Every finding on record at Presbyterian Homes of Bloomington

Based on interview and document review, the facility failed to ensure medication orders received following a hospital visit were obtained, transcribed, and implemented timely for 1 of 3 residents (R110) reviewed for hospital return. The facility's failure resulted in a five-day delay in implementing an emergency department order increasing R110's torsemide dosage following treatment for worsening heart failure symptoms and placed the resident at risk for worsening fluid overload and respiratory compromise.Findings include: R110's admission Minimum Data Set, dated [DATE], identified R110 had moderate cognition and diagnoses included acute respiratory failure and hypoxia, heart failure, orthostatic hypotension, nonrheumatic tricuspid (valve) insufficiency, and atrial septal defect. R110 had shortness of breath or trouble breathing with exertion and received oxygen therapy and diuretics daily.R110's care plan dated 2/23/26 identified R110 required assistance of one staff for activities of daily living including bed mobility, transfers, toileting and ambulation. The plan identified R110 had an alteration in respiratory status and required oxygen via nasal cannula due to acute respiratory failure with hypoxia.R110's geriatric services provider visit dated 3/5/26, identified R110 was taking Torsemide (a medication used to treat fluid retention [edema] in people with medical conditions including heart failure) 5 mg daily.R110's emergency department note dated 3/6/26, identified R110's Torsemide was increased from 5 mg daily to 10 mg daily.R110's after visit summary from the 3/6/26 emergency room visit was requested although not received.R110's geriatric services provider visit dated 3/16/26, identified R110 was taking Torsemide 20 mg daily.R110's progress notes identified the following:n 3/3/26 at 7:45 a.m., R110 received torsemide 5 mg, one tablet by mouth in the morning.On 3/6/26 at 8:57 a.m., change of condition note: R110 was admitted to the facility with post right sided heart failure exacerbation. During the stay, R110's weight steadily increased, resident noted to have increased edema to bilateral lower extremities and upper extremities in the hands. Lungs were clear, resident denied shortness of breath, was noted to be using accessory muscles for respiration. Resident required oxygen via nasal cannula at 4 LPM (liters per minute), which was a change from baseline at 2 LPM. Updated doctor. R110 and wife agreed to transfer resident to ER for further assessment. R110 placed on non-rebreather face mask (a mask used to deliver high concentrations of oxygen quickly).On 3/6/26 at 21:39 p.m., R110 returned from the hospital in stable condition except R110's oxygen saturation (O2 sats) was 83% on 2 LPM oxygen. The note failed to identify if the doctor ordered any changes in medications.On 3/12/26 at 10:06 a.m., a progress note identified R110 started an increased dose of torsemide. The note did not identify the dosage administered.R110's progress notes dated 3/7/26 through 3/11/26 contained no evidence the emergency department order increasing torsemide had been obtained, reviewed, transcribed, or implemented.R110's Medication Administration Record dated 3/1/26 through 3/31/26, identified R110 received the following medications:3/1/26 through 3/11/26, R110 received Torsemide 5 mg tablet once daily in the morning. The order was discontinued on 3/11/26.3/12/26 through 3/13/26, R110 received Torsemide 5 mg two tablets (10 mg) by mouth in the morning. The order was started on 3/11/26 and discontinued 3/14/26.3/14/26, R110 received Torsemide 20 mg tablet once daily in the morning. The order was started on 3/13/26 and discontinued 3/14/26.3/15/26 through 3/16/26, R110 received Torsemide 20 mg tablet once daily in the morning. The order started on 3/14/26 and discontinued 5/11/26.The facility continued administering torsemide 5 mg daily from 3/7/26 through 3/11/26 despite the emergency department order dated 3/6/26 increasing the medication to 10 mg daily. R110's quality concern form dated 6/15/26, identified the administrator received a voicemail from family member (FM)-A regarding concerns after R110's