Every finding on record at Penick Village

Based on observations, record review, family member and staff interviews, the facility failed to maintain a resident's dignity by not placing a cover over her urine collection bag for 1 of 1 resident reviewed for dignity (Resident #21). A reasonable person would not want their urine visible to the public. The findings included:Resident #21 was readmitted to the facility on [DATE] with diagnoses that included retention of urine and neuromuscular dysfunction of bladder.Resident #21's quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #21 was severely cognitively impaired and coded as having an indwelling urinary catheter.An observation was completed on 4/15/26 at 11:27 AM of Resident #21 sitting in the Activity Room with other residents and staff (Life Enrichment/ Activity personnel). Resident #21's urine collection bag was observed without a cover in place. Her urine was observed at a level of 200 milliliters (ml) volume and yellow in color.An observation was completed on 4/15/26 at 3:22 PM of Resident #21 in the Activity Room during the 3:00 PM activity with the Chaplain, along with other residents. Resident #21 was observed in her wheelchair. Her urine collection bag remained exposed and uncovered which was visible through the glass windows from the hallway. Her urine was observed to be yellow in color. An observation was completed on 4/15/26 at 3:50 PM of Resident #21 observed sitting in her wheelchair in the small dining area adjacent to the nurse's station. Other residents, staff, hospice staff and visitors were observed passing the small dining area or entering the small dining area during this time. Resident #21's urine collection bag was observed without a cover in place and yellow urine was visible from the hallway.A telephone interview with Resident #21's Family Member was conducted on 4/16/26 at 2:28 PM. She revealed Resident #21 would absolutely want her urine collection bag concealed with a cover when out of room and in activities. An interview with Nurse Aide (NA) #1 was completed on 4/15/26 at 4:00 PM and revealed she was assigned to Resident #21. NA #1 stated she assisted Resident #21 into her wheelchair with the assistance of another staff person due to Resident #21 being a mechanical lift transfer. NA #1 explained she was agency staff but had received training on urinary catheter care and maintaining a resident's dignity. NA #1 explained she would transfer the urine collection bag from the bed to the wheelchair and back as care was provided to Resident #21. NA #1 further stated she would inform her nurse of any concerns regarding the urinary catheter and the urine collection bag. NA #1 did not recall if Resident #21's urine collection bag had a cover in place on 4/15/26. NA #1 indicated she was not aware of where covers for urine collection bags were located and stated the nurse would take care of any catheter needs except for rendering care if the NA was not available. An interview was completed with Medication Aide #1 on 4/15/26 at 4:35 PM. Medication Aide #1 stated she had been trained for urinary catheter care and maintaining dignity for residents with urinary catheters. Medication Aide #1 expressed the training included ensuring urine collection bags had a cover in place or was placed in a dignity bag concealing the urine collection bag. She confirmed she overlooked the application of the cover for Resident #21 when she emptied the urine collection bag around 2:00 PM on 4/15/26. Medication Aide #1 explained she would normally empty the urine collection bag in the afternoon, make sure the anchor for the catheter remained in place, and check for any other issues. Then she would make sure the urine collection bag had a cover in place. Medication Aide #1 verbalized this was an oversight by not making sure Resident #21's urine collection bag had a cover in place after completing the above tasks.An interview was completed with the Director of Nursing (DON) on 4/16/26 at 10:05 AM. She reported residents with urine collection bags should have covers in place unless care was being rendered. She confirmed that covers were available and staff have been trained in proper application. She was uncertain as to the reason why Resident #21 did not have a cover in place for her urinary catheter.On 04/16/26 at 3:33 PM an interview was conducted with the Administrator. She reported a dignity cover should be in place for all residents with urine collection bags. The Administrator was uncertain as to why Resident #21 did not have a cover in place.

Based on observation and staff interviews, the facility failed to ensure clean dishware was dry prior to stacking for 1 of 2 kitchen observations. Wet nesting has the potential for bacterial growth on dishware and could affect the food served to residents.The findings included:The initial tour of the kitchen occurred on 04/13/26 at 11:10 AM with the Dietary Manager and Director of Dietary. The initial observation of the dishware storage area revealed dishware that was ready for use, put away and stacked wet. The following clean dishes were observed wet and nesting: 3 metal 1/3 serving pans and 2 metal half serving pans were stacked upside down visibly wet with pooled water on the sides and water pooled around the rim. An interview with the Dietary Manager on 04/13/26 at 11:28 AM revealed dishware should be cleaned, dried thoroughly, and stored facing down to prevent wet nesting. The Dietary Manager stated wet nesting could cause bacteria to grow. The Dietary Manager was unable to identify which dietary staff was responsible for stacking the serving pans while wet. An interview was conducted with the Administrator on 4/13/26 at 4:20 PM. The Administrator indicated items should not be stored wet, as retained moisture could promote bacterial growth.

Based on record review and staff interviews, the facility failed to provide the CMS Skilled Nursing Facility Advanced Beneficiary Notice (SNF-ABN) prior to discharge from Medicare Part A skilled services for 1of 3 residents reviewed for the beneficiary protection notification review (Resident #1).The findings included: Resident #1 was readmitted on [DATE]. A review of Resident #1's medical record revealed a CMS-10123 Notice of Medicare Non-Coverage (NOMNC) form was issued to Resident #1 which explained Medicare Part A coverage for skilled nursing and therapy services would end 3/26/26. The NOMNC was reviewed and signed by the Care Navigator, via telephone consent from the Responsible Party (RP) on 3/24/26. Resident #1 resided in the facility during the time the survey was conducted from 4/13/26 to 4/16/26. A review of Resident #1's medical record revealed a CMS-10055 Skilled Nursing Facility Advanced Beneficiary Notice (SNF-ABN) form was not provided to Resident #1 or Resident #1's RP.On 4/16/26 at 3:02 PM an interview was conducted with the Care Navigator, who confirmed the CMS-10123 NOMNC form was issued to Resident #1 when Medicare Part A services were ending. The Care Navigator stated the CMS-10055 SNF-ABN for Resident #1 was not provided to Resident #1 or the RP. The Care Navigator further stated she was unaware that residents who remained in the facility after Medicare Part A coverage ends should receive a CMS-10055 SNF ABN. The Care Navigator communicated Resident #1 had 37 days left of Medicare Part A coverage.On 4/16/2026 at 3:35 PM an interview with the Administrator revealed the facility's process for SNF beneficiary notification for residents that remain in the facility required that both a NOMNC and SNF-ABN be accurately completed and provided, by the Care Navigator, to residents who remained in the facility. The Administrator confirmed Resident #1 should have received a CMS-10055 SNF-ABN form.

Based on record review and staff interviews the facility failed to accurately code the Minimum Data Set (MDS) assessment in the area of medications for 1 of 5 residents (Resident #19) reviewed for unnecessary medications. Findings included: Resident #19 was admitted to the facility on [DATE]. A review of Resident #19's physician orders revealed an order dated 9/4/24 for Lantus insulin (a long acting injectable medication to control blood sugar) 10 units subcutaneously (injected with a needle beneath the skin) daily at bedtime. A review of Resident #19's Medication Administration Record for December 2024 revealed documentation Resident #19 received Lantus insulin 10 units subcutaneously at bedtime on 12/6/24, 12/7/24, 12/8/24, 12/9/24, 12/10/24, 12/11/24 and 12/12/24. A review of Resident #19's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed documentation she received insulin injections on 4 of the 7 day look-back period days of the assessment. On 1/23/25 at 11:41 AM in an interview the MDS Nurse indicated she completed the medication section of Resident #19's MDS assessment dated [DATE]. She stated the look-back period for the assessment would have been from 12/6/24 through 12/12/24. She reported she could see documentation on Resident #19's MAR that Resident #19 received insulin injections on all 7 of the look-back days. The MDS Nurse stated she missed this when coding Resident #19's 12/12/24 MDS assessment. She reported this was an oversight on her part and she would correct it. On 1/23/25 at 11:51 AM in an interview the Director of Nursing confirmed Resident #19 received insulin injections on all 7 of the look-back period days of her 12/12/24 quarterly MDS assessment. She stated Resident #19's MDS assessment should have accurately reflected the number of days she received insulin injections. On 1/23/25 at 12:00 PM an interview with the Administrator indicated MDS assessments should accurately reflect the medication a resident received.

Based on record review and staff interviews the facility failed to have an active order for hospice for 1 of 2 residents reviewed for hospice care. (Resident #3) Findings included: Resident #3 was admitted to the facility on [DATE]. Review of physician orders revealed on 1/10/24 Resident #3 was ordered to have hospice consult and care. This order was discontinued on 8/8/24 by Nurse #3. During an interview on 1/22/25 at 4:49 PM Nurse #3 stated she must have incorrectly discontinued the hospice order for Resident #3 by accident in August 2024. Resident #3 had no break in her hospice care and was still currently receiving hospice care. Review of Resident #3's Hospice Certification dated 1/11/24 revealed Resident #3's hospice election date was 1/11/24. Review of Resident #3's Minimum Data Set assessment dated [DATE] revealed the resident was assessed to be receiving hospice services. Review of Resident #3's care plan dated 1/10/25 revealed Resident #3 was care planned to receive hospice services. During an interview on 1/22/25 at 4:45 PM Nurse #2 stated Resident #3 was on hospice and had been on hospice a long time. Resident #3 and any resident on hospice should have an active order for hospice. She stated Resident #3 was currently receiving hospice care and did not have any breaks in her hospice care since January 2024 but could not find an active order for hospice care in the health record. During an interview on 1/22/25 at 4:37 PM the Director of Nursing stated there was no active hospice order in Resident #3's medical record and there should be an active order for hospice. She stated the floor nurse was responsible for entering the hospice order and she could not find it. There was no break in Resident #3's hospice care. During an interview on 1/22/25 at 4:44 PM the Administrator stated there should be an active order for hospice if a resident was admitted to hospice.

Based on observations, record review and staff interviews, the facility failed to date multi-use medications per manufacturer's recommendations upon opening in 1 of 1 medication cart (station 2 medication cart) reviewed for medication storage and labeling. Findings included: An observation was conducted on 10/22/23 at 11:21 AM of the medication cart at station 2 in the presence of Nurse #1. The observation revealed no opened date on the following multi-dose medications: 1. One multi-dose 10ml bottle of lubricant 0.4%-0.03% solution eye drops. (Manufacturer's recommendation to discard 90 days after opening). 2. One multi-dose 10ml bottle of Lumigan Sol 0.01% solution eye drops. (Manufacturer's recommendation to discard 4 weeks after opening). 3. One multi-dose package of Ipratropium Bromide and Albuterol Sulfate 0.5 milligram (mg)/3mg per 3 milliliter (ml) inhalation vials. Nurse #1 confirmed the medications were not dated and she removed them from the medication cart and discarded them. She indicated nurses were to write the date on all multi-dose medications upon opening and check dates prior to administration. She stated she did not realize they were not dated. She also stated that the pharmacy consultant checks medication carts for undated medications monthly. An interview was conducted with the Director of Nursing (DON) on 10/24/23 at 3:45 PM. She stated it was the nurse ' s responsibility to date multi-dose medications upon opening and they should be checking for dates daily prior to administration.

Based on record review and staff and interviews, the facility failed to provide care in a safe manner which resulted in a fall from the bed for 1 of 5 residents reviewed for accidents (Resident #19). Findings included: Resident #19 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease. Review of quarterly Minimum Data Set (MDS) dated [DATE] indicated the resident was severely cognitively impaired, nonverbal, rarely understood others, and rarely understood by others. Resident #19 was totally dependent upon staff for all activities of daily living, toileting, and personal hygiene. A review of Resident #19's care plan, last reviewed 9/14/2023, contained a focus for risk of decline in ability to perform self-care related to Alzheimer's dementia, osteoarthritis and debility. Interventions included the resident was total care for bed mobility. The intervention was dated 8/10/2021. The resident had additional interventions that included total assist for any toileting, incontinent care, and brief changes, related to incontinence of bowel and bladder. Resident #1 also had a focus for risk of injury from falls related to decreased safety awareness and impulsivity secondary to my cognitive impairment, weakness, balance issues, and need for assistance with mobility and self-care. Review of the incident report dated 5/11/2023 indicated Resident #19 fell out of the bed during incontinent care by Nurse Assistant (NA) #1. The resident sustained a superficial laceration (1.5 centimeters in length) to her head during the fall. The resident was assessed by Nurse #2 prior to being moved from the floor to the bed. The resident's Responsible Party (RP), the Medical Director (MD), and the Director of Nursing (DON) were notified of the fall. The resident was placed on neurological checks and frequent observation. Review of nursing progress note dated 5/11/2023 indicated the RP did not want the resident sent to the Emergency Department (ED). The resident's bed was placed in a low position and the resident remained on frequent observation. On 10/24/2023 at 9:00AM an attempt to interview the resident was unsuccessful. Resident #19 did not respond to writers questions. On 10/24/2023 at 10:52 a phone interview was conducted with NA#1. She stated she was performing incontinent care alone and turned the resident on her side. When she turned to grab an incontinent brief from the bedside table, the resident rolled away from her. She could not catch her before she slid off the opposite side of the bed. She stated she yelled out for help and Nurse #2, who was assigned to Resident #19 at that time, came into the room. Nurse #1 assessed the resident, and three staff members placed the resident back into the bed. She stated the resident was bleeding from her head. NA #1 stated she was familiar with Resident #19 and had performed incontinent care on her many times in the past without assistance. She was not sure if she had the resident positioned too far away from her or it happened because she let go of the resident to reach for the incontinent brief. NA#1 stated she was provided education by the DON on having all supplies within reach prior to beginning incontinent care and on turning the resident toward you and not away from you to prevent falls. On 10/24/2023 atv11:00 AM a phone interview was conducted with Nurse #2. She stated she heard NA#1 yell out from Resident #19's room. When she entered the room, she observed Resident #19 on the floor between the bed and the wall. The resident was bleeding from her head. Once she assessed the resident, three staff placed her back into the bed. Nurse #2 asked NA#1 what happened. NA#1 told her she turned the resident away from and took her hand off her briefly to grab an incontinent brief off the bedside stand and the resident rolled off the bed. The nurse stated the resident was typically provided incontinent care by one staff and not two. Nurse #2 stated she called the MD, the RP, and the DON to make them aware of the fall. The RP did not want the resident sent out to the Emergency Department for a superficial laceration. The resident was placed on increased observation and the MD gave orders to clean and cover the superficial laceration on her head. During an interview with the DON on 10/24/2023 at 4:00PM. Stated the resident was 1-2 staff assistance with incontinent care at the time of the incident. The facility provided education to staff regarding how to maintain safety while providing care to include having all supplies within reach and turning resident toward caregiver and not away.

