hose of the machine. On 08/12/24 at 09:30 AM, the resident stated she used the CPAP every night when she slept. The resident stated she did not think the staff were cleaning her mask in between uses. On 08/14/24 at 08:15 AM, Administrative Nurse D stated she would expect for a resident who utilized a CPAP machine to have it included on her care plan. The facility policy for Comprehensive Care Plans, undated, included: The facility shall develop and implement a comprehensive person-centered care plan for each resident including measurable objectives and timeframe's to meet the resident's medical and nursing needs identified in the resident's comprehensive assessment. The facility failed to complete a comprehensive care plan for this resident who utilized a CPAP machine.

The facility reported a census of 35 residents with 14 residents sampled, including two residents reviewed for positioning. Based on interview, record review, and observation, the facility failed to ensure appropriate positioning for one Resident (R)4, while in her specialized wheelchair. Findings included: - Review of Resident (R)4's electronic medical record (EMR) revealed a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion). The Significant Change Minimum Data Set (MDS), dated [DATE], documented the staff assessment to reveal severe cognitive impairment. The resident was dependent on staff for mobility in a wheelchair. The Functional Abilities Care Area Assessment (CAA), dated 02/29/24, did not trigger. The Cognitive Loss/Dementia CAA, dated 02/29/24, triggered but lacked an analysis of findings. The Quarterly MDS, dated [DATE], documented the resident's Brief Interview for Mental Status (BIMS) score of five, indicating severe cognitive impairment. The resident was dependent on staff for mobility in a wheelchair. The care plan, revised 07/23/24, documented the resident was dependent on staff for mobilization in her wheelchair. Review of the resident's EMR from 07/16/24 through 08/13/24, revealed the resident was dependent on staff for mobilization in her wheelchair. On 08/12/24 at 11:34 AM, the resident sat in the dining room awaiting lunch. The resident's feet dangled above the footrest of her wheelchair approximately eight inches. On 08/14/24 at 06:51 AM, Certified Nurse Aide (CNA)P propelled the resident from the spa room to the table in the living room. The resident's feet dangled above the footrest of her wheelchair approximately eight inches. On 08/14/24 at 07:51 AM, CNA P stated the resident's feet did not always reach the footrest of the wheelchair. On 08/14/24 at 07:01 AM, Licensed Nurse (LN) G stated the resident's feet should be able to reach the footrest and not just dangle in the air. On 08/14/24 at 08:15 AM, Administrative Nurse D stated it was the expectation for staff to ensure resident's feet rested comfortably on the footrest of their wheelchairs. The facility policy for Use of Assistive Devices, implemented 04/2023, included: Direct care staff will be trained on the use of assistive devices, such as wheelchairs, as needed to carry out their roles and responsibilities regarding the devices in a safe, comfortable manner for the residents. The facility failed to ensure this dependent resident was positioned properly in her wheelchair.

The facility reported a census of 35 residents with 12 residents sampled, including five residents reviewed for accidents. Based on observation, interview, and record review, the facility failed to provide safe transfers for two Residents (R)4 and R 15, and failed to provide safe wheelchair transport for one R 28. Findings included: - Review of Resident (R)15's electronic medical record (EMR), revealed a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion). The Significant Change Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of five, indicating severe cognitive impairment. She required supervision to touching assistance with chair to bed to chair transfers and had no limitation in functional range of motion (ROM). The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 01/04/24, triggered but lacked an analysis of findings. The Functional Abilities CAA, dated 01/04/24, did not trigger. The Quarterly MDS, dated [DATE], documented the resident had a BIMS score of two, indicating severe cognitive impairment. She required substantial to maximal assistance with chair to bed to chair transfers and had no limitation in functional ROM. The care plan, revised 05/29/24, instructed staff the resident required substantial assistance of two staff for transfers. Staff were to encourage the resident to wear non-skid footwear. Review of the resident's EMR from 07/16/24 through 08/13/24, revealed the resident required substantial/maximal to dependent assistance of two staff for all transfers. On 08/13/24 at 08:28 AM, Certified Nurse Aide (CNA) N and CNA Q transferred the resident from her specialized wheelchair to her bed. The resident was unable to bear weight during the transfer and lacked non-skid footwear. The resident's legs became twisted, and her feet slid on the floor during the transfer. On 08/13/24 at 08:28 AM, CNA N confirmed the resident was not wearing non-skid footwear during the transfer and was unable to bear weight. On 08/14/24 at 06:51 AM, Licensed Nurse (LN) G confirmed the resident was unable to bear weight on her legs. LN G stated staff should use a full body mechanical lift for residents who were unable to bear weight during a transfer. On 08/14/24 at 08:15 AM, Administrative Nurse D stated all residents should wear non-skid footwear during transfers. Staff were expected to use a mechanical lift for residents who were unable to bear weight. The facility policy for Safe Resident Transfers, revised 01/01/23, included: It is the policy of the facility to ensure residents are transferred safely to prevent or minimize risks for injury. Mechanical lifting equipment will be used based on the resident's needs to prevent manual lifting. The facility failed to safely transfer this dependent resident. - Review of Resident (R)4's electronic medical record (EMR), revealed a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion). The Significant Change Minimum Data Set (MDS), dated [DATE], documented the staff assessment for cognition revealed severe impairment. The resident required substantial/maximal assistance of staff for transfers and had no limitation in functional range of motion (ROM). The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 02/29/24, triggered but lacked an analysis of findings. The Functional Abilities CAA, dated 02/29/24, did not trigger. The Quarterly MDS, dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of five, indicating severe cognitive impairment. The resident required substantial/maximal assistance of staff for transfers and had no limitation in functional ROM. The care plan for Activities of Daily Living (ADL)s, revised 07/23/24, instructed staff the resident