emergency room (ER) visit on 3/6/26. The report identified R110's Torsemide was increased, although the medication change was not completed until five days later. During interview on 6/23/26 at 11:02 a.m., FM-A stated on 3/6/26, R110 was sent to the ER and returned later the same day with medication changes. The ER doctor increased R110's Torsemide from 5 mg daily to 10 mg daily, although the facility didn't make the change until five days later. Then the day after the facility changed the resident's medication, the provider increased the residents Torsemide again to 20 mg daily. FM-A stated the facility failed to increase R110's Torsemide according to the doctor's orders.During interview on 6/23/26 at 5:54 p.m., registered nurse (RN)-A stated when a resident returned from the ER, the facility would receive the ER orders via fax or verbal order from the ER nurse. If the resident returned without paperwork, the receiving nurse would contact the hospital for orders. Either the health unit coordinator (HUC) or receiving nurse would enter the orders.During interview on 6/24/26 at 8:19 a.m., the director of nursing (DON) stated that when R110 returned from the ER on [DATE], the nurse did not receive the ER paperwork from the family. If the nurses don't receive paperwork from the hospital, they would assume there were no new orders. When asked the DON if it was the nurses' responsibility to contact the ER if they didn't receive paperwork, the DON stated, I will have to get back to you on that. At the time of survey exit, the DON failed to provide an answer.When interviewed on 6/24/26 8:51 a.m., RN-B stated generally, when a resident was readmitted by the ER, the ER would provide paperwork including an after-visit summary (AVS) identifying if there were any new orders. If a resident returned without paperwork, the receiving nurse should contact the ER and verify if there were new orders. When R110 returned from the ER on [DATE], the nurses should have contacted the ER for nurse-to-nurse report and/or request an AVS, and there should have been a chart note completed identifying what the new orders included. RN-B stated the risks of not knowing what happened during an ER visit, included potential changes in medications that could be missed which may cause changes in the resident's medical condition.On 6/24/26 at 10:35 a.m., the administrator stated the facility did not have a specific policy for readmissions. The administrator stated the facility did not have a policy to define the process for when residents returned without paperwork and were readmitted from the hospital; and they were still working on the investigation on what happened.A facility readmission policy was requested although not received.

Based on interview and document review, the facility failed to maintain a complete and accurately documented medical record in accordance with accepted professional standards and practices for 2 of 3 residents (R1, R3) reviewed for change of condition and oxygen use.Findings include:R1's admission Minimum Data Set (MDS) dated [DATE], indicated R1 had intact cognition and diagnoses of coronary artery disease, hypertension, kidney disease, pneumonia, chronic obstructive pulmonary disease, and respiratory failure. R1's MDS indicated R1 used continuous oxygen therapy.R1's Comprehensive Data Collection Review dated 1/29/26, indicated R1 had right sided pneumonia, ordered antibiotics, crackles to left lower lobe, and supplemental oxygen at two liters per minute.R1's physician order dated 1/31/26, indicated R1 used continuous supplemental oxygen at two liters per minute via nasal cannula to keep oxygen saturation over 89% (percent).R1's physician order dated 2/4/26, directed staff to wean R1's supplemental oxygen as able.R1's Skilled Documentation dated 2/6/26, indicated R1's supplemental oxygen was weaned. R1's oxygen saturation was 92% at room air (RA).R1's Oxygen Saturation Summary, indicated R1 was on room air 2/6/26 at 11:44 a.m.; however, R1 had oxygen via nasal cannula on 2/11/26 at 3:22 a.m. and 9:46 a.m., was on room air on 2/11/26 at 4:26 p.m., and oxygen via nasal cannula on 2/12/26 at 6:19 a.m. and 7:50 a.m R1's Progress Notes dated 2/6/26 through 