Based on record reviews, observations, resident, and staff interviews, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to maintain implemented procedures and monitor interventions the committee put into place following the annual recertification survey conducted on 07/28/21, 08/10/22 and during a complaint investigation on 08/23/23. This was for 1 deficiency that was cited in the area of Free of Accident Hazards/Supervision/Devices. The deficient practice area was recited on the current recertification and complaint survey of 10/24/23. The duplicate citation during three federal surveys of record shows a pattern of the facility ' s inability to sustain an effective QAPI program. The findings included: This citation is cross referenced to: F689-Based on record review and staff and interviews, the facility failed to provide care in a safe manner which resulted in a fall from the bed for 1 of 5 residents reviewed for accidents (Resident #19). During a complaint investigation on 08/23/23, the facility failed to safely transfer a resident from her bathroom to the recliner using the mechanical lift that resulted in the dislocation of the left shoulder which required treatment at a hospital. The facility also failed to safely transfer a resident from her motorized wheelchair to the bed using the mechanical lift that resulted in a fracture to the right hip which required treatment at a hospital. This was for 2 of 6 residents reviewed for supervision to prevent accidents. During the facility's recertification survey of 08/10/22, the facility failed to identify the root cause and implement effective interventions to prevent multiple falls for a resident. In addition, the facility failed to identify the root cause for multiple falls for another resident and failed to safely utilize a total body (hydraulic lift utilizing a body sling) lift while attempting to transfer a resident resulting in a fall without injuries for a third resident. This was for 3 of 3 residents reviewed for accidents. During the facility's recertification survey of 07-28-21, the facility failed to determine the root causes of each fall and put effective interventions in place following each fall to prevent repeated falls for 1 of 5 sampled residents reviewed for falls. An interview was conducted with the Director of Nursing (DON) and Infection Control (IC) Nurse on 10/24/23 at 3:54 PM. They both stated they felt the repeat citation was the result of miscommunication between [NAME] Village nursing staff and agency staff. They also stated they had recently changed their approach to the accidents Performance Improvement Project (PIP).

Based on observations, record review, resident, staff, and Physician Assistant (PA) interviews the facility failed to safely transfer a resident (Resident #3) from her bathroom to the recliner using the mechanical lift that resulted in the dislocation of the left shoulder which required treatment at a hospital. The facility also failed to safely transfer a resident (Resident #2) from her motorized wheelchair to the bed using the mechanical lift that resulted in a fracture to the right hip which required treatment at a hospital. This was for 2 of 6 residents reviewed for supervision to prevent accidents. Findings included: 1. Resident #3 was admitted to the facility on [DATE] with diagnosis that included osteoporosis, repeated falls, and pain to left arm. A care plan dated 12/28/22 revealed in part; Resident #3 had a focus area to maintain current level of physical mobility and ability to perform any assist with her self-care. Interventions read in part staff to assist with all transfers and to transfer with the stand up mechanical lift on days she ' s not able to assist staff with standing. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #3 cognition was severely impaired she exhibited no behaviors. She required extensive assistance with the help of two people with toilet use and total assistance with the help of two people with transfers. No limitations to mobility of upper or lower extremities. Resident #3 ' s incident report dated 01/24/23 at 6:40 PM that read in part that Resident #3 had a large area bruise on the left anterior thigh and complained of left shoulder pain. She was examined by the Physician Assistant (PA) which ordered an x-ray of her left shoulder. The x-ray revealed a dislocated left shoulder and Resident #3 was sent to the emergency room for further evaluation. An interview with Physician Assistant (PA) was conducted on 08/23/23 at 10:32 AM. He indicated staff called him to the Resident #3 ' s room on 01/24/23 due to a complaints of pain to her left shoulder. After assessing resident, he recommended Physical Therapy (PT) to assess her and to apply ice packs as needed. He further stated staff denied any injury or fall. PT recommended obtaining an x-ray for further evaluation which he ordered, and results revealed Resident #3 had a dislocated left shoulder. She was sent to the emergency room for further evaluation and treatment. A phone interview with Nurse #1 was conducted on 08/23/23 at 12:10 PM. She confirmed she did work on 01/24/23 from 6 AM-6 PM and was Resident #3 ' s nurse. She indicated she was told by Nursing Assistant (NA) #2 that Resident #3 had complained of left shoulder pain prior to breakfast and requested pain medication. She stated upon entering Resident #3 ' s room, she was sitting up in her recliner. She then administered the pain medication and assessed her shoulder. She indicated that she could wiggle her fingers, move her wrist in a circle, bent her arm at the elbow, and shrugged her shoulders without complaints of pain, however she was unable to lift her arm up. Resident #3 was unable to give a reason for the pain to her left shoulder. Nurse #1 then notified the Physician Assistant (PA) that was in the facility at the time. She also indicated NA #2 did not report any type of injury or fall. Nurse #1 verified she worked with Resident #3 on 01/23/23 and she did not complain of shoulder pain nor did staff report pain to shoulder or a bruise to her left thigh area. A phone interview with Nursing Assistant (NA) #3 was conducted on 08/23/23 at 12:10 PM. She stated she did work 6 AM-6 PM on 01/24/23 but she did not provide direct care to Resident #3. She indicated she did bring the resident her breakfast tray the morning of 01/24/23 and that she complained of left shoulder pain at that time. She further stated she notified the nurse of the residents ' complaints of pain. She also stated she did not assist NA #2 with any transfers with Resident #3 during her shift. A phone interview with Nursing Assistant (NA) #4 was conducted on 08/23/23 at 1:12 PM. She stated she did work 6 AM-6 PM on 01/24/23 but she did not provide direct care to Resident #3. She further stated she did not assist NA #2 with any transfers with Resident #3 during her shift. A phone interview with Nursing Assistant (NA) #5 was conducted on 08/23/23 at 1:21 PM. She stated she did work 6 AM-6 PM on 01/23/23 and she provided direct care to Resident #3. She indicated she did not see any skin discolorations, bruises, nor did Resident #3 complain of any new pain or discomfort during her shift. A phone interview with Nurse #3 was conducted on 08/23/23 at 1:49 PM. She stated she did work 6 PM-6AM on 01/24/23 but she did not provide direct care to Resident #3. She indicated she assisted Nurse #4 with performing an assessment on the resident and instructed her to notify the Director of Nursing (DON) due to a large, bruised area to Resident #3 ' s left thigh area. Nurse #4 was unavailable for interview. According to Nurse #4 ' s statement dated 01/24/23 during 6 PM-6AM shift she indicated she received report from Nurse #1 that Resident #3 had complained of left shoulder pain during her shift. She indicated that the Physician Assistant (PA) and Physical Therapy (PT) had evaluated Resident #3 and an x-ray had been ordered. She stated the Nursing Assistant (NA) notified her of a large bruised are to the residents left thigh area. She performed an assessment and noted the bruise/hematoma to her left thigh, resident denied pain at the time. X-ray results revealed Resident #3 had a dislocated left shoulder and was sent to the emergency room for evaluation and treatment. An interview with the Director of Nursing (DON) was conducted on 08/23/23 at 2:12 PM. She stated she received a call from Nurse #4 on 01/24/23 informing her the x-ray results revealed a dislocated shoulder and she reported a bruised area to Resident #3 ' s left leg. She also stated that she was being sent to the emergency room for evaluation and treatment. She returned to work on the morning of 01/25/23 and performed an investigation of the dislocated shoulder and bruised leg. She indicated Nursing Assistant (NA) #2 was Resident #3 ' s direct care NA for 01/24/23 from 6 AM-6 PM. She had a phone interview with NA #2 which stated that when she went in to provide AM care to Resident #3, she had complained of shoulder pain. She indicated NA #2 then explained that during a transfer using the stand-up mechanical lift that the residents ' legs gave out and she lowered her to floor. She then stated NA #2 indicated a short girl with black hair assisted her in getting Resident #3 off the floor but was unable to provide a name. No employee ' s that worked on 01/24/23 matched the description that NA #2 gave. She verified NA #2 stated she did not have assistance by another staff member while utilizing the mechanical lift. The DON then stated that NA #2 had not reported the fall to the nurse and that her description of a staff member that assisted her with getting Resident #3 from the floor did not match anyone that had worked on 01/24/23. She further stated mechanical lifts require 2 person staff assistance. She indicated all nursing staff had received training on using the mechanical lift. She further stated NA #2 should have asked for assistance before transferring Resident #3 alone. A phone interview with Nursing Assistant (NA) #2 was conducted on 08/23/23 at 2:45 PM. She stated she did work 6 AM-6 PM on 01/24/23 and she provided direct care to Resident #3. She also stated that when she went in to provide AM care to Resident #3, she had complained of left arm pain. She indicated that during a transfer using the stand-up mechanical lift the morning of 01/24/23 the residents ' legs gave out and she lowered her to floor, she did not have another staff member in the room with her during the transfer. NA #2 stated a short girl with black hair assisted her in getting Resident #3 off the floor, but she did not know the girl ' s name. She further stated Resident #3 had no difficulty holding the handles during the transfer and did not complain of pain. NA #2 indicated she did not observe any bruising to residents left thigh area when providing incontinence care but that she did not remove her pants, only enough to put the incontinence brief on. 2. Resident #2 was readmitted to the facility on [DATE] with diagnosis that included orthopedic aftercare after right hip fracture due to a fall, osteoarthritis, and spondylosis with myelopathy of the cervical region. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #2 was cognitively intact. She required extensive assistance with the help of two people with bed mobility, transfers, and activities of daily living. Impaired mobility to both sides of upper and lower extremities and as having no falls. A care plan dated 04/07/23 revealed in part; Resident #2 had a focus area of impaired functional status related to no functional use of her legs. Interventions included in part; to transfer with the total mechanical lift. She also had a focus area of at risk for falls related to no functional use of her legs. Interventions included in part; staff will assist me during transfers from surface to surface as needed. Resident #2 ' s incident report dated 04/10/23 at 1:10 PM completed by Nurse #1 read in part that Resident #2 was being transferred to the emergency room for possible right hip fracture due to a fall. Resident complained of back pain and right hip pain, and her right leg was rotated outward. Resident #2 ' s fall scene investigation report dated 04/13/23 read in part that she fell from the mechanical lift during a transfer from her electric wheelchair to the bed. The report included contributing factors observed at time of fall were staff/equipment error and that the mechanical lift pad caught the arm of her wheelchair. The report summary revealed staff member transferred resident using total lift without having a second clinical staff member present. Discharge summary dated 04/14/23 read in part that Resident #2 presented to the emergency department related a mechanical lift fall with osteoporotic bone disease. The fall resulted in a right hip fracture that required a surgical right hip partial repair on 04/11/23. Investigation report revealed Resident #2 had a fall from a mechanical lift during a transfer. The Physician Assistant (PA) was in facility at the time of the incident and assessed resident promptly. Emergency Medical Assistants (EMS) was called, and resident was transferred to the hospital and admitted for a right hip fracture. Nursing Assistant (NA) #1 was written up for failure to follow policy and training to have a second staff member present at the time of lifts. After a detailed fall investigation and witness statements, it was determined that there was no failure through inattentiveness, intentional or reckless behavior, or carelessness to provide resident services. All care staff immediately in serviced in safe operation of equipment and following established safety operating policy. An interview with Nursing Assistants (NA) #1 was conducted on 08/22/23 at 2:41 PM. She indicated Resident #2 was in her electronic wheelchair and requested to be put in bed because she needed to use the bed pan. She stated Resident #2 required the use of a mechanical lift for all transfers and when she retrieved the lift, she did not see another staff member to assist her. She proceeded to Resident #2 ' s room and applied the lift pad to the mechanical lift, assuring the clasps were securely locked into place. NA #1 then stated when she went to lift her up in the lift, she double checked that the clasps were in place and proceeded to raise her approximately two feet from her chair. She indicated she then went around to the back of the lift to turn it around to get to the bed when Resident #2 stated she was falling. She stated before she could get around the lift to assist, Resident #2 slid out of the lift pad landing on the floor in front of her wheelchair. NA #1 then went to get assistance from the nurse. NA #1 further stated that she does not know what could have happened and indicated the lift pad may have got caught on the wheelchair. An interview with the Director of Nursing (DON) was conducted on 08/22/23 at 3:07 PM. She stated she was called to Resident #2 ' s room due to a fall from the mechanical lift. Upon entering the room, Resident #2 was on the floor and at that time denied pain or discomfort. She assisted Resident #2 onto her back, and she then complained of back pain. Resident #2 agreed to go to the emergency room for evaluation. She indicated she questioned Nursing Assistant (NA) #1 in reference to what had occurred, and she stated she did not know what could have happened that caused the fall with Resident #2. She indicated the lift pad may have got caught on the wheelchair handle. She stated she had NA #1 perform a reenactment of the incident and reeducated her regarding safe transfers and facility policy guidelines. She revealed that Resident #2 obtained a right hip fracture due to the fall from the mechanical lift. An interview with Physician Assistant (PA) was conducted on 08/23/23 at 10:32 AM. He indicated staff called him to the Resident #2 ' s room on 04/10/23 due to a fall from the mechanical lift. Upon entering the room Resident #2 was lying on the floor with complaints of pain to the back of her head and right hip. He indicated Resident #2 was stable and comfortable while awaiting Emergency Medical Services (EMS). He further indicated staff should follow the facility protocol and the resident care plan when utilizing mechanical lifts to help prevent accidents and injuries. An interview with Resident #2 was conducted on 08/23/23 at 10:54 AM. She indicated that she did remember the fall on 04/10/23 and that it was just an accident. She indicated normally there were two staff members who assisted her with transfers using a mechanical lift. She recalled Nursing Assistant (NA) #1 transferred her from her wheelchair to the bed by herself. She stated during the transfer she told NA #1 that she felt like she was sliding out of the sling, but NA #1 was unable to get around the lift before she fell out. She further stated she doesn ' t know how she fell , maybe she was off center in the sling because she knew the clasps were fastened and locked into place. Resident #2 indicated the NA left the room to get help. She was sent to the emergency room for hitting her head, back pain and a possible fractured right hip. She revealed that she underwent a repair of the right hip due to a fracture she obtained during the fall. An interview with the Director of Nursing (DON) was conducted on 08/23/23 at 2:12 PM. She stated the mechanical lift required 2 person staff assistance. The DON indicated the facility implemented a corrective action plan on 04/10/23 to prevent a reoccurrence. She indicated all nursing staff had received training on 04/11/23 using the mechanical lift. She further stated Nursing Assistant (NA) #1 should have asked for assistance before transferring Resident #2 alone. Corrective action for the involved resident dated 04/11/23 read as follows: Resident #2 was assessed for potential injuries by the licensed nurse. Resident #2 was sent to the hospital for an evaluation and treatment. Employee providing care received disciplinary action. Corrective action for other potentially affected residents dated 04/11/23 read as follows: Audit of all current residents was conducted by the Director of Nursing (DON) regarding transfer status. All current residents identified as being transferred using a mechanical lift were audited to make sure the transfer status was accurate in the chart and care plan by the Minimum Data Set (MDS) nurse. Systemic Changes and Education initiated on 04/11/23 read as follows: All current nursing staff were educated by the Staff Development Coordinator (SDC) regarding the mechanical lift policy which requires two staff members be present for each transfer on 04/11/23. Any licensed or nursing staff that cannot be reached within the initial reeducation time frame will not take an assignment until they have received this reeducation. Agency licensed nurses or nursing staff and newly hired licensed nurses or nursing staff will have this education during their orientation. Quality Assurance (QA) Plan initiated on 04/11/23 read as follows: The Director of Nursing (DON), Staff Development Coordinator (SDC) or Registered Nurse Supervisor will randomly audit a mechanical lift transfer 3 times per week for 3 months. Reports would be presented to QA committee by the DON to ensure corrective action was appropriate. Compliance would be monitored, and ongoing auditing program would be reviewed at monthly QA meetings for the timeframe of the monitoring period or as it is amended by the committee. The April monthly QA meeting was attended by the Medical Director (MD), Administrator, DON, MDS Nurse, Social Worker (SW), medical records, Chief Executive Officer (CEO), Director of Rehab, and the Dietary Manager. The May monthly QA meeting was attended by the Medical Director (MD), Administrator, DON, SDC, MDS Nurse, Social Worker (SW), medical records, and Director of Rehab. The June monthly QA meeting was attended by the Medical Director (MD), Administrator, DON, SDC, MDS Nurse, Social Worker (SW), medical records, Chief Executive Officer (CEO), Director of Rehab, Dietary Manager, and Resident Care Coordinator. The plan alleged compliance on 04/12/23. Review of the facility plan of correction revealed evidence of 100% auditing of staff using correct transfer techniques for residents requiring a mechanical lift, evidence of 100% all staff interviewing and observation of utilizing mechanical lifts completed on 08/08/23. The facility provided evidence of 100% staff education on correct transfer techniques for residents requiring a mechanical lift completed on 04/12/23. The facility also provided evidence of a QA audits of observations for correct transfer techniques for residents requiring a mechanical lift completed on 08/08/23. Residents deemed alert and oriented revealed no current concerns related to staff using correct transfer techniques requiring a mechanical lift to include having two staff members present. Observations revealed two staff were transferring a resident with a mechanical lift as specified on the care plan. The facility ' s date of compliance was validated as 04/12/23. The facility ' s date of compliance was validated on 08/23/23.