required substantial assistance of two staff for transfers. Staff were to ensure the resident wore non-skid footwear. Review of the resident's EMR, from 07/15/24 through 08/12/24, documented the resident required substantial/maximal to dependent assistance of two staff with transfers. On 08/12/24 at 10:09 AM, Certified Nurse Aides (CNA) O and CNA Q transferred the resident from her bed to her specialized wheelchair with extensive assistance. The resident lacked non-skid footwear, was unable to bear weight and her feet slid on the floor during the transfer. The staff failed to use a gait belt (a device put on a patient who has mobility issues, by a caregiver prior to that caregiver moving the patient). On 08/12/24 at 10:09 AM, CNA O confirmed the resident was not wearing non-skid footwear and had not been able to bear weight during the transfer. On 08/13/24 at 08:39 AM, CNA M stated the resident was not able to bear weight during transfers. On 08/14/24 at 06:51 AM, Licensed Nurse (LN) G confirmed the resident was unable to bear weight on her legs. LN G stated staff should use a full body mechanical lift for residents who were unable to bear weight during a transfer. On 08/14/24 at 08:15 AM, Administrative Nurse D stated all residents should wear non-skid footwear during transfers. Staff were expected to use a mechanical lift for residents who were unable to bear weight. The facility policy for Safe Resident Transfers, revised 01/01/23, included: It is the policy of the facility to ensure residents are transferred safely to prevent or minimize risks for injury. Mechanical lifting equipment will be used based on the resident's needs to prevent manual lifting. The facility failed to safely transfer this dependent resident. - Review of Resident (R)28's electronic medical record (EMR) revealed a diagnosis of weakness. The Significant Change Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of three, indicating severe cognitive impairment. She required partial to moderate assistance of staff for wheelchair mobility. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 07/18/24, triggered but lacked an analysis of findings. The Functional Abilities CAA, dated 07/18/24, did not trigger. The Quarterly MDS, dated [DATE], documented the resident had a BIMS score of four, indicating severe cognitive impairment. She was independent for mobility with the use of her wheelchair. The care plan, revised 06/26/24, instructed staff the resident required staff assistance with the use of her wheelchair. Staff were to remove the foot pedals from the wheelchair when not propelling the resident. Review of the resident's EMR, from 07/15/24 through 08/13/24, revealed the resident was dependent on staff for mobility in her wheelchair. On 08/12/24 at 12:25 PM, Certified Nurse Aide (CNA) O propelled the resident in her wheelchair from the dining room to her room. The foot pedals were in place to the wheelchair, but the resident had her shoed feet pulled back underneath the wheelchair with the tips off her toes skimming the floor. On 08/14/24 at 06:48 AM, CNA P propelled the resident from the front commons area to the dining room for breakfast. The resident's left shoed foot was pulled back underneath the wheelchair and the toe of her shoe skimmed the floor. The resident's right foot remained on the foot pedal during transport. On 08/12/24 at 12:25 PM, CNA O stated the resident was not able to keep her feet on the foot pedals of the wheelchair because the foot pedals were to far out in front for the resident to reach them with her feet. On 08/14/24 at 06:48 AM, CNA P stated the resident was unable to propel her wheelchair anymore and required the assistance of staff. CNA P confirmed the resident's left foot had been underneath the wheelchair during transport. On 08/14/24 at 06:51 AM, Licensed Nurse (LN) G stated staff should ensure resident's feet are securely on the foot pedals of the wheelchair during transport. On 08/14/24 at 08:15 AM, Administrative Nurse D stated it was the expectation for staff to use foot pedals while propelling residents in their wheelchairs. The facility policy for Use of Assistive Devices, implemented 04/2023, included: Direct care staff will be trained on the use of assistive devices, such as wheelchairs, as needed to carry out their roles and responsibilities regarding the devices in a safe, comfortable manner for the residents. The facility failed to safely transport this dependent resident in her wheelchair.

The facility reported a census of 35 residents with 14 residents sampled, including two residents reviewed for respiratory services. Based on observation, record review, and interview, the facility failed to obtain a physician's order for the use of a Continuous Positive Airway Pressure (CPAP-a non-invasive positive airway pressure) for one Resident (R)33. Findings included: - Review of Resident (R) 33's electronic medical record (EMR) revealed a diagnosis of sleep apnea (a sleep disorder characterized by periods without respirations). The Modification of Admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The resident did not utilize a Continuous Positive Airway Pressure (CPAP-a non-invasive positive airway pressure). The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 07/08/24, did not trigger. The care plan, revised 07/12/24, lacked staff instruction on the use and care of the resident's CPAP. Review of the resident's EMR lacked a physician's order and indication for the CPAP. On 08/12/24 at 09:30 AM, the resident sat in the recliner in her room. Her CPAP mask was inside a plastic bag on the table next to her recliner. The mask contained a dried white substance and remained connected to the hose of the machine. On 08/14/24 at 07:37 AM, the resident sat in the recliner in her room. Her CPAP mask was inside a plastic bag on the table next to her recliner. The mask contained a dried white substance and remained connected to the hose of the machine. On 08/12/24 at 09:30 AM, the resident stated she used the CPAP every night when she slept. The resident stated she did not think the staff were cleaning her mask in between uses. On 08/13/24 at 01:37 PM, Certified Nurse Aide (CNA) N stated the resident cared for the CPAP mask on her own. On 08/14/24 at 07:30 AM, CNA M stated the resident cared for her CPAP mask. On 08/14/24 at 08:15 AM, Administrative Nurse D confirmed the facility lacked an order for the CPAP machine. The facility policy for Noninvasive Ventilation, implemented 01/21/24, included: The facility shall document the use of the CPAP machine, the resident's tolerance, any skin, respiratory or any other changes, as ordered by the physician. The facility failed to obtain a physician's order for the use of a CPAP machine for this dependent resident with a diagnosis of sleep apnea and failed to ensure the mask was clean/changed according to professional standards to prevent possible respiratory illness.