Based on observation, staff interviews, Physician Assistant (PA) interview and Responsible Party (RP) interview and record review the facility failed to identify the root cause and implement effective interventions to prevent multiple falls (Resident #32). In addition, the facility failed to identify the root cause for multiple falls (Resident #18) and failed to safely utilize a total body (hydraulic lift utilizing a body sling) lift while attempting to transfer a resident resulting in a fall without injuries (Resident #29). This was for 3 of 3 residents reviewed for accidents. The findings included: 1. Resident #32 was admitted on [DATE] with cumulative diagnoses of Dementia, [CONDITION(S)], a history of a femur fracture and a history of falls. Her annual Minimum Data Set (MDS) dated [DATE] indicated severe cognitive impairment, extensive assistance with transfers and she was coded as have two falls with minor injuries since the previous MDS assessment. She was also coded for a prognosis of less than six months and hospice services. Resident #32 was care planned for falls initially on 6/30/21 and last revised on 7/30/22. Interventions included in part frequent checks, encourage her to stay in the common area for closer staff supervision, routine toileting and staff were not to lock her wheelchair brakes. Review of Resident #32's electronic care guide utilized by the aides included the same interventions as her comprehensive care plan. Resident #32's fall incident reports read the following: *4/14/22 at 5:15 PM, Resident #32 fell from her wheelchair and on the floor in the hallway. She sustained a laceration to her forehead and sent to the hospital for an evaluation. Her CT Scan was negative for head or spine injuries and she returned to the facility with steri-strips to her forehead laceration. The intervention read to encourage her to stay in the common area for closer staff supervision. There was no documented evidence of the facility completing a root cause analysis. *5/8/22 at 4:00 PM, Resident #32 was on the floor in the Dining Room with her wheelchair behind her. She sustained a skin tear to her left hand. The intervention read to remind staff to provide routine toileting. There was no documented evidence of the facility completing a root cause analysis. *6/6/22 at 8:20 PM, Resident was observed lying on the floor with her back close to the bed. She sustained a skin tear to her left forearm, left wrist, right shin and a raised area to her right forehead with an abrasion. Neurological checks initiated and steri-strips were applied to her skin tears. The intervention read for staff to provide routine rounds for safety. There was no documented evidence of the facility completing a root cause analysis. Review of the nursing notes read the skin tear to her right shin appeared red on 6/14/22 at 8:50 PM and a nursing note dated 6/16/22 at 10:19 PM read the area to her right shin had increased redness, slough with moderate exudate. The Physician was notified and orders were given on 6/17/22 for a wound consult. A nursing note dated 6/20/22 at 11:15 PM read there was [CONDITION(S)] to her right shin, ankle and foot with foul smelling drainage. A nursing note dated 6/21/22 at 1:42 PM read Resident #32 was seen by the wound consultant and new orders were given for wound care and an antibiotic. A nursing note dated 6/29/22 at 10:22 AM read the wound consultant assessed the area and noted improvement with no evidence of an infection and the wound consult dated 7/5/22 indicated the area to her right shin was healed. *7/30/22 at 4:00 PM, Resident #32 was observed on the floor in front of her wheelchair with her wheelchair brakes locked. Location was not documented and she did not sustain any injuries. Staff were in-serviced not to lock Resident #32's wheelchair brakes while she was up in her wheelchair. There was no documented evidence of the facility completing a root cause analysis. An observation was completed on 8/8/22 at 10:36 AM. Resident #32 was sitting in a high back wheelchair at Nurses Station #1. She was trying to propel herself but was not able to make any significant progress. The wheelchair brakes were unlocked and Nurse #4 was standing beside her. Review of another fall incident report dated 8/8/22 read the following: *8/8/22 at 5:30 PM, Resident #32 was sitting in her wheelchair at Nursing Station #1. She was observed leaning forward and Nurse #4 asked her to lean back. Nurse #4 continued charting when she heard a noise. She looked up and did not see Resident #32. She found her lying on the floor on her stomach in front of the wheelchair. Resident #32 had a lump to the left side of her forehead and was sent out to the hospital for an evaluation. The intervention read to place Resident #32 in bed after being up for 2 or more hours unless there was an activity to keep her preoccupied. A nursing note dated 8/8/22 at 10:00 PM read Resident #32 returned to the facility and her CT scan was negative for head or spine injuries. She returned with a large hematoma covering the entire left side of her forehead from above her left eye up to her scalp. There was no documented evidence of the facility completing a root cause analysis. An interview was completed on 8/9/22 at 2:05 PM with Nurse #4, She stated the fall dated 7/30/22 occurred at NS #1 when an agency aide placed her at Nurses Station #1 and locked her wheelchair brakes. She stated the agency aides were not familiar with interventions put in place to prevent Resident #29 from falling. A telephone interview was completed on 8/9/22 at 3:00 PM with agency Nursing Assistant (NA) #5. She stated she did not recall being assigned Resident #32 on 7/30/22 but did recall leaving early at 2:00 PM that day and rolling Resident #32 up to Nurses Station #1 as she was leaving. She stated she did not recall locking her wheelchair brakes but confirmed an in-service about it on 8/1/22. An interview was completed on 8/10/22 at 8:20 AM with the Administrator. He stated the managers discussed any falls from the day/night before every Monday through Friday and discussed weekend falls on Mondays. He stated at that time, the Director of Nursing (DON) put interventions in place and the MDS Nurse revised the care plan. He stated the facility also reviewed resident falls during the Resident at Risk (RAR) monthly meeting and included the Director of Nursing, Nurse Managers, the MDS Nurse and himself. He stated the RAR meetings were weekly up until recently but offered no explanation as to why the weekly meetings were discontinued. The Administrator stated they were resuming the weekly RAR meetings weekly on 9/5/22. The Administrator was unable to answer how agency staff were educated about how to care for the residents, he stated he was not sure if there was any sort of orientation and deferred the question to the interim DON. A telephone interview was completed on 8/10/22 at 9:30 AM with the previous DON. She stated her last day at the facility was 7/28/22. She stated all managers met Monday through Friday and discussed all resident falls. She stated the facility could not provide 24 hour/7 days a week supervision but they did the best they could. She stated staffing was a challenge but it was a challenge everywhere in healthcare. An observation was completed on 8/10/22 at 10:00 AM of Resident #32. She was in her room sitting up in a recliner. Observed was a large dark blue and purple discoloration to the entire left side of her forehead and around her left eye. An interview was completed on 8/10/22 at 12:10 PM with Nurse #4. She stated Resident #9 was at Nursing Station #1 on 8/8/22 while she was charting. She stated she and other staff had to keep reminding Resident #32 to not lean forward but rather lean back in her wheelchair. Nurse #4 stated she continued charting when she heard a bump and found Resident #32 on the floor in front of her wheelchair. She stated her wheelchair brakes were not locked at the time of the fall and she sustained a bump to her left forehead. Nurse #4 stated she notified the hospice nurse and the Physician and orders were given to send her to the hospital for an evaluation. Nurse #4 stated she left for the day around 7:00 PM and did not receive Resident #32 when she returned from the hospital but was surprised at the bruising the next day. An interview was completed on 8/10/22 at 12:16 PM with the PA. He stated he would like to know more details involving the circumstances prior to a resident fall for example what medications were administered prior or when was the last time the resident was toileting, etc. to identify a trend or pattern. The PA stated it seemed that the staff were in the resident's rooms too long and if there was only two aides on the floor and the nurse was passing medications, there was a lack of enough staff to oversee residents' safety. An interview was completed on 8/10/22 at 1:20 PM with the Activity Director (AD). She stated once Resident #29 was up and after lunch, she was taken to the afternoon activities but she did not actively participate and would get fidgety and roll herself out of the activity. A telephone interview was attempted on 8/10/22 at 2:15 PM with Resident #29's hospice nurse. There was no return telephone call. An interview was completed on 8/10/22 at 2:30 PM with the Rehabilitation Manger (RM). She stated Resident #29 was a hospice resident and in order to evaluate and treat Resident #29, hospice would need to approve it and she stated that seldom if ever happened. The RM stated resident falls were discussed in the morning meeting and she would offer ideas or suggestions but she was not a part of the RAR meetings. A telephone interview was completed on 8/10/22 at 4:55 PM with Resident #32's RP. She stated she was concerned about her falls and afraid a fall could result in a serious injury or worse for Resident #32. The RP stated she was not sure if the facility was doing all they could to monitor Resident #32 for safety. An interview was completed on 8/10/22 at 5:04 PM with the interim DON. She stated the facility should resume the weekly RAR meetings to better identify the root cause of a fall and to help identify trends or patterns timely. She also stated it was her expectation that the facility identify the root cause for each fall and implement effective interventions to lessen the number of falls that had occurred with Resident #32. 2. Resident #29 was admitted on [DATE] with a diagnosis of Multiple [CONDITION(S)]. Review of the significant change Minimum Data Set (MDS) dated [DATE] indicated Resident #29 had severe cognitive impairment was coded for no transfers out of bed during the 7 day look back period. She was coded as having no falls since prior MDS assessment. Review of Resident #29's care plan for falls initiated 9/20/21 read she had an assisted fall on 7/7/22. The intervention read to remind staff to take extra time to ensure equipment was ready for a transfer. Review of an incident report dated 7/7/22 at 8:45 PM read the aide was using the total body lift to transfer Resident #29 from her chair to the bed. When the aide attempted to put the lift sling under Resident #29 and secure the lift sling loops on the lift hooks, Resident #29 started to slide to the floor and was lowered to the floor. She did not sustain any injuries. A telephone interview was completed on 8/10/22 12:10 PM with Nursing Assistant (NA) #2. She stated she was assigned Resident #29 on 7/7/22 at the time of her fall at 8:45 PM. NA #2 stated the evening of 7/7/22, there was only herself and one other aide working. NA #2 stated she was aware that when transferring a total body lift resident, two staff had to be present but because the facility was short staffed, she tried to transfer Resident #29 using the lift alone without any assistance. She stated when only two aides were working, it was impossible to have two staff present for every total body lift. NA #2 stated that since she began working at the facility in June 2022, Resident #29 was transferred using the total body lift. NA #2 stated there was a document posted at Nurses Station (NS) #2 listing all the total body lift residents along with the correct sling size for each resident and Resident #29 was on that list. She stated the lift sling had been removed from underneath Resident #29 and she was attempting to get it under her and hook the sling to the lift but Resident #29 started to slide to so she eased her to the floor. She stated she was in-serviced at the time of the fall to have two staff present for a lift transfer. A telephone interview was completed on 8/10/22 at 3:30 with Nurse #4. She stated she was working the evening of 7/7/22 when there was one aide for each end of the hall and she was busy in another resident's room. The call light was going off in Resident #29's room and when she entered, she saw Resident #29 on the floor. NA #2 stated she tried to transfer Resident #29 using the total body lift by herself. NA #2 reported Resident #29 slid from her chair while she was attempting to put the sling underneath her and she could not reach the hooks on the lift to fasten the sling loops and eased Resident #29 to the floor. Nurse #4 stated Resident #29 did not sustain any injuries and she had been a total body lift transfer since admission per her family request and due to her stiffness. An interview was completed on 8/9/22 at 4:03 PM with NA #3. She stated due to Resident #29's muscle stiffness, she was difficult to transfer and required the use of a total body lift. NA #3 stated she thought Resident #29 had been a total body lift transfer since her admission. She further stated that there had to be two staff present when completing a total body lift transfer. An interview was completed on 8/10/22 at 8:20 AM with the Administrator. He stated the managers discussed any falls from the day/night before every Monday through Friday and discussed weekend falls on Mondays. He stated at that time, the Director of Nursing (DON) put interventions in place and the MDS Nurse revised the care plan. He stated the facility also reviewed resident falls during the Resident at Risk (RAR) monthly meeting and included the Director of Nursing, Nurse Managers, the MDS Nurse and himself. He stated the RAR meetings were weekly up until recently but offered no explanation as to why the weekly meetings were discontinued. The Administrator stated they were resuming the weekly RAR meetings weekly on 9/5/22. A telephone interview was completed on 8/10/22 at 9:30 AM with the previous DON. She stated her last day at the facility was 7/28/22. She stated all managers met Monday through Friday and discussed resident falls. She stated the facility could not provide 24 hour/7 days a week supervision but they did the best they could. She stated staffing was a challenge but it was a challenge everywhere in healthcare. An interview was completed on 8/10/22 at 12:16 PM with the PA. He stated it seemed that the staff were in the resident's rooms too long and if there was only two aides on the floor and the nurse was passing medications, there was a lack of enough staff to oversee residents' safety. An observation was completed on 8/10/22 at 1:30 PM with the interim Director of Nursing (DON). Located on the employee bulletin board in the breakroom at NS #2 was an undated document indicating Resident #29 used a total body lift for transfers. The DON stated the document had been posted on the bulletin board for a least 6 months when the new slings came in so staff would know the correct sling size to use when transferring any total body lift resident. Resident #29's name appeared on the list as requiring a medium size sling. The interim DON also stated the electronic care guide was also utilized by the aides identifying the resident's lift status. Review of Resident #29's electronic care guide utilized by the aides read that Resident #29 was a Sit-to Stand lift ((lift designed to assist a resident who lacked the strength or muscle control to rise to the standing position) for all transfers on 11/19/21. The electronic care guide also read for the staff were to take extra time to ensure equipment was ready for a transfer as of 7/7/22. An interview was completed on 8/10/22 at 5:04 PM with the interim Director of Nursing (DON). She stated it was her expectation that two staff assist with transferring any total body lift resident. 3. Resident #18 was originally admitted to the facility on [DATE] with multiple diagnoses including Alzheimer's disease and fracture of the left wrist. The admission Minimum data Set (MDS) assessment dated [DATE] indicated that Resident #18 had severe cognitive impairment, was occasionally incontinent of bladder, and was always continent of bowel. The assessment also indicated that the resident was able to walk in the room with supervision/set up help only, she needed limited assistance with 1-person physical assist with transfers and she was using a wheelchair for mobility. The assessment further indicated that the resident had history of falls and had a fracture related to a fall in the last 6 months prior to admission. A fall risk assessment dated [DATE] was completed for Resident #18, and she scored 12. The assessment indicated that if the score was 10 or greater, the resident should be considered at high risk for potential falls. A prevention protocol should be initiated immediately and documented on the care plan. Resident #18's incident reports and nurse's notes from 3/15/22 through 8/9/22 were reviewed. The reports/notes revealed that the resident had 5 falls at the facility. The report/note dated 4/9/22 at 12:00 PM revealed that Resident #18 was observed sitting on the floor in front of a raised recliner with no injury noted. A family member stated that she slid out of the chair. The intervention to prevent further fall was to remind the resident to call for staff assistance for safety. The report did not include the root cause of the fall. The report/note dated 4/23/22 at 4:45 AM revealed that Resident #18 was observed sitting on her buttocks on the floor near the bathroom with her left leg turned outwards. The resident stated that she needed to go to the bathroom. She was placed in wheelchair and was assisted to the bathroom and back to bed. The physician was notified, and x-ray of the left tibia and fibula was ordered, and the report was negative for fracture. The intervention was to educate the resident on proper footwear when ambulating. The report did not include the root cause of the fall. The report/note dated 4/30/22 at 6:40 AM revealed that Resident #18 was noted on the floor between the foot of the bed and the dresser. Her walker was tipped over on the right side of the bed. The resident stated, I went to the bathroom and was getting back into bed. There was no injury noted from the fall. The intervention to prevent further falls was to provide frequent check for safety. The report did not include the root cause of the fall. The report/note dated 6/4/22 at 7:15 AM revealed that Resident #18 was noted on the floor. A few drops of blood were noted on her nose. The intervention to prevent further fall was to continue to provide frequent reminders to use her call bell for staff assistance. The report did not include the root cause of the fall. Nurse #1 was interviewed on 8/9/22 at 9:37 AM. She stated that she was assigned to Resident #18 when the resident had a fall on 6/4/22. The Nurse reported that when a resident had a fall an incident report was completed, the description of the fall, date, time, the location of the incident and type of injury, if any. On 6/27/22, Resident #18 was discharged to an assisted living facility and on 7/26/22, she was readmitted to the facility with a diagnosis of intertrochanteric fracture of the right femur. A fall risk assessment dated [DATE] was completed for Resident #18, and she scored 13. The assessment indicated that if the score was 10 or greater, the resident should be considered at high risk for potential falls. A prevention protocol should be initiated immediately and documented on the care plan. The incident report dated 7/29/22 at 8:20 PM revealed that Resident #18 was observed in the room next door. She was on the floor in front of the bathroom. The resident stated that she was trying to go to the bathroom. The resident stated that her right hip was sore and that she had a bad hip and was patting on her right hip. The intervention to prevent further fall was toileting schedule in place. The report did not include the root cause of the fall. The admission MDS assessment dated [DATE] indicated that Resident #18 had severe cognitive impairment, was occasionally incontinent of bladder and was frequently incontinent of bowel. She needed extensive assist with transfers, ambulation in room occurred only once or twice with 1-person physical assist and she was using a walker and a wheelchair for mobility. She had a fall with no injury since admission, entry, reentry or prior assessment and had a fracture related to a fall in the last 6 months prior to admission. Resident #18's care plan dated 8/1/22 for falls was reviewed. The care plan problem was I am at risk for injury related to weakness, balance issues, needs for assistance with mobility and self-care and episodes of incontinence. I have very poor insights and judgment into my own deficits, and I receive medications that can make me dizzy. The goal was my staff will attempt to reduce risk of falls related injury. The approaches included staff will complete a fall risk assessment per facility protocol, staff will assist me during transfers from surface to surface as needed, staff will provide physical therapy and occupational therapy as ordered and to be offered toileting during rounds and as needed. Resident #18 was observed on 8/9/22 at 9:10 AM in bed with the door closed and on 8/10/22 at 10:01 AM up in a reclined chair in her room with the door closed. An interview was completed on 8/10/22 at 5:04 PM with the acting DON. She stated the facility should resume the weekly Resident At Risk (RAR) meetings to better identify the root cause of a fall and to help identify trends or patterns timely. She also stated it was her expectation that the facility identifies the root cause for each fall and implement effective interventions to lessen the number of falls. An interview was completed on 8/10/22 at 8:20 AM with the Administrator. He stated the managers discussed any falls from the day/night before every Monday through Friday and discussed weekend falls on Mondays. He stated at that time, the Director of Nursing (DON) put interventions in place and the MDS Nurse revised the care plan. He stated the facility also reviewed resident falls during the Resident at Risk (RAR) monthly meeting and included the Director of Nursing, Nurse Managers, the MDS Nurse and himself. He stated the RAR meetings were weekly up until recently but offered no explanation as to why the weekly meetings were discontinued. The Administrator stated they were resuming the weekly RAR meetings weekly on 9/5/22.

Based on record review, observation and interview with the Registered Dietician (RD), Dietary Manager (DM), Physician Assistant (PA), resident and staff, the facility failed to address and to intervene when a resident was identified to have a weight loss (Residents #13,& #3) which resulted in continued weight loss and failed to provide a nutritional supplement on admission for a resident with history of weight loss and continued to lose weight (Resident #14). This was for 3 of 4 sampled residents reviewed for nutrition (Residents # 13, #3, #14). Findings included: 1. Resident # 13 was admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #13 had severe cognitive impairment, was independent with eating and was on a mechanically altered diet. The assessment further indicated that the resident's weight was 189 pounds (lbs.). Resident #13's care plan for nutrition dated 5/29/22 was reviewed. The care plan problem was I am at risk for nutritional decline related to dysphagia from a stroke and on a dysphagia 1, puree consistency and nectar thick liquids. The goal was I will tolerate diet as ordered with no complications and will maintain my weight within 5% of 189 lbs. The approaches included staff to monitor my weight as ordered and notify the physician and my family of any concerns, Registered Dietician (RD) will assess my weight and nutritional status as needed throughout my stay at the facility. Resident #18's weights were recorded as follows: 5/13/22 - 189 lbs. 6/10/22 - 154 lbs. 7/5/22 - 168 lbs. - 21 lbs. weight loss in 2 months 8/5/22 - 147 lbs. - 42 lbs. weight loss in 3 months (since admission) and 21 lbs. weight loss in 1 month. Review of the RD documentation revealed that Resident #13 was last assessed by the RD on 5/20/22. The RD note indicated that the resident was on puree diet nectar thick liquids, and feeds self with set up help. His meal intakes were at 75% and has good appetite prior to admission. His current body weight was 188.9 lbs. Continue to monitor nutritional status, skin integrity, meal intakes and laboratory (labs) as available. Interventions/goals were for the resident to maintain current body weight +/- 5%, will maintain meal intake of more than 50% of all meals, will tolerate puree texture, nectar thick liquids, will monitor weights, intakes, labs and skin integrity. Review of the meal intake documentation for June, July and August 2022 revealed that some days there were no documentation of meal intake. There were no documentation for breakfast, lunch and dinner on 6/1/22, 6/3/22, 6/4/22, 6/5/22, 6/7/22, 6/8/22, 6/11/22, 6/12/22, 6/17/22, 6/18/22, 6/19/22, 6/24/22, 6/26/22, 6/28/22, 7/1/22, 7/2/22, 7/3/22, 7/9/22, 7/10/22, 7/12/22, 7/15/22, 7/16/22, 7/17/22, 7/22/22, 7/26/22, 7/28/22, 8/1/22 and 8/7/22. Resident #13 was observed on 8/8/22 at 12:40 PM with the Speech Therapist and on 8/10/22 at 12:30 PM. He was in his room eating lunch. He was served regular portion of puree diet with nectar thick liquids. He ate almost 100% of his food during each observation. The Dietary Manager was interviewed on 8/10/22 at 11:12AM. The DM stated that the RD has oversight of resident's weights and weight loss. The acting Director of Nursing (DON) was interviewed on 8/10/22 at 10:13 AM. The acting DON stated that residents were weighed monthly by nursing unless it was ordered differently. The weights were recorded electronically on the Medication Administration Records (MARs) and on the weight tracking form. She stated that nobody from nursing was responsible for monitoring/tracking weight loss/gain, however, the RD had access to the resident's weights recorded on the electronic records. The Physician Assistant (PA) was interviewed on 8/10/22 at 12:15 PM. The PA stated that he was never notified that Resident #13 had a significant weight loss. However, if nursing notified him of weight loss, he would normally refer the resident to the RD to assess and to intervene. The Nursing Aide (NA) #4, assigned to Resident #18 was interviewed on 8/10/22 at 3:25 PM. The NA stated that Resident #13 was confused and was able to feed himself. He has good appetite most of the time. She reported that the facility was short of staff, and she tried her best to provide the care and most of the time she did not have the time to document meal intakes. The RD was interviewed on 8/10/22 at 3:49 PM. The RD stated that she started working at the facility in February 2022. She came to the facility 2-3 times per week to see the residents and the rest of the week, she reviewed the residents remotely. She normally assessed residents with weight loss, new admission and quarterly. She reported that from 6/2/22 through 7/11/22, she had not been coming to the facility due to a medical reason, so she reviewed the residents remotely. She had access to the residents' weights electronically and was aware that Resident #13 had a significant weight loss from 189 lbs. in May 2022, 168 lbs. in July 2022 and 147 lbs. in August 2022. The RD reviewed her notes and stated that the last time she assessed Resident #13 was on 5/20/22. The RD did not have an explanation as to why she did not assess and intervene when she identified Resident #13 having a significant weight loss. 2. Resident #3 was admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #3's cognition was intact, was independent with eating and was on a mechanically altered diet. The assessment further indicated that the resident's weight was 169 pounds (lbs.). Resident #3's care plan for nutrition dated 5/30/22 was reviewed. The care plan problem was I am at risk for nutritional decline related to dysphagia diet and recent weight loss of 10 lbs. The goal was I will tolerate diet as ordered with no complications and will maintain my weight within 5% of my admission weight. The approaches included Registered Dietician (RD) will assess my weight and nutritional status as needed though out my stay at the facility. Resident #3's weights were recorded as follows: 4/29/22 - 169 lbs. 5/13/22 - 169 lbs. 6/5 - no recorded weigh 7/5/22 - 156 lbs. - 13 lbs. weight loss in 3 months (more than 7.5 % in 3 months) Review of the meal intake documentation for June, July and August 2022 revealed that some days there were no documentation of meal intake. There were no documentation for breakfast, lunch and dinner on 6/1/22, 6/2/22, 6/4/22, 6/5/22,6/6/22, 6/7/22, 6/8/22, 6/12/22, 6/17/22, 6/19/22, 6/24/22, 6/25/22, 6/26/22, 6/28/22, 7/1/22, 7/2/22, 7/9/22, 7/10/22, 7/15/22, 7/16/22, 7/17/22, 7/22/22, 7/23/22, 8/2/22, 8/5/22, 8/6/22, and 8/7/22. Review of the RD documentation revealed that Resident #3 was last assessed by the RD on 5/12/22. The note indicated that Resident #3 received mechanically altered diet with thin liquids, feeds self with set up help and his meal intakes were 25-100%. Prostat (a protein supplement) 30 milliliter was added to provide additional 100 kilo calories, 15 grams of protein for wound healing. His admission weight was 169 lbs. Interventions/goals were for the resident to maintain current body weight of +/- 5%, will maintain meal intake of more than 50% of all meals, will tolerate mechanically altered diet with thin liquids. Will monitor weights, meal intakes, laboratory and skin integrity. Resident #3 was observed on 8/8/22 at 12:37 PM and on 8/10/22 at 12:25 PM. He was in his room eating lunch. He was served regular portion of soft diet with thin liquids. He did not eat much of the food in his tray. When interviewed, he stated that he ate what he wants, and he had no appetite. The Dietary Manager was interviewed on 8/10/22 at 11:12AM. The DM stated that the RD has oversight of resident's weights and weight loss. The acting Director of Nursing (DON) was interviewed on 8/10/22 at 10:13 AM. The acting DON stated that residents were weighed monthly by nursing unless it was ordered differently. The weights were recorded electronically on the Medication Administration Records (MARs) and on the weight tracking form. She stated that nobody from nursing was responsible for monitoring/tracking weight loss/gain, however, the RD had access to the resident's weights recorded on the electronic records. The DON stated that she was aware that Resident #3 had a missing weight in June 2022. The Physician Assistant (PA) was interviewed on 8/10/22 at 12:15 PM. The PA stated that he was never notified that Resident #3 had a significant weight loss. However, if nursing notified him of weight loss, he would normally refer the resident to the RD to assess and to intervene. The Nursing Aide (NA) assigned to Resident #3 was interviewed on 8/10/22 at 3:25 PM. The NA stated that Resident #3 was able to feed himself. He had poor appetite most of the time. She reported that the facility was short of staff, and she tried her best to provide the care and most of the time she did not have the time to document meal intakes. The RD was interviewed on 8/10/22 at 3:49 PM. The RD stated that she started working at the facility in February 2022. She came to the facility 2-3 times per week to see the residents and the rest of the week, she reviewed the residents remotely. She normally assessed residents with weight loss, new admission and quarterly. She reported that from June 2 through July 11, 2022, she had not been coming to the facility due to a medical reason, so she reviewed the residents remotely. She had access to the residents' weights electronically and was aware that Resident #3 had a significant weight loss from 169 lbs. in April 2022 to 156 lbs. in July 2022. She reviewed her notes and stated that the last time she assessed Resident #3 was on 5/12/22. The RD did not have an explanation as to why she did not assess and intervene when she identified Resident #3 having a significant weight loss. 3. Resident #14 was admitted with palliative care on 5/24/22 with cumulative diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Her admission Minimum Data Set (MDS) dated [DATE] indicated Resident #14 had severe cognitive impairment, required extensive assistance with eating, a pressure ulcer and her height of 63 inches with her weight recorded as 120 pounds (lbs.). The MDS was coded as unknown for any weight loss or weight gain. Resident #14 was care planned on 5/31/22 for a risk of a nutritional decline due to her poor appetite. Interventions included discussing her likes and dislikes, monitoring her weight and to notifying the Physician for any concerns. Interventions also included the Registered Dietitian (RD) would assess her weight and nutritional status as needed. Review of Resident #14's August 2022 Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Another order dated 7/20/22 was for a frozen nutritional supplement twice daily due to poor nutrition and the ordered read it was started on 7/20/22. She was also ordered a regular diet and not prescribed a diuretic. Review of Resident #14's oral intake from 5/25/22 to 8/9/22 ranged from 0 to 100%. There was not any documented evidence of patterns for her meal refusals or zero consumption. Review of Resident #14's most recent lab work dated 5/27/22 indicated her [MEDICATION(S)] was low at 3.1. Review of Resident #14's electronic medical record read her admission weight on 5/25/22 was 116.4 lbs. Her following weights were as follows: * 5/31/22 weight recorded at 109.8 lbs. * 6/5/22 and 6/7/22 weight recorded at 110 lbs. *7/5/22 weight recorded at 106.5 lbs. * 8/5/22 weight recorded at 103.6 lbs. This data revealed an 11% weight loss in the past 74 days (5/24/22 to 8/5/22). Review of Resident #14's Physician/Physician Assistant (PA) notes revealed the following: *6/21/22 Initial encounter-noted was a pressure ulcer to her left heel with no mention of her appetite or weight loss *6/28/22 routine encounter-eating well *7/5/22 routine encounter-eating well *7/12/22 routine follow up encounter-resident was in the dining room eating well and feeding herself Cheerios *7/18/22 routine follow up encounter-eating well and noted weight loss *7/25/22 routine follow up encounter-eating well *8/1/22 routine follow up encounter-eating well and noted weight loss. *8/8/22 routine follow up encounter-in room drinking a protein drink. Eating well Review of the comprehensive nutrition assessment completed by the RD and dated 5/31/22 read as follows: *Resident #14 receives a consistent carbohydrate diet with regular textures and thin liquids. Poor appetite reported, noted intakes of 0-50% for all meals per her seven day look back. Resident #14 received a nutritional drink three times daily to aid in meeting nutritional needs. She required assistance with most meals. Recent weight loss reported. Current body weight 116.4 lbs., body mass index 20.6 is low for her age. Continues weekly weights. Unstageable pressure wound to her left heel. Will continue to monitor weights, labs, oral intake and nutritional status. The interventions goals read to maintain her current body weight +/- 5%, maintain oral intake of >50% at all meals and to continue to tolerate regular textures. Will continue to monitor weights, oral intakes, lab work, skin integrity through next review. Review of the only other documented RD note dated 7/18/22 read as follow: *RD visited Resident #14 due to weight loss. Current body weight was 106.5. Resident #14 on a consistent carbohydrate regular diet and a nutritional drink was ordered three times daily for weight loss. The Nurse in the room reported that Resident #14 did not eat well. Noted her oral intakes over 7 days varied from 0-100%. Recommend liberalizing diet to regular to provide more options and encourage oral intakes. Will continue to monitor oral intakes, weights and labs through the next review. There were no recommendations or evidence that the Physician or PA were notified of continued weight loss. An observation and interview was completed on 8/8/22 at 12:25 PM. Resident #14 was in the dining room with Nursing Assistant (NA) #3 prompting her with lunch. NA #3 stated her appetite was poor and she was losing weight. She stated the staff try to get her up for all meals. She stated Resident #14 needed more staff assistance if she was eating in bed. NA #3 stated she normally ate 0 to 50% of all her meals but drink her nutritional drink if it was chocolate. An observation and interview was completed on 8/10/22 at 8:00 AM. Nurse #2 stated Resident #14's appetite was poor and she had lost weight since her admission but she ate 100% of her breakfast. Nurse #4 stated ate better when up in the dining room but Resident #14 was still in bed to allow for the observation of her wound care. Nurse #4 stated Resident #14 liked the chocolate nutritional drink and she ate better when she was served items that she could pick up to eat rather than eating with a fork or spoon. She stated Resident #14 liked to snack on Cheerios. A review of Resident #14's electronic wound care provider notes also indicated healing to her left heel pressure ulcer. An interview was completed on 8/10/22 at 8:20 AM with the Administrator. He stated previously the facility employed a full-time RD but the current RD started in February 2022 and only worked part-time. He stated the facility reviewed resident's with weight loss during the monthly Resident at Risk (RAR) meeting and included the Director of Nursing, Nurse Managers, the MDS Nurse and himself. He stated the RAR meetings were weekly up until recently but offered no explanation as to why the weekly meetings were discontinued. An interview was completed on 8/10/22 at 12:16 PM with the PA. He stated any time a resident was admitted on palliative care, it was understood that the resident was expected to recover. He stated when a resident was admitted to hospice, the resident was not expected to recover. The PA stated since Resident #14 was on palliative care, it was expected that she would recover and return to her baseline. The PA stated the delay in implementing the nutritional drink may have impacted her weight loss. He stated he had not been notified on Resident #14's weight loss and he expected the RD to have identified her weight loss, notified him and implement interventions timely but apparently that did not happen. A telephone interview was completed on 8/10/22 at 3:45 PM with the RD. She stated she started working part-time at the facility 2/28/22 and she was at the facility 2-3 times weekly. The RD stated she was out for surgery 6/2/22 through 7/11/22 but she worked remotely during that time. She stated she last saw Resident #14 on 7/18/22 and she was aware of her weight loss. The RD stated she did not notify the Physician or the PA about Resident #14's weight loss. The RD stated Resident #14 was prescribed a nutritional drink on admission 5/24/22 but she was not aware that the order was not implemented until 6/29/22. The RD stated she received a list of residents with MDS assessment due so she could complete her quarterly nutritional assessments. She stated she also completed a nutritional assessment for all new admissions and she reviewed all the residents weights monthly to see which residents were having weight loss. An interview was completed on 8/10/22 at 5:04 PM with the interim Director of Nursing (DON). She stated apparently when Resident #14 was admitted on [DATE] with orders for a nutritional drink three times a day, the dietary department was not made aware or given a copy of the order. She stated it appeared as if someone realized this on 6/29/22 and notified the dietary department. The DON stated the RD was not able to write her own orders unless they were approved by the Physician or the PA. She stated the current RD was not involved in the IDT process and apparently did not communicate effectively with the facility regarding the residents with identified with undesired weight loss.