The facility identified a census of 33 residents. Based on record review, and interviews, the facility failed to provide a certified infection preventionist to oversee the facility's Infection Prevention and Control Program (IPCP). This deficient practice placed all residents at increased risk of infections related tor lack of identification, tracking/trending, and treatment of infections. Findings included: - On 12/08/22 at 01:56 PM Administrative Nurse E reported that she assumed the responsibilities of infection preventionist after the previous nurse quit the facility last August. She stated that she was currently working on becoming certified and only had four learning modules left. On 12/08/22 at 0245 PM Administrative Nurse D reported that the facility's previous certified infection preventionist left the faciity on [DATE]. The she stated that Administrative Nurse E had assumed the IPCP duties and began taking classes to become certified in August of 2022. The facility was unable to provide a policy related to the Infection Preventionist as requested on 12/08/22. The facility failed to provide a certified infection preventionist to oversee the facility's IPCP program. This deficient practice placed all residents at increased risk of infections related to lack of identification, tracking/trending, and treatment of infections.

The facility reported a census of 33 residents with 13 selected for review. Based on observation, interview, and record review, the facility failed to conduct an assessment for Resident (R)15 to determine the safety for self-administration of vaporizing rub ointment. This placed R15 at risk to use the vaporizing rub ointment in an unsafe manner. Findings included: - The Medical Diagnosis tab for R15 included diagnoses of chronic obstructive pulmonary disease (COPD - progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), chronic respiratory failure with hypoxia (inadequate supply of oxygen), and pulmonary hypertension (high blood pressure affecting arteries in the lungs and right side of the heart that can cause shortness of breath, chest pressure, and dizziness). The Quarterly Minimum Data Set (MDS) dated [DATE] assessed R15 with a Brief Interview of Mental Status (BIMS) score of 15, indicating intact cognition and required oxygen. The Annual MDS dated [DATE] for R15 revealed no changes from the prior assessment. The Care Plan dated 11/22/22 revealed R15 was at risk for altered respiratory function related to COPD and she required oxygen at all times. The staff were to administer nebulizer treatments as scheduled and as needed. The Orders tab included a physician order for R15, dated 12/30/21, for oxygen per nasal cannula at three liters. The Orders tab did not include an order for vaporizing rub (white petrolatum based topical ointment used for cough suppressant/topical analgesic). The Medication Self-Administration Screen dated 06/27/22 for R15 lacked the vaporizing rub topical ointment. The screen revealed the staff were to complete the assessment prior to a resident initiating self-administration of medication and with any medication order changes, change in function/condition that might affect the resident's ability to safely self-administer medications. On 12/06/22 at 11:17 AM observed R15 sitting in her recliner in her room with oxygen in place per nasal cannula. R15 opened a jar of vaporizing rub, placed the jar below her nose and sniffed at the ointment, then applied the ointment to her nose and lips. A second jar of vaporizing rub was on the table next to her recliner. On 12/06/22 at 11:18 AM R15 stated when she applies the ointment to her lips and mouth it makes her feel like she is open and helps if she is having a big coughing fit. R15 stated she had heard it was not safe to use with the oxygen but had done it for years. On 12/06/22 at 11:22 AM Licensed Nurse (LN) G stated she had a conversation with R15 several times, she had asked R15 if she knew it was not safe to use the vaporizing rub with oxygen and informed R15 staff could try something else but R15 wanted to continue to use it. LN G stated she could not recall when the conversations were, did not document the conversation, and had let the charge nurse know. On 12/06/22 at 11:28 AM Administrative Nurse D stated she was not aware R15 was applying the petroleum-based vaporizing rub to her nose and lips with oxygen in place. On 12/08/22 at 01:23 PM Administrative Nurse D stated R15 should have not had the vaporizing rub in the room and would have expected the staff to fill out a form for self-administration of medication and send it to the doctor. Administrative Nurse D stated she would expect the staff to report when they observe medications in a resident room. The policy for self-administration of medication is the assessment form. The American Lung Association webpage Oxygen Therapy: Using Oxygen Safely dated 11/17/22, revealed oxygen safety guidelines, which included to avoid flammable creams and lotions such as vapor rubs, petroleum jelly, or oil-based hand lotion, use water-based products instead. The facility failed to conduct an assessment for medication self-administration for R15, who required oxygen, to ensure safe use of vaporizing rub topical ointment. This placed R15 at risk for unsafe administration.

The facility reported a census of 33 residents with 13 selected for review. One resident was reviewed for elopement (when a cognitively impaired resident leaves the facility without staff knowledge and /or supervision). Based on observation, interview, and record review, the facility failed to accurately code the Minimum Data Set (MDS) for one of the residents, Resident (R)4, for wander/elopement alarm (device worn on the resident or attached to assistive device such as walker or wheelchair or other personal belongings, to alert the staff when a resident nears or exits a specific area of the building). This placed the resident at risk for uncommunicated care needs. Findings included: - The Admission Minimum Data Set (MDS) dated [DATE] for R4 revealed she wandered one to three days of the assessment period and did not require the use of a wander/elopement alarm. The facility Elopement Risk binder included a Missing Resident Identification form, dated 11/04/22 for R4. On 12/06/22 at 07:10 AM observed a wander/elopement alarm attached to R4's walker. On 12/07/22 at 03:20 PM Certified Nurse Aide (CNA) N stated R4 had a wander/elopement alarm that the staff applied after she entered the facility, not the day of, but when R4 started talking about going home and finding her car. On 12/07/22 at 03:49 PM Administrative Nurse D stated the date the staff filled out the form for the elopement risk binder would be the day the wander/elopement alarm would have been placed, and the alarm should be coded on the Admission MDS. On 12/08/22 at 09:15 AM Administrative Nurse E stated the wander/elopement bracelet should be coded on the Admission MDS. The MDS 3.0 Resident Assessment Instrument [RAI] User's Manual instructs the staff to code a wander/elopement alarm used at any time in the seven-day lookback period. The facility failed to code the wander/elopement alarm, to ensure staff provided appropriate needed cares for R4. This placed the resident at risk for uncommunicated care needs.

The facility reported a census of 33 residents with 13 selected for review. Based on observation, interview, and record review, the facility failed to develop a comprehensive care plan to direct staff care for one of the resident's, Resident (R)4, to address her risk of elopement (when a cognitively impaired resident leaves the facility without staff knowledge and/or supervision). This placed the resident at risk for uncommunicated care needs. Findings included: - The Medical Diagnoses tab for R4 included a medical diagnosis of disorientation (confusion about the time, your location, or even who you are). The Admission Minimum Data Set (MDS) dated [DATE] assessed R4 with a Brief Interview of Mental Status score of six, indicating severe cognitive impairment. R4 had disorganized thinking and inattention, she wandered one to three days of the assessment period. She required supervision and setup for walking and required the use of a walker for mobility. The Cognitive Loss/Dementia Care Area Assessment (CAA) dated 11/08/22 revealed R4 had a BIMS score of six and wandering review score of 32 indicating high risk to wander. R4 was redirectable but could get agitated easily. R4 had a diagnosis of disorientation and the staff frequently provided re-orientation to her to place and situation. The Behavioral Symptoms CAA dated 11/08/22 revealed R4 could get easily agitated due to her recent admission to the facility and her decline in cognition. The Care Plan dated 11/07/22 revealed R4 would exit seek at times, however lacked interventions for the exit seeking behavior, including presence of a wander/elopement alarm. The Elopement/Wandering Review assessment on 10/31/22 and 11/03/22 revealed a score that indicated R4 was at high risk to wander. The Progress Note dated 11/01/22 at 03:27 PM revealed R4 talked about leaving once and was easily redirected. The Progress Note dated 11/01/22 at 10:42 PM revealed R4 ambulated in room and throughout the facility with a walker. The Progress Note dated 11/02/22 at 05:24 PM revealed R4 had intermittent confusion and during the afternoon she said she was not staying here and that she was going home. R4 became agitated with staff but was able to be redirected and re-orientated fairly easily. The Progress Note dated 11/03/22 at 01:05 PM revealed R4 was alert and oriented to herself only and had not accepted living here yet. R4 was looking to go home at times. After an episode of bowel incontinence R4 was upset and walking the hall looking to go home. The staff re-oriented /re-directed her back to her room and helped her change which was effective in calming her down. The Progress Note dated 11/04/22 at 12:10 PM revealed R4 had a urinary tract infection and continued to be confused and anxious about where she was and why she was at the facility. R4 was surprised when told the year and thought her daughter was young and she needed to go home to take care of her. The staff reassured her and R4 talked to her daughter which was effective. The Progress Note dated 11/04/22 at 04:33 PM revealed R4 continued to be anxious, wandering halls, wondering where her daughter was. and wanting to go home. R4's daughter stated she had been called by R4 multiple times concerned her restlessness could be pain related. The Progress Note dated 11/04/22 at 06:16 PM revealed R4 was on the phone with her daughter and stating she was upset about being at the facility. The Progress Note dated 11/05/22 at 12:25 PM revealed R4 had confusion today and did not know where she was or what was going on. The Progress Note dated 11/07/22 at 10:14 AM revealed R4 had been up and down the hallway upset with staff and had been exit seeking. R2 was not easily redirected this morning after several different approaches tried. The Progress Note dated 11/10/22 at 12:18 PM revealed R4 was looking for the outside door after lunch and was easily redirected. On 12/06/22 at 07:10 AM observed R4 in her room making her bed with her walker beside her. The walker had a wander/elopement alarm attached to it. On 12/07/22 at 09:39 AM Certified Nurse Aide (CNA) M stated R4 was exit seeking and at risk for elopement. CNA M stated R4 had exited a dining room door before, and the staff seen her go out the door. CNA M stated R4 lacked a wander/elopement alarm, and when a resident does have a wander/elopement alarm they are checked every day to make sure they are working. On 12/07/22 at 10:02 AM Certified Medication Aide (CMA) R stated if a resident was at risk for elopement, it would be on the care plan, the nurse would tell staff, or it would be in the electronic medical record documentation on a task for the CNA's, or anyone, to check every day. CMA R stated R4 did exit seek and did not know if she had a wander/elopement alarm. The staff could redirect her by showing and talking about the quilts in her room or talking to one of the staff members here. CMA R stated when exit seeking, she would ask if she was having pain because a lot of times that is why she is exit seeking, and interventions to redirect would be on the care plan. On 12/07/22 at 10:47 AM Licensed Nurse (LN) I stated R4 was at risk for elopement and was not sure if R4 had a wander/elopement alarm. LN I stated when the staff determined a resident to be at risk for elopement a note would be placed in the electronic communication board for all staff to see and on the resident care plan. LN I stated R4 could be distracted when exit seeking sometimes by bringing her to the puzzle table, talk about her quilts, offer her a Pepsi or snack, or talking to her daughter. LN I stated she did not participate in developing the initial care plan and the wander/elopement alarm and interventions for when R4 was exit seeking should be on the care plan. On 12/07/22 at 03:06 PM CMA S stated R4 had a wander/elopement alarm and she thought the staff placed the alarm the day she admitted to the facility. CMA S stated the staff redirect R4 when exit seeking by asking if she wanted to watch TV, read the newspaper, or just sit and have a conversation with her if she allowed. On 12/07/22 at 03:20 PM CNA N stated R4 was at risk for elopement, had a wander/elopement alarm, had been exit seeking on her shift. On 12/07/22 at 03:31 PM Administrative Nurse D stated when a resident was at risk for elopement, a wander/elopement alarm would be placed on the resident and the form would be filled out for the elopement book that included a picture and physical description of the resident; the facility front door had the wander/elopement alarm system in place. The wander/elopement alarm should be on the care plan. On 12/08/22 at 09:15 AM Administrative Nurse E stated R4's care plan should include interventions to deter her when she is exit seeking. The facility policy Elopement Prevention and Management Standard dated 01/2016, revealed when the staff determined a resident to be at risk for elopement appropriate interventions would be implemented immediately. All residents at risk were to be care planned for elopement risk by Social Services or Nursing and approaches are implemented and maintained. Elopement risk should be care planned separately on the care plan. The facility failed to develop a care plan for R4 for her elopement risk and exit seeking behaviors, to direct the staff care. This placed R4 at risk for uncommunicated care needs.