Based on record reviews, observations, and interviews with residents and staff, the facility failed to honor a resident's preference for showers for 1 of 2 (Resident #15) reviewed for choices. The findings included: Resident #15 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #15's quarterly Minimum Data Set (MDS) dated [DATE], with an assessment reference date of 6/3/2022 indicated the resident was cognitively intact, required extensive assistance with activities of daily living, and was dependent with bathing. On 8/08/2022 at 10:56 AM an interview was conducted with Resident #15. He stated his scheduled shower days were Monday and Thursday. He had no problem getting shower on Mondays but he did not get his scheduled shower on Thursdays. He stated he got bed baths instead of showers on Thursdays. He stated he has been told it was due to low staffing. He further stated he filed a grievance in July regarding not getting scheduled showers. He was told by the Administrator showers were a safety issue when there was not adequate staff available and that he may need to consider being flexible with his shower days. Resident #15 stated very little had changed since his discussion with the Administrator, he was still not getting 2 showers a week and staffing continued to be a serious problem in the facility. Resident #15's shower/bath log for July 2022 indicated he received a shower on 7/7/, 7/10, and 7/11/2022. On 8/10/2022 at 2:40 PM a phone interview was conducted with Nursing Assistant (NA#9) who documented bath/shower for Resident #15 on 7/11/2022. She stated she did not give Resident #15 a shower on 7/11/2022. She further stated she did his morning care which included a bed bath. NA#9 stated the problem with their documentation system was that it did not allow you to differentiate between bed bath and shower. On 8/10/22 at 2:54 PM a phone interview was conducted with NA#1 who documented bath/shower for Resident #15 on 7/10/2022. She stated she did not recall is she gave the resident a bed bath or a shower on 7/10/2022 and the documentation system did not differentiate between bed bath and shower. She stated the facility was short staffed and there were times she had to give Resident #15 a bed bath instead of his scheduled showers due to lack of staff. Attempts to contact the NA who documented giving Resident #15 a shower on 7/7/2022 were not successful. An interview was conducted with the Director of Nursing (DON) on 8/10/2022 at 4:50 PM. She stated the facility was experiencing staffing challenges. It was her expectation residents received scheduled showers.