The facility identified a census of 33 residents. The sample included 13 residents with two reviewed for care plan revisions. Based of observations, record review, and interviews, the facility failed to implement updated fall interventions after Resident (R) 7 fell while using the restroom. This deficient practice placed R7 at risk for preventable falls and injuries due to uncommunicated care needs. Findings Included: - The Medical Diagnosis section within R7's Electronic Medical Records (EMR) included diagnoses of cerebral palsy (progressive disorder of movement, muscle tone or posture caused by injury or abnormal development in the immature brain, most often before birth),blindness in one eye, dysphagia (swallowing difficulty), epilepsy (progressive disorder of movement, muscle tone or posture caused by injury or abnormal development in the immature brain, most often before birth), and osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk). R7's Quarterly Minimum Data Set (MDS) dated [DATE] noted a Brief Interview for Mental Status (BIMS) score of six indicating severe cognitive impairment. The MDS noted that he required extensive assistance from one staff for transfers and toileting. The MDS noted he required supervision for locomotion and used a wheelchair. The MDS noted that he was frequently incontinent of urine but occasionally incontinent of bowel with no toileting program in place or attempted. The MDS noted he had no falls since admission. R7's Urinary Incontinence Care Area Assessment (CAA) dated 05/23/22 noted he required limited to extensive assistance from one staff for toileting. The CAA noted that care plan approaches would be developed and updated to promote her maximum level of function. R7's Falls CAA dated 05/23/22 noted he was potentially at risk for falls. The CAA noted that he had a history of falls. The CAA noted that care plan approaches would be developed and updated to reduce the risks of falls and injuries. A review of R7's Care Plan created 07/05/17 noted R7 had a history for falls related to his impaired gait and poor balance. The plan noted fall interventions of wearing non-skid padding on his seat ( 07/05/22), wearing specialized shoes (07/05/22), maintain clutter-free environment (07/05/17), ensure wheelchair is locked (07/05/17), ensure personal items are within reach (07/05/17), anticipate his needs (07/05/17), and physical therapy evaluation (created 06/14/18). The care plan lacked interventions for a documented fall that occurred on 11/07/22. The care plan noted that R7 required extensive assist from one staff for toileting and for all transfers. A review of R7's EMR revealed a Nursing Progress note dated 11/07/22 indicating that R7 fell in his bathroom while being assisted by staff. The note indicated that when R7 attempted to stand up from his wheelchair his hands slipped, and he fell forward. The note indicated that he hit his head on the metal grab bar. The note indicated that he received a small red mark on his forehead. On 12/07/22 at 12:28PM R7 was quickly locomoting down the hallway in his wheelchair towards his room. R7 entered his room and went towards his restroom. R7 stood up holding the grab bars and attempted to self-transfer to his toilet. Certified Nurses Aid (CNA) O noticed R7 and quickly entered the room to assist R7 with toileting. CNA assisted R7 with transferring him to the toilet and back to his wheelchair. CNA O stated that R7 was very quick and sometimes will not ask for help or wait for staff to come and assist him. On 12/08/22 at 11:12 AM in an interview with Certified Nurses Aid (CNA) P, she stated that all direct care staff have access to view the care plan and the nurses can update and add additional information to the plans if needed. She stated that R7 required extensive assistance from staff during transfers and toileting. She stated that R7 likes to stand on his own, but staff should always be supporting him during transfers. On 12/08/22 at 01:35 PM in an interview with Licensed Nurse (LN) I, she stated that while staff do complete a two-hour check and change of the residents, she was not sure if R7 had an individualized toileting program or personalized care plan interventions for his incontinence. She stated that R7 will usually attempt to toilet himself, but staff is required to assist him. She stated that the direct care staff review the care plans and the nursing staff can add interventions to the care plan. On 12/08/22 at 02:25 PM Administrative Nurse E stated that the interdisciplinary team reviews the care plans and implements interventions after falls occur. She stated that the nursing staff can add interventions to the care plan and the interdisciplinary team will review them. A review of the facility's Fall Prevention and Management revised 02/2019 indicated that residents will be assessed for fall risk upon admission, quarterly, during significant changes, and after a fall has occurred. The policy noted that the resident's care plan will be updated with approaches and interventions for the identified risk. The policy noted that the fall episode would be reviewed by the interdisciplinary team for review of the appropriateness of the interventions. The facility failed to implement updated fall interventions after R7 fell while using the restroom. This deficient practice placed R7 at risk for preventable falls and injuries due to uncommunicated care needs.

The facility identified a census of 33 residents. The sample included 13 residents with 13 reviewed for quality of care. Based on observations, record review, and interviews, the facility failed to follow physician ordered instructions to weigh Resident (R)3 daily. The facility additionally failed to report weight changes to the medical provider as instructed in the order parameters. This deficient practice placed R3 at risk for complications related to edema (swelling resulting from an excessive accumulation of fluid in the body tissues). Findings Included: - The Medical Diagnosis section within R3's Electronic Medical Records (EMR) included diagnoses of type two diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), bradycardia (low heart rate, less than 60 beats per minute), localized edema, chronic kidney disease, congestive heart failure (CHF- when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), and hypertension (high blood pressure). R3's Quarterly Minimum Data Set (MDS) dated [DATE] noted a Brief Interview for Mental Status (BIMS) score of ten indicating mild cognitive impairment. The MDS indicated that she weighed 189 pounds (lbs.) and had no noted weight loss or gain within the last six months. The MDS noted that she was taking a diuretic medication (medication to promote the formation and excretion of urine). A review of R3's Nutritional Care Area Assessment (CAA) dated 05/12/22 noted that she was on a regular diet. The CAA noted that staff were to offer her choice foods and fluids at all meals and keep water available in her room at all times. The CAA noted that care plan approaches would be to ensure all nutritional requirements are met. A review of R3's Care Plan dated 09/16/22 indicated that she was taking furosemide (diuretic medication used to treat edema) and at risk for diuresis (increased formation and secretion of urine) with water and electrolyte depletion. The care plan noted that she required careful medical supervision and dosage adjustments to meet her individual needs. The plan noted that staff were to report significant weight gain or loss to the medical provider. The care plan lacked interventions related to refusal of cares and services. A review of R3's Physician's Orders revealed an order dated 09/07/22 for staff to weigh R3 every morning for edema management related to her CHF. The order instructed staff to notify the provider if R3 gained more than three pounds in 24 hours or five pounds in one week. A review R3's of Medication Administration Record (MAR) between 09/01/22 to 12/08/22 (99 days reviewed) revealed that her weight was not attained on eight occasions with the instructions to See Progress Note marked. A review of the marked dates (10/4, 10,22, 10/27, 10/28, 11/1, 11/3, 11/13, and 11/15) revealed no indication of why the weights were not attained. The review indicated that she had refused to be weighed by staff on eleven occasions, but the EMR lacked documentation showing the reason for refusal or if staff offered to weigh her at a different time. The MAR review revealed three occurrences of weight gain outside the parameters. On 11/10/22 R3 gained four pounds with no documentation indicating the medical provider was notified. On 11/14/22 R3 gained five pounds with no documentation indicating the medical provider was notified. On 11/25/22 R3 gained seven pounds with no documentation indicating the medical provider was notified. On 12/06/22 at 08:00AM R3 sat in her recliner watching television. She reported that she was waiting for her breakfast. Her room was clean and organized. She reported that she had to watch what she was eating and drinking because of her edema on her legs. She stated that she was taking medication that caused her to need to use the restroom frequently. On 12/08/22 at 11:12 AM in an interview with Certified Nurses Aid (CNA) P stated that R3 had never refused to weigh by her but maybe with some of the other staff. She stated that if a resident refused care or a task the nurse would be notified. She stated that another direct care staff or nurse would attempt to weigh the resident. She stated that all residents were weighed after their assigned spa bath. She stated that the weights were entered into the EMR once reviewed by the nurse. On 12/08/22 at 01:35 PM in an interview with Licensed Nurse (LN) I, stated the direct care staff should be attaining the weights directly after the residents were bathed unless otherwise noted in the orders. She stated that she was not aware of R3 refusing many weights. She stated that if a weight was out of parameters the nurse would call the medical provider as ordered and note the communication in the EMR. On 12/08/22 at 02:45PM in an interview with Administrative Nurse D, she stated that the nurses should be weighing the residents as ordered and notifying the medical provider with any changes listed in the parameters. She stated that the nurses should be calling the doctor and documenting the communication in the resident's chart. The facility failed to follow physician ordered instructions to weigh R3 daily. The facility additionally failed to report weight changes to the medical provider as given in the orders parameters. This deficient practice placed R3 at risk for complications related to edema.

The facility reported a census of 44 residents. The sample consisted of 3 residents, reviewed for accidents. Based on observation, interview, and record review, the facility failed to provide adequate supervision and/or assistive devices to prevent falls for 1 out of 3 residents reviewed, including, the facility's failure to utilize a planned intervention for falls, as required by the care plan, when on 5/27/19, facility staff failed to ensure a pressure pad alarm was in place and functioning in the recliner of resident #1, and the resident experienced an injury fall. The resident sustained [REDACTED]. In addition, the facility failed to develop appropriate interventions following this fall, as well as additional falls on 3/27/19 and 5/29/19; and the facility failed to develop appropriate interventions, following falls, on 3/30/19 and 5/13/19, for resident #2. Findings included: - Resident #1's signed physician's orders, dated 6/5/19, documented the resident admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident's significant change MDS (minimum data set), dated 4/2/19, assessed the resident with a BIMS (brief interview for mental status) of 10, indicating the resident experienced moderately impaired cognition. The resident experienced disorganized thinking, which fluctuated in severity, and required limited to extensive assistance from one to two staff in order to complete his/her ADLs (activities of daily living). The resident had unsteady balance, and could only stabilize with staff assistance. The resident experienced two or more non-injury falls since his/her prior MDS assessment. The CAA (care area assessment), for falls, dated 4/4/19, documented that the resident had a [DIAGNOSES REDACTED]. The resident's fall care plan, dated 8/6/18, documented that the resident had a