Based on record review, observation and interview with the Physician Assistant (PA), resident and staff, the facility failed to notify the Physician and or the PA when a resident had a significant weight loss for 2 of 4 sampled residents reviewed for nutrition (Residents #13, #3). Findings included: 1. Resident # 13 was admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #13 had severe cognitive impairment, was independent with eating and was on a mechanically altered diet. The assessment further indicated that the resident's weight was 189 pounds (lbs.). Resident #13's care plan for nutrition dated 5/29/22 was reviewed. The care plan problem was the resident was at risk for nutritional decline related to dysphagia. The goal was for the resident to tolerate diet as ordered with no complications and to maintain her weight within 5% of 189 lbs. The approaches included staff to monitor resident's weight as ordered and to notify the physician and her family of any concerns. Review of Resident #13's weights revealed that he had lost 42 pounds (lbs.) in 3 months (May 2022 through August 2022). Resident #13 weighed 189 lbs. on 5/13/22 and 147 lbs. on 8/5/22. Review of the Physician/Physician Assistant (PA) progress notes revealed that Resident #13 was seen by the PA on 6/30/22, 7/7/22, 7/14/22, 7/21/22, 7/28/22 and 8/3/22. The notes did not address the resident's weight loss. The Physician Assistant (PA) was interviewed on 8/10/22 at 12:15 PM. The PA stated that he expected to be notified when a resident had a significant weight loss, and he also expected the RD to identify weight loss and to implement interventions to prevent further weight loss. The PA reported that he was never notified that Resident #13 had a significant weight loss, however, if nursing notified him of weight loss, he would normally refer the resident to the RD to assess and to intervene. 2. Resident #3 was admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #3's cognition was intact, was independent with eating and was on a mechanically altered diet. The assessment further indicated that the resident's weight was 169 pounds (lbs.). Resident #3's care plan for nutrition dated 5/30/22 was reviewed. The care plan problem was the resident was at risk for nutritional decline related to dysphagia and recent weight loss of 10 lbs. The goal was I will tolerate diet as ordered with no complications and will maintain my weight within 5% of my admission weight. The approaches included staff to monitor my weights as ordered and notify the physician and my family of any concerns. Review of Resident #3's weights revealed that he had lost 13 lbs. in 3 months (April 2022 through July 2022). He weighed 169 lbs. on 4/29/22 and 156 lbs. on 7/5/22. Review of the Physician/Physician Assistant (PA) progress notes revealed that Resident #3 was seen by the PA on 7/11/22, 7/18/22, 7/22/22, 8/2/22 and 8/8/22. The notes did not address the resident's weight loss. The Physician Assistant (PA) was interviewed on 8/10/22 at 12:15 PM. The PA stated that he expected to be notified when a resident had a significant weight loss, and he also expected the RD to identify weight loss and to implement interventions to prevent further weight loss. The PA reported that he was never notified that Resident #3 had a significant weight loss, however, if nursing notified him of weight loss, he would normally refer the resident to the RD to assess and to intervene.

Based on record review, observation and staff interview, the facility failed to develop a comprehensive care plan for the use of the indwelling urinary catheter for 1 of 3 sampled residents reviewed for indwelling catheters (Resident #3). Findings included: Resident #3 was admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Resident #3 had a doctor's order dated 4/29/22 for indwelling urinary catheter for urinary retention. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #3's cognition was intact, and he had an indwelling urinary catheter. Resident #3's care plan dated 5/30/22 was reviewed. There was no care plan developed for the use of the indwelling urinary catheter. Resident #3 was observed on 8/8/22 at 11:37 AM. He was in bed and had an indwelling urinary catheter in place. When interviewed, the resident stated that he had the urinary catheter since admission. The MDS Nurse was interviewed on 8/10/22 at 3:05 PM. The MDS Nurse reviewed the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She indicated that she missed to develop a comprehensive care plan for the urinary catheter. The acting Director of Nursing (DON) was interviewed on 8/10/22 at 4:50 PM. The acting DON stated that she expected a comprehensive care plan developed when a resident had an indwelling urinary catheter.

Based on observation, interviews and record review, the facility failed to revise the comprehensive care plan after a Significant Change in Status Assessment for 1 of 3 residents reviewed for accidents (Resident #29). The findings included: Resident #29 was admitted on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Significant Change in Status Assessment Minimum Data Set (MDS) dated [DATE] indicated Resident #29 had no transfers during the 7-day look back period. Review of Resident #29's mobility care plan initiated 9/20/21 indicated she was to be transferred using a sit-to-stand lift (lift designed to assist a resident who lacked the strength or muscle control to rise to the standing position) for all transfers as of 11/19/21. Review of an incident report dated 7/7/22 at 8:45 PM noted Resident #29 had been lowered to the floor during a transfer using a total body lift device (hydraulic lift utilizing a body sling). An interview was completed on 8/9/22 at 4:03 PM with Nursing Assistant (NA) #3. She stated Resident #29 was very stiff and required the use of a total body lift for all transfers and she could not recall a time when she used a sit-to-stand lift. On 8/10/22 at 1:30 PM an observation with the interim Director of Nursing (DON) was conducted. Located on the employee bulletin board was an undated document indicating Resident #29 used a total body lift for transfers. The DON stated the document had been posted on the bulletin board for a least 6 months so staff would know the correct sling size to use when transferring any total body lift resident. Resident #29's name appeared on the list as requiring a medium size sling. The interim DON also stated the electronic care guide was also utilized by the aides identifying the resident's lift status. Review of Resident #29's electronic care guide utilized by the aides read the staff were to take extra time to ensure equipment was ready for a transfer as of 7/7/22. The interim DON stated maybe Resident #29's transfer status needed to be re-evaluated to determine the correct method of transferring her. A telephone interview was completed on 8/10/2 at 2:55 PM with Nurse #4. She stated Resident #29 had required use of a total body lift for transfers since her admission due to her muscle stiffness and inability to actively participate in transfers. An interview was completed on 8/10/22 at 3:00 PM with the MDS Nurse. She stated at the time she added the sit-to-stand lift for transfers to Resident #29's care plan on 11/19/21, it was likely during an Interdisciplinary Team (IDT) Meeting. The MDS Nurse stated at the time she completed the most recent care plan revision on 6/16/22, she asked to floor staff how Resident #29 was transferred and they reported she used a sit-to-stand lift for transfers. An interview was completed on 8/10/22 at 5:04 PM with the interim DON. She stated it was her expectation Resident #29's care plan to be accurate and reflect her accurate transfer status.

Based on record reviews, observations, and interviews with residents and staff, the facility failed to provide nail care for 2 of 2 dependent residents (Residents #15, #30) reviewed for activities of daily living. The findings included: 1. Resident #15 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #15's quarterly Minimum Data Set (MDS) dated [DATE], with an assessment reference date of 6/3/2022 indicated the resident was cognitively intact, required extensive assistance with activities of daily living, and was total dependent with bathing. Resident # 15's comprehensive care plan was last updated 6/10/2022 and include a focus for risk of decline with activities of daily living related to [CONDITION(S)] and limited range of motion. Interventions included staff would set up clothing and personal hygiene supplies, bathing supplies, and assist as needed. On 8/10/2022 at 9:30 AM Resident #15's fingernails were observed to be long. When asked about his fingernails, he stated he did not like his nails to be long. He further stated staff would sometimes trim his nails, but it was infrequent. He stated he was not able to trim his nails himself due to his hands being unsteady. Attempts to interview Nurse Assistant (NA) #4 who was assigned to Resident #15 at the time of the observation on 8/10/22 were not successful. An interview was conducted with Nurse #1 on 8/10/2022 at 9:45 AM. She stated there was one NA on the hall for over 30 residents. She further stated nail care was provided during showers. On 8/10/2022 at 9:50 AM an interview was conducted with the Director of Nursing (DON) she stated the NAs were responsible for providing nail care for residents when providing showers. She further stated she was aware of Resident #15 missing his scheduled showers but was not aware he needed nail care. 2. Resident #30 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Resident #30's quarterly Minimum Data Set (MDS) dated [DATE] indicated the resident had moderate cognitive impairment, had highly impaired hearing, and could understand and be understood by others. The resident required extensive assistance with activities of daily living and was dependent with personal hygiene and bathing. On 8/10/2022 at 9:40 AM Resident #30's was observed to have long fingernails on both hands. When asked if he liked his nails long, he stated he did not. Resident #30 stated the NAs trim his nails, but they had not been trimmed in a while. He indicated he probably couldn't trim his own nails. When asked about showers, he stated he got bed baths most days, showers were painful for him. Attempts to interview Nurse Assistant (NA) #4 who was assigned to Resident #30 at the time of the observation on 8/10/22 were not successful. An interview was conducted with Nurse #1 on 8/10/2022 at 9:45 AM. She stated there was one NA on the hall for over 30 residents. She further stated nail care was provided during showers. On 8/10/2022 at 9:50 AM an interview was conducted with the Director of Nursing (DON) she stated the NAs were responsible for providing nail care for residents when providing showers. She was not aware Resident #30 was not getting nail care.