history of [REDACTED]. The resident had a [DIAGNOSES REDACTED]. -On 8/6/18, facility staff updated the resident's care plan to include that facility staff must ensure that the resident wore non-skid footwear when ambulating, that the environment was clutter-free and free of safety hazards, and that therapy complete a screen quarterly and as needed. -On 8/13/18, keep frequently used items within reach, and keep the environment well-lit. -On 8/15/18, the resident's family agreed to visit in the evening to minimize the resident's sundowning. -On 9/4/18, facility staff must remind the resident to ask for assistance with transfers, and re-educated the resident on how to use the call light system. On 1/23/19, facility staff must ensure the resident's bathroom light was kept on throughout the night. -On 3/26/19, facility staff must ensure they placed an alarm on the resident. -On 4/29/19, facility staff must ensure the resident's walker was in reach. -On 5/29/19, facility staff must ensure that a motion sensor alarm must be used in addition to the pressure alarm, when the resident was in his/her room. The resident's fall assessments, dated 2/15/19, 5/5/19, 5/27/19, and 5/29/19, assessed the resident as high risk for falling. Review of a nursing note, dated 3/27/19 at 8:56 PM, revealed that facility staff overheard the resident making noise, went to his/her room, and found him/her laying on the floor on his/her left side. The resident experienced hallucinations, and received medication for the hallucinations earlier in the day. The resident was free of injuries. The nursing note lacked documentation of an immediate intervention to prevent further falls from occurring, as required. Review of a nursing note, dated 5/27/19 at 4:45 PM, revealed that facility staff responded to the resident's call light. Facility staff observed him/her on the floor, lying on his/her right side, with his/her head against the dresser. Blood was on the dresser. Family was talking to the resident, and requested that he/she be sent to the emergency room for treatment. Facility staff documented that upon entry to the room, no alarms were sounding. Review of a nursing note, dated 5/27/19 at 9:51 PM, revealed that the resident returned to the facility at 9:30 PM, after receiving 7 staples for a laceration on the head, sustained during the fall. Review of the facility's fall investigation, regarding the fall on 5/27/19, revealed that direct care staff D and direct care staff [NAME] transferred the resident to his/her recliner, but neither staff could recall transferring the resident's pressure pad alarm from the wheelchair to the recliner. Staff D and [NAME] left the resident in the room with family, and did not activate the resident's motion alarm, due to the presence of family in the room. Review of a physician communication form, dated 5/29/19 at 1:31 AM, revealed that the resident experienced an additional fall. Facility staff failed to turn the resident's pressure alarm on after placing it on the resident's bed, and the resident later got up out of bed, ambulated to his/her bathroom to toilet, and fell . The resident was not injured. Facility staff placed a motion sensor alarm at the foot of the resident's bed. This intervention failed to address the actual causative factors which contributed to the residents fall. On 6/26/19 at 8:16 AM, the resident sat in his/her wheelchair, in his/her room, with family present. The control box for the resident's pressure pad alarm hung from the back of the resident's wheelchair. A small light, labeled in use, failed to blink, indicating that the alarm failed to be functional, as required by the care plan. At 8:25 AM, direct care staff D and direct care staff F assisted the resident to toilet, and following toileting, turned the resident's pressure pad alarm on. The in use light began blinking green approximately once every three seconds after being turned on, indicating the pressure pad alarm was functional, and made two audible beep sounds, when the resident sat down in his/her recliner. On 6/26/19 at 2:20 PM, the resident sat in his/her recliner in his/her room, watching television. The control box for the pressure pad alarm hung on the arm of his/her recliner, however, the cord for the alarm failed to be plugged into the box, and the alarm failed to be functional. At 2:25 PM, the resident's motion sensor alarm was activated, and direct care staff H responded. Staff H deactivated the alarm, and greeted the resident. Staff H looked in the direction of the control box for the pressure alarm, failed to check the alarm, and then left the room. On 6/26/19 at 2:30 PM, the resident remained alone in his/her room, with his/her pressure alarm still unplugged, in violation of his/her care plan. On 6/26/19 at 2:36 PM, licensed nursing staff B and direct care staff G entered the resident's room to assist him/her with toileting. As Staff B and G entered the room, the resident's motion alarm sounded. As staff B assisted the resident to stand, the resident's pressure alarm failed to alarm, confirming the alarm failed to be in use, in violation of the resident's care plan. Following toileting, staff B and G assisted the resident to sit in his/her recliner. Staff B picked up the control box to the pressure alarm, turned it over, and noted that the alarm failed to be plugged in. Staff G asked staff B if he/she turned the alarm on, and staff B stated that yes, the alarm was on. Both staff then left the room. Staff B failed to properly activate the pressure alarm, as required by the care plan. On 6/26/19 at 2:43 PM, the pressure pad alarm remained unplugged. On 6/26/19 at 8:16 AM, the resident's family member stated that he/she was the person who found the resident on the floor, when the resident fell on [DATE], and had to go to the emergency room . The family member stated that on 5/27/19, the facility staff failed to place the resident's pressure alarm underneath of the resident, when they assisted the resident to sit in his/her recliner. On 6/26/19 at 1:50 PM, direct care staff D confirmed that when pressure pad alarms are on, the in use light would blink green, and if the alarm was not on, the light would not blink. Staff D confirmed that he/she assisted staff [NAME] in transferring the resident to his/her recliner prior to the fall on 5/27/19, but that he/she did not remember moving the resident's pressure alarm from the wheelchair to the recliner. On 6/26/19 at 2:46 PM, direct care staff [NAME] stated that pressure pad alarms must be plugged into the control box in order to function. The in use light would then blink green, approximately once every three seconds, to indicate that the alarm was functional. Staff [NAME] confirmed that he/she assisted staff D in transferring the resident to his/her recliner, prior to the fall on 5/27/19. Staff [NAME] stated that he/she did not remember moving the resident's pressure alarm from the wheelchair to the recliner, in violation of the care plan. On 6/26/19 at 2:55 PM, staff B confirmed that he/she failed to properly activate the resident's pressure pad alarm