Based on record review, observation and staff interview, the facility failed to secure the urinary catheter tubing to prevent accidental removal for 1 of 3 sample residents reviewed for urinary catheters (Resident #5). Findings included: Resident #5 was admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The significant Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #5 had severe cognitive impairment and she has an indwelling urinary catheter. Resident #5's care plan dated 5/27/22 was reviewed. The care plan problem was I require use of indwelling urinary catheter related to history of [CONDITION(S)]. The goal was I will remain free of complications related to use of catheter. The approaches included for the staff to monitor for signs/symptoms of complications related to catheter and notify the physician as needed. A nurse's note dated 8/2/22 at 2:55 PM revealed that during care, the nursing assistant (NA) notified the nurse that the resident's catheter was completely out, the resident was assessed, and no bleeding or signs of trauma noted. The note further indicated that a new catheter was inserted. The note was written by Nurse #2. When interviewed on 8/10/22 at 11:01 PM, the nurse stated that she did not remember the name of the NA who reported that Resident #5's urinary catheter was out on 8/2/22. She also reported that she could not remember if the catheter tubing was secured to the resident's thigh the day it was noted to be out. Resident #5 was observed in bed on 8/9/22 at 9:40 AM. The resident had an indwelling urinary catheter, and the catheter tubing was not secured to her thigh. Resident #5 was again observed on 8/10/22 at 10:45 AM with Nurse #1. The resident's catheter tubing was still not secured to her thigh. Nurse #1 was interviewed on 8/10/22 at 10:46 AM. The nurse stated that the NAs were responsible for providing catheter care to residents and to report to the nurse when the catheter tubing did not have a securement device. Nurse #1 indicated that nobody had informed her that Resident #5's urinary catheter did not have a securement device. The acting Director of Nursing (DON) was interviewed on 8/10/22 at 4:50 PM. The acting DON stated that she expected resident's catheter tubing to be secured at all times to prevent accidental removal.

Based on observations, record reviews, resident and staff interviews the facility failed to provide sufficient nurse staff to ensure a resident got scheduled showers (Resident #15) and provide activities of daily living for dependent residents (Resident #15 and Resident #30). This affected 3 of 11 sampled residents. The findings included: This tag is cross-referenced to: 1. F561 Based on record reviews, observations, and interviews with residents and staff, the facility failed to provide scheduled showers for 1 of 2 (Resident #15) reviewed for choices. 2. F677 Based on record reviews, observations, and interviews with residents and staff, the facility failed to provide nail care for 2 of 2 (Residents #15, #30) reviewed for activities of daily living. On 8/10/2022 at 10:48 AM an interview was conducted with the scheduler. She stated she was covering scheduling since the previous scheduler had been out for several weeks. She further stated the facility had staffing challenges. The morning of 8/10/2022 several staff called out. She stated they sent out a message to all staff via email, text message, voicemail asking for assistance. They also pulled staff from other areas to assist with patient care. When asked about staffing on 8/10/2022 at 10:48 AM, she stated there were 2 nurses and 1 NA for 34 residents, but she was also a Nursing Assistant (NA) and was assisting on the hall. She felt the staffing challenges made it difficult but not impossible for staff to complete scheduled showers, nail care, and safely transfer residents. The Director of Nursing (DON) was interviewed 8/10/2022 at 8:39 AM she stated they have had staffing challenges. She stated today there was one NA on the floor so other nurses were called from other areas to assist. She did not believe current staffing challenges were contributing to accidents or preventing residents from getting showers and nail care.

Based on record review, and interview with a resident's responsible party (RP) and staff, the facility failed to notify the resident or the responsible party in writing of the reason for discharge to the hospital for 2 of 2 residents reviewed for hospitalization s (Residents #13 and #36). The findings included: 1. Resident #13 was originally admitted to the facility on [DATE]. A nurse's note dated [DATE] at 4:59 AM revealed that Resident # 13 was transferred to the emergency room (ER) and was admitted . The note was written by Nurse #3. A nurse's note dated [DATE] at 5:20 PM revealed that Resident #13 was readmitted back to the facility. Review of the medical records revealed no documentation that a written notice was provided to the responsible party (RP) regarding the reason for the hospitalization . Nurse #3 was interviewed on [DATE] at 4:20 PM. The Nurse reported that when a resident was discharged to the hospital, the responsible party (RP) was called via telephone to inform her/him that the resident was discharged to the hospital. She indicated that she didn't know that the facility has to notify the resident or the responsible party (RP) in writing of the reason for the discharge. The acting Director of Nursing (DON) was interviewed on [DATE] at 4:50 PM. The Acting DON stated that she didn't know that the facility has to notify the resident or the RP in writing when a resident was discharged to the hospital. 2. Resident #36 was admitted [DATE] and discharged [DATE]. The resident's medical record included a progress note written on [DATE] by the Physician Assistant (PA) indicated Resident #36 needed to be transferred to the hospital for fever and low blood oxygen. Resident #36's Minimum Data Set (MDS) dated [DATE] indicated she was discharged to the hospital with return anticipated. A nursing progress note dated [DATE] revealed Resident #36 had been admitted to the hospital on [DATE]. Her family opted for hospice care, and she was transferred to a Hospice House where she expired. On [DATE] at 3:55 PM an interview was conducted with Nurse #3. She stated when residents were transported to the hospital, the facility sent a face sheet (resident demographic information), medication administration record (MAR), and a copy of the bed hold policy. She further stated the residents' families were notified via phone call, but she did not know of a written notification of discharge. On [DATE] at 4:00 PM an interview was conducted with the Director of Nursing (DON). The DON stated a bed hold policy was sent out with the resident along with the face sheet, MAR and summary as to why the resident was being transported to the hospital. She further stated the family or RP was contacted via phone but there was no written notification of discharge sent to them. On [DATE] at 4:50PM an interview was conducted with the DON. She stated it was her expectation a written notification of reason for discharge be sent to residents and/or resident's responsible party. She was not aware a written notice was required.

Based on record review and staff interview, the facility failed to code the Minimum Data Set (MDS) assessments accurately in the areas of diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings included: 1. Resident #13 was admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #13 had doctor's orders dated 5/20/22 for [MEDICATION(S)] Sulfate 325 milligrams (mgs) by mouth daily for [CONDITION(S)], [MEDICATION(S)] ([MEDICATION(S)]) 1 drop (gtt.) to both eyes daily for [CONDITION(S)] and Lansoprazole ([MEDICATION(S)]) 30 mgs by mouth daily for ulcers. The May 2022 Medication Administration Records (MARs) were reviewed and revealed that Resident #13 had received the [MEDICATION(S)] Sulfate, [MEDICATION(S)] eye drops and [MEDICATION(S)] during the assessment period. The admission MDS assessment dated [DATE] was reviewed. The assessment did not indicate that Resident #13 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS Nurse was interviewed on 8/10/22 at 3:08 PM. The MDS Nurse reviewed the resident's doctor's orders, the May 2022 MARs and the MDS dated [DATE]. She verified that Resident #13 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated that she missed to code the [CONDITION(S)], [CONDITION(S)] and ulcer under the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The acting Director of Nursing (DON) was interviewed on 8/10/22 at 4:50 PM. The acting DON stated that she expected the MDS assessments to be coded accurately. 2. Resident #29 was admitted on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Her significant change Minimum Data Set (MDS) dated [DATE] indicated Resident #29 was coded for an indwelling urinary catheter and for intermittent catheterization. A review of Resident #29's August 2022 Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #29's nursing notes from 6/1/22 to 6/14/22 did not include documented evidence of intermittent catheterization but rather the presence of an indwelling urinary catheter. An observation was conducted on 8/9/22 at 4:30 PM with Nurse #2 of Resident #29's urinary catheter care. She presented with an indwelling urinary catheter. An interview was conducted with Nurse #2 on 8/9/22 at 4:30 PM, she stated Resident #29 has had an indwelling urinary catheter a very long time and she was unable to recall any occasion that intermittent catheterization was completed or required. An interview was completed on 8/10/22 at 3:00 PM with the MDS Nurse. She stated she thought she saw a nursing note during the 7-day MDS look back period where Resident #29 was catharized for urinalysis. She stated she coded the 6/14/22 MDS in error for intermittent catheterization. An interview was completed on 8/10/22 at 5:04 PM with the interim Director of Nursing. She stated it was her expectation that Resident #29's MDS be coded accurately in the area of bladder appliances. 3. Resident #15 was admitted to the facility 1/15/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's medical record revealed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The start date was 5/13/2022. There was no end date. The medical record also included a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . [MEDICATION(S)] is a combination pain reliver containing the opioid [MEDICATION(S)] and a non-opioid pain reliever, acetaminophen. The start date for the [MEDICATION(S)] was 10/20/2021 and there was no end date. Resident #15's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #15's quarterly Minimum Data Set (MDS) dated [DATE], with an assessment reference date of 6/3/2022 indicated the resident did not receive diuretics or opioids during the assessment period. On 8/09/2022 at 11:36 AM an interview was conducted with the MDS nurse. She reviewed Resident #15's MDS dated [DATE] and stated she thought the system would have pulled those medications, [MEDICATION(S)] and [MEDICATION(S)], into the MDS. She further stated she had just realized the system did not. The MDS nurse stated both the diuretic and the opioid should have been coded 3 out of 7 days. On 8/10/2022 at 5:00 PM and interview was conducted with the Director of Nursing. She stated it was her expectation that the MDS be coded accurately.

Based on observations, staff interviews and clinical record review, the facility failed to provide treatment for 1 of 3 (Resident #73) sampled residents with pressure sores. The findings are: Resident #73 was admitted on [DATE]. His [DIAGNOSES REDACTED]. The initial 9/21/10 nursing assessment indicated no skin breakdown. The 9/25/10 pressure sore Resident assessment protocol indicated Resident #73 was at risk for pressure sores. The 10/1/10 pressure sore risk care plan included interventions " 1. Assist with and encourage repositioning often. Use pillows as needed for bony prominence's. 2. Treatment to skin impairment per MD orders. Monitor and chart healing process, noting signs/symptoms of infection. 3. Alternating air mattress to bed. 4. Anti-coagulant med therapy-monitor for such as excessive bleeding, nosebleeds, easy bruising, blood in stool/emesis/urine etc. Report and chart any abnormalities. 5. Decreased intake of food and supplements-offer substitutes as possible and give supplements, snacks, etc per MD orders and dietary recommendations. 6. History of [MEDICAL CONDITION]-monitor for abnormalities such as discoloration, non-healing, change in moles. Etc 7. Incontinence of bladder at times-provide protective skin care, etc." The 10/17/10 nurses notes revealed a stage II pressure sore measuring 4 centimeters (cm) by 5 cm and 0.4 cm deep with granulation tissue. The physician was notified. The physician order [REDACTED]. " On 10/18/10, a physician order [REDACTED]. " The 10/1/10 pressure sore risk care plan was not revised with the development of the pressure sore. The 10/25/10 wound measurements were 4 cm by 4.5 cm and 0.3 cm but with 25% necrotic tissue. The 11/1/10 wound measurements indicated the left heel was not stageable due to 75% necrotic tissue. The clinical record contained no documentation that the physician was notified of the wound stage worsening. On 11/4/10 at 12:11 pm, Resident #73 was in his wheelchair. He was wearing regular shoes and socks. He denied any pain his left foot. On 11/4/10 at 252 pm, Nurse #1 removed Resident #73's dressing on his left heel. The heel was 100 % necrotic tissue measuring the size of a silver dollar. The heel was cleansed with normal saline and dressed with a non-adherent foam dressing and secured with tape. Nurse #1 did not apply [MEDICATION NAME] or skin prep. Nurse #1 did no elevate his foot on pillow or apply a pressure relieving boot. During an interview, on 11/4/10 at 302 pm, Nurse #1 stated Nurse #2 did wound measurements for all residents with pressure sores. Nurse #1 stated if the pressure sore worsened she would notify the physician and obtain new orders. Nurse #1 stated last week Resident #73 did not have necrotic tissue when she provided his wound care his dressing last week. During an interview, on 11/4/10 at 4:45 pm, Nurse #1 stated she did not do the dressing change according to the physician order [REDACTED]. On 11/4/10 at 5:00 pm, Nurse #2 stated she performed the wound measurements on 11/1/10 for Resident #73. Nurse #2 stated she did not notify the physician of the wound stage worsening because the [MEDICATION NAME] was a " [MEDICATION NAME] agent. " On 11/4/10 at 5:15 pm, the Director of Nursing stated his expectation for all nursing staff would be to notify the physician of worsening pressure sores by the end of the shift the assessment had been completed.