before leaving the resident's room earlier in the day. On 6/26/19 at 3:30 PM, licensed nursing staff C confirmed that he/she was the nurse on duty at the time of the resident's fall on 5/27/19. Staff C stated that he/she went to the resident's room, and found him/her lying on the floor with his/her family at his/her side. Staff C confirmed that the resident's alarms were not sounding when staff entered the room. Staff C confirmed that the resident required treatment at the emergency room , and required 7 staples for the laceration on his/her head. Staff C further revealed interventions for falls were put in place immediately following a fall, by the staff who were on duty, and depended on what caused the resident to fall. On 6/26/19 at 4:49 PM, administrative staff A stated that the facility reviewed fall interventions put in place by staff on duty at the time of a fall as a group, either immediately or the next business day. Staff A was not aware that staff failed to put interventions in place for the resident's falls on 3/27/19, 5/5/19, and 5/27/19. Review of the facility policy, revised 02/2019, for Fall Prevention/Management Standards, documented that based on the circumstances of the fall, appropriate interventions to prevent further falls from occurring would be implemented; and that every effort should be attempted to reduce the use of alarms in the facility, as they could increase the risk of falling. The facility failed to utilize a planned intervention for falls, after which the resident fell , and sustained a laceration to the head, which required treatment at the emergency room and 7 staples. Furthermore, the facility continued to fail to utilize those same planned interventions, as observed on 6/27/19; and failed to develop and implement appropriate interventions, following additional falls, on 3/27/19 and 5/29/19. - Resident #2's signed physician's orders, dated 5/7/19, documented the resident admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident's admission MDS (minimum data set), dated 12/13/19, assessed the resident with a BIMS (brief interview for mental status) of 11, indicating the resident experienced moderately impaired cognition. The resident required limited to extensive assistance from one to two staff to complete his/her ADLs (activities of daily living), and was free of falls upon admission to the facility. The CAA (care area assessment), for falls, dated 12/17/19, documented the resident required assistance with transferring and mobility, and had a history of [REDACTED]. The resident's quarterly MDS assessment, dated 5/31/19, assessed the resident as having experienced two or more non-injury falls since the prior assessment, and experienced one injury fall since the prior assessment. The resident's care plan, for falls, dated 12/19/18, documented the resident had a history of [REDACTED]. -On 12/19/18, facility staff updated the resident's care plan to include that facility staff must ensure the resident wore non-skid footwear for ambulation, facility staff must remind the resident not to transfer or walk without assistance, facility staff must keep commonly used items within reach, and for therapy to screen the resident quarterly for assistive devices. -On 12/20/18, facility staff must use a gait belt with all transfers. -On 1/7/19, facility staff must check on the resident every thirty minutes at night. -On 2/12/19, facility staff must toilet the resident at midnight, to prevent incontinence and falls. -On 2/26/19, facility staff must assist the resident with toileting after meals, and then offer to transfer the resident to a seating area of his/her choice. -On 3/23/19, facility staff must not leave the resident unattended in his/her room. -On 3/25/19, facility staff must toilet the resident every 2 hours. -On 3/30/19, facility staff must complete an orthostatic blood pressure log for three days, then report. -On 5/6/19, facility staff placed a motion sensor alarm in the resident's room. Review of the residents fall assessments, dated 3/8/19, 5/5/19, 5/13/19, and 5/31/19, assessed the resident as high risk for falling. Review of a nursing note, dated 3/30/19 at 3:31 PM, revealed that facility staff found the resident sitting on the floor in front of his/her bed on his/her bottom, with his/her back against the bed. The resident stated that he/she was attempting to readjust the sheets on his/her bed, when he/she sat down. Facility staff updated the resident's care plan with an intervention to perform orthostatic blood pressure measurements for three days, then to report the findings to the resident's physician. This intervention failed to address the causative factors of the fall, and failed to immediately reduce the resident's risk of falling, as required. Review of a nursing note, dated 5/13/19 at 3:21 PM, revealed that facility staff found the resident on the floor beside his/her recliner, and the resident was free of injuries. The note documented that facility staff failed to activate the resident's motion sensor alarm, and the alarm failed to sound. The resident stated that he/she could hear music playing, and wanted to turn the music off. The note failed to document implementation of an immediate intervention. On 6/26/19 at 2:30 PM, the resident self-propelled his/her wheelchair in the hallway, towards the commons area. Staff greeted him/her, and escorted her to the commons area. On 6/26/19 at 1:50 PM, direct care staff D stated that the resident required a motion alarm in his/her room, as well as keeping his/her closet door shut, because he/she would attempt to organize the clothing. On 6/26/19 at 2:46 PM, direct care staff [NAME] stated that the resident must have his/her closet door kept shut, because if he/she saw his/her clothes, he/she would attempt to organize them. The resident also required a motion alarm. On 6/26/19 at 3:30 PM, licensed nursing staff C stated that fall interventions must immediately reduce the risk of the resident falling again. Staff C stated that orthostatic blood pressure measurements, taken over three days, would not be an appropriate immediate intervention. On 6/26/19 at 4:49 PM, administrative staff A stated that the facility reviewed fall interventions put in place by staff on duty at the time of a fall as a group, either immediately or the next business day. Staff A was not aware that staff failed to put an intervention in place for the resident's fall on 5/13/19. Staff A acknowledged that the orthostatic blood pressure measurements failed to be an appropriate fall intervention for the residents fall on 3/30/19. Review of the facility policy, revised 02/2019, for Fall Prevention/Management Standards, documented that based on the circumstances of the fall, appropriate interventions to prevent further falls from occurring would be implemented; and that every effort should be attempted to reduce the use of alarms in the facility, as they could increase the risk of falling. The facility failed to develop and implement appropriate interventions, following falls, on 3/30/19 and 5/13/19, for this resident, at risk for falls.