Based on observations, interviews and clinical record review, the facility failed to supervise eating for one (Resident #29) cognitive impaired resident resulting in a choking incident. The facility failed to provide preventative measures for 1 of 3 (Resident # 7 ) sampled residents with falls. 1. Resident #29 was admitted on [DATE]. Cumulative [DIAGNOSES REDACTED]. Her 9/7/2010 Quarterly Minimum Data Set (MDS) assessment indicated she had short term and long term memory problems and was moderately impaired in decision making. She was easily distracted, had periods of altered perception, periods of lethargy and her mental function varies over the course of the day. She was totally dependent in eating. The 9/16/10 nutritional care plan interventions stated " 1. Encourage resident to eat all meals. 2. Give supplement as ordered by MD. 3. Encourage resident to drink at meals. 4. Offer fluids between meals. 5. Supervision needed at all meals. 6. Assist as needed. 7. Resident eats with family in main dining when she is having a good day. " 10/30/10 1115 pm nurses note stated " nurse heard elder assistant scream out for her. This nurse ran from the medication room into the dining area elder assistant stated " she ' s choking " elder assistant started the Heimlich maneuver as the nurse put on gloves and preceded to scoop the object out of the resident ' s mouth resident at the time which was 1055 pm. Eyes were rolling back and skin was turning bluish gray in color, other staff members and station #2 nurse came down to assist a second elder assistant helped pick the resident up in a standing position as this nurse stuck her gloved finger further down the resident ' s throat and finally scooping out a piece of wiener approximately 1 inch long. Resident then began to speak and was and was lowered to the floor. Oxygen was administered EMS had been called as this was going on. Resident ' s color changed back to pale skin, and she began complaining of her chest bone hurting resident responded " please don ' t move me it hurts " resident lied still in the elder assistant lap until EMS arrived at 11:15 pm to transfer the resident to hospital. " The 10/31/10 2:20 am nurses ' note indicated Resident #29 returned to the facility with a new [DIAGNOSES REDACTED]. During an interview, on 11/3/10 at 5:00 pm, nurse aide (NA) #1, stated Resident #29 woke up at 10:40 pm on 10/30/10 and stated she was hungry. She had not eaten her evening meal. NA #1 stated she got the resident up and took her to the dining room. She cut up a hot dog into one inch pieces and gave her beans. NA #2 came into the dining room to request her assistance with other residents. NA #1 told Nurse #4 to watch the resident in the dining room because she was eating. Nurse #1 was at the desk outside the dining room area. NA #1 stated she was gone from the dining room for 5 minutes. NA #1 returned to the dining room when she heard NA #2 yelling for assistance. NA #2 was found doing the Heimlich maneuver on Resident #29. NA #1 did not put Resident #29 ' s artificial teeth partial plates before taking her to the dining room. During an interview, on 11/3/10 at 5:15 pm, NA #2 stated she assisted NA #1 to get Resident #29 into her wheelchair to go to the dining room. NA #2 left NA #1 in the dining room with the resident eating. NA #2 stated she came back to ask NA #1 to assist getting 3 other residents back into bed. NA #2 stated NA #1 told Nurse #4, who was at nurses desk that Resident #29 was in the dining room eating. NA #2 stated on return to the dining room in 5-6 minutes, Resident #29 ' s lips were blue and she was waving her arms. NA #2 stated the resident was choking and needed the Heimlich maneuver. NA #2 stated no one was in the dining room with Resident #29. NA #2 stated Nurse #4 came in the dining room put on gloves and was able to remove a piece of hot dog out of the resident ' s mouth. On 11/4/10 at 11:00 am, Nurse #3 stated Resident #29 was able to eat with supervision. Nurse #3 stated Resident #29 had one choking episode on 10/30 when eating. Nurse #3 stated that since the choking episode, if the resident did not wear her teeth, staff would get a soft diet for her. During an interview, on 111/5/10 at 11:20 am, NA #3 stated on 10/30 during the day shift Resident #29 would not wear her partial plates. NA #3 stated a family member was present in the room when Resident #29 bite her when trying to put in her dentures. During a phone interview, on 11/5/10 at 4:32 pm, Nurse #4 stated she was in the medication room and heard NA #2 yelling for help in the dining room. NA #2 was yelling Resident #29 was choking. Nurse #4 went to the dining room, put on gloves and assisted NA #2 to perform the Heimlich maneuver and remove the hot dog. Nurse #4 stated she put oxygen on until EMS staff arrived to take the resident to the hospital. Nurse #4 stated she did not recall NA #1 telling her the resident was eating in the dining room. Nurse #4 stated she would never leave Resident #29 alone when she was eating. 2. Resident # 7 was admitted to the facility 11/02/2004 with [DIAGNOSES REDACTED]. Resident #7 ' s most recent Quarterly MDS (Minimum Data Set) dated 10/28/2010 indicated that she had severely impaired cognition with periods of disorganized thinking characterized by disorganized or incoherent conversation unclear or illogical flow of ideas, or unpredictable switching from subject to subject. The MDS also revealed that Resident#7 needed extensive assistance of one person for transfers, walking in her room, and toileting as well as limited assistance of 1 person for locomotion on and off the unit. It noted that Resident # 7 was not on a toileting program and had occasional bladder incontinence. A Care Plan dated 2/16/2010 for high risk for a fall related injury indicated Resident #7 had impaired mobility and strength, impaired cognitive status with delusions, disorientation and agitation episodes, visual defect of macular degeneration, PVD with edema of both ankles, and Psychotropic, Narcotic, and HTN medications. The goal of the Care Plan was to decrease falling episodes as evidenced by no daily falls for the next 90 days. Interventions included: 1. Monitor effects of medications such as: dizziness, increased confusion, and unsteadiness, etc. Report all abnorms (abnormals). 2. Keep environment as clutter-free as possible. 3. Provide walker and supervision and assist for transfers/ambulation as needed. Keep walker within reach with tendency to forget. 4. Provide & apply nonskid footwear while out of bed. Monitor for walking in socks and redirect as possible. 5. No full side rails to be up with a tendency to climb over if fully up therefore, greater risk for harm. 6. Assess environment to be certain it is free from hazards such as poor lighting, obstacles, items on floor, poorly arranged furniture, liquid spills, etc. 7. Keep bed in lowest position when leaving bedside. 8. No fall mat to be on floor with greater risk of injury with resident having tendency to take long step over and possible tripping. 9. Monitor effects of medications such as: Increased confusion, lethargy, more unsteadiness, etc. that may put resident at risk for falls. Update MD of any abnorms & chart. 10. Alarm to be on while in bed & OOB. Check each shift and prn (as needed) for proper functioning order. Monitor for removing and turning off. and having alarm on while in bed and out of bed. 11. Visual Deficit-Point out items/environment as needed. Eye specialist states of not to change eyeglasses with used to present eyeglasses. POA (Power of Attorney) desires no follow up for glasses at this time. Assist with donning of eyeglasses daily. 12. Edema of lower extremities-Attempt & re-approach resident to encourage elevation of lower extremities to alleviate edema. Monitor for escalation of edema. Document all refusals. 13. Do not send to hospital MD order (2/2/10) 14. PT eval and treat as indicated (2/4/10) 15. Lock w/c (wheelchair) when @ meals unlock after meals. L. Gattis RN. " A Care Plan review dated 5/20/10 read " Goal not met. Continue POC (Plan of Care). " A Care Plan review for 8/12/10 indicated goal not met, continue Plan of Care including Resident #7 was oblivious to safety and direction and had wandering behavior. The Physician was updated concerning almost daily use of as needed medications. A Care Plan review for 11/4/10 indicated falls with risk for injuries continued. The review also indicated a revision of goals for non-compliant behavior episodes and that Resident #7 continued to wander with Secure Alarm in place. It revealed that re-direction was not successful. The only addition to the Care Plan at that time was to continue POC (Plan of Care). The non use of a fall mat was not changed. Record review of Nurses ' Notes and Incident/Accident Reports related to Resident #7 ' s falls 5/31/10-10/6/10 revealed the following: 5/31/10: Nurse ' s Note- Resident #7 got OOB (out of bed) to go to the restroom and was found sitting in her closet with a skin tear to her left lower leg. The alarm sounded. Incident Report Recommendation/New Intervention-When resident wakes up in am go ahead and get her toileted, washed, and dressed for day and assist to DR (dining room). This intervention was observed in place. 6/5/10: Nurse ' s Note-At 10:30 pm Resident #7 was attempting to get OOB to use the bathroom, slipped and fell hitting her head on the bed rail and sustained a laceration to the back of her head. Facility First aid protocol was used to treat the laceration. Incident Report Recommendation/New Intervention- Continue past interventions (bed and chair alarms, fall mat, toilet every 2 hours while awake) with new interventions of " if resident is restless encourage her to come out of room to activities or dining room. " Resident # 7 was observed being encouraged to engage in activities when already out of her room. 6/29/10: Nurse ' s Note- Resident #7 found sitting at the foot of her bed by a CNA (certified nursing assistant) at 8:30 pm after attempting to get into her bed. Incident Report Recommendation/New Intervention-Continue all above (bed alarm, chair alarm, fall mat, bed in low position, toileting schedule) and checking on concave (scoop mattress). No evaluations of existing interventions or updates to interventions were made. 7/1/10: Nurse ' s Note-At 4:00 am Resident #7 fell in the doorway to her bathroom with no resulting injuries. Incident Report Recommendation/New Intervention-Both alarms checked and were functioning with sensory pad in place; checking on scoop/concave mattress. Alarms were in place and functioning prior to the fall. No evaluations of existing interventions or updates to interventions were made. 7/2/10: Nurse ' s Note-At 5:50 am an alarm sounded in Resident #7 ' s room, a CNA went to assist her and found that she slid OOB trying to get up to go to the bathroom. Her gown was off and she received 1 " skin tear to her left elbow. Incident Report Recommendation/New Intervention-Continue bed and chair alarms-sensor type, fall mat, bed in low position, toilet every 2 hours and " checking on mattress (concave/scoop), move resident closer to nurse ' s station when bed available. " Resident #7 ' s room observed to be at end of the hall away from the nurse ' s station. No evaluation of existing interventions or updates to interventions was made. 7/13/10: Nurse ' s Note-At 8:43 pm Resident #7 was found sitting on the mat by her bed, alarm sounding, after trying to transfer self from her wheel chair to the bed. Incident Report Recommendation/New Intervention-Continue use of alarms and fall mat to reduce risk of injuries. No evaluations of existing interventions or updates to interventions were made. 9/3/10: Nurse ' s Note-At 11:30 am Resident #7 was found on the floor in the doorway to her room with a skin tear to her right forearm. Incident Report Recommendation/New Intervention-Personal alarm on bed and chair, redirect and round every 2 hours and as needed. These interventions had been in place prior to the fall. 9/6/10: Nurse ' s Note-At 10:30 pm A CNA reported to the nurse finding Resident #7 on the floor in her room in a puddle of urine with no apparent injury. Incident Report Recommendation/New Intervention-Offer to toilet with assist every 2 hours while awake. These interventions had been in place prior to the fall. No evaluation of effectiveness or update made. 10/6/10: Nurse ' s Note-At 6:45 pm A CNA reported to the nurse that Resident #7 was in the hallway scooting on the floor on her bottom, possibly after a fall. Incident Report Recommendation/New Intervention-Re-direct as needed. This intervention had been in place prior to the fall. No evaluation of effectiveness or update was made. On ll/4/10 at 3:20 pm in an interview NA #5 (Nursing Assistant) stated that Resident #7 could get up and walk, but was not stable on her feet and tired out easily. She indicated that Resident #7 fell when she was up and rambling. NA #5 also revealed that Resident #7 moved around the facility mostly by wheelchair and on good days just rolled around, but on other days she was constantly up and down. NA#5 also stated that Resident #7 had a bed and chair alarm that sounded when she stood up. Resident #7 was observed on 11/4/10 at 5:24 pm in her wheelchair with alarm in place, outside the Station 1 dining room asking for more coffee. Staff re-directed her to the dining room. Resident # 7 was observed on 11/5/10 at 8:30 am in the dining room in her wheelchair with alarm in place eating breakfast. At 10:21 am on 11/5/10 Resident #7 was observed wheeling up and down the hall near Nurse ' s Station #2 with alarm in place. In an interview on 11/5/10 at 2:24 pm NA #6 stated that Resident #7 would let you know when she had to go to the bathroom, but she checked on her at least every 2 hours. NA#6 also indicated that when Resident #7 was lying down her alarm would sound when she tried to get up, but she tried to look in on her every hour to see if she was sleeping. On 11/5/10 at 2:30 pm Resident #7 was wheeling herself in her wheelchair up and down the hall near Station 2. Staff members directed Resident #7 to a staff member ' s office. When asked during an interview on 11/5/10 at 2:32 pm what was the normal procedure to inform staff of new interventions, the Administrator stated that they alerted the staff verbally assuring the staff then reported to the next shift. She indicated the interventions were placed on the Care Plan with evaluation and monitoring tools within a time frame to make sure the interventions were appropriate. The Administrator also revealed that the fall risk interventions had not been evaluated for effectiveness or updated for Resident #7 and that no attempt had been made to move her closer to the Nurse ' s Station. On 11/5/10 at 2:57 pm Nurse #5 indicated in a telephone interview that Resident #7 used to use a walker, but recently has been in a wheelchair. She also stated that Resident #7 did not understand about getting help to get up. Nurse #5 revealed that she felt Resident #7 was too far away from the nurse ' s station because by the time you heard the alarm and got to her room she had already fallen. She indicated that she had reported this to her DON (Director of Nurses) who no longer worked at the facility. In an interview on 11/5/10 at 3:53 pm the Rehabilitation Department Manager stated that she had never had a referral for a resident as a result of a fall since she started working at the facility in July 2010. She also indicated that if a resident was already receiving therapy, no referral would have been made after a fall. When asked if Resident #7 was receiving therapy the Manager indicated that she was seen 2/5/10-3/10/10 for increasing her strength and stability, but had not been seen by therapy since that time.