2/12/26, indicated R1's vital signs were stable and/or within normal limits (besides a 100.6 degrees Fahrenheit temperature on 2/11/26); however, did not specify reason or respiratory indication for R1's supplemental oxygen use on 2/11/26.R1's Occupational Therapy Treatment Encounter Note dated 2/11/26, indicated R1 reported a rough night and needed supplemental oxygen related to shortness of breath and was weaned off the supplemental oxygen again.R1's Physical Therapy Treatment Encounter Note dated 2/12/26, indicated R1 reported she had a fever, felt awful, and needed supplemental oxygen at one liter per minute last night.R1's Discharge Summary note dated 2/12/26, indicated R1 did not have a drop in oxygen saturation level and was not sure if supplemental oxygen use was for shortness of breath or anxiety.R1's General Note dated 2/12/26, indicated nurse practitioner (NP)-A met with R1 and completed a lung assessment. R1's lung sounds were clear with consistent diminished sounds in bases, and NP-A removed R1's supplemental oxygen.R1's physician order dated 2/12/26, indicated R1 used supplement oxygen as needed at two liters per minute via nasal cannula to keep oxygen saturation above 89%.During interview on 4/22/26 at 3:31 p.m., registered nurse (RN)-A stated staff followed physician's orders for supplemental oxygen use and reapplied supplemental oxygen if oxygen saturation was not maintained at the order specified level. RN-A was not sure why R1 had supplemental oxygen after weaned.During interview on 4/23/26 at 2:49 p.m., RN-B did not remember R1, or the reason supplemental oxygen was applied to R1 on 2/11/26. RN-B stated residents need to be assessed for supplemental oxygen use by listening to lung sounds and checking oxygen saturation. RN-B stated they would assess if oxygen intervention was successful and call the provider if intervention was not successful.During interview on 4/23/26 at 3:02 p.m., physical therapist (PT)-B and physical therapy assistant (PTA)-C reviewed R1's therapy notes. PT-B stated R1 functionally progressed well with therapy. PT-B stated they wanted to see R1 weaned off oxygen to eliminate the oxygen tubing as a tripping hazard, and R1 was anxious about weaning her oxygen. Therapy usually removed oxygen during their sessions as able but returned supplemental oxygen via nasal cannula back onto residents after their therapy sessions. Nursing was able to fully wean residents and remove supplemental oxygen.R3's diagnoses list dated 4/24/26 included encephalopathy, Parkinson's disease, chronic atrial fibrillation and pulmonary hypertension.R3's care plan dated 4/16/26 included an alteration in respiratory status focus with interventions including but not limited to assist with applying continuous positive airway pressure (CPAP) and provide oxygen per nasal cannula see orders for liters per minute.R3's Brief Interview for Mental Status assessment dated [DATE] indicated no cognitive impairments.R3's provider order dated 4/18/26 instructed supplemental oxygen at one liter per minute via nasal cannula nocturnal to keep saturations above 91%.R3's provider note dated 4/16/26 instructed supplemental oxygen one liter at night if not wearing CPAP machine.R3's nursing MDS note dated 4/21/26 at 10:20 a.m. indicated R3 reported no shortness of breath or trouble breathing and the medical record and staff interviews indicated shortness of breath (SOB) appeared to be absent or well controlled with current medications.R3's oxygen saturation summary for April 2026 indicated R3 was on room air during the day and used supplemental oxygen at night until 4/21/26 when documentation indicated R3 oxygen saturation was 98% on supplemental oxygen at 3:22 p.m. R3 utilized supplemental oxygen until 4/23/26 at 8:49 a.m.R3's skilled documentation dated 4/22/26 at 6:26 p.m. indicated R3's vital signs were stable. R3 denied SOB.R3's physical therapy (PT) note dated 4/22/26 at 12:38 p.m. indicated R3 was on one liter supplemental oxygen upon arrival for the PT session. R3's oxygen saturation was 96% at the beginning of the session. R3 was placed on room air during the session and maintained oxygen saturation of 96-99% on room air while participating with the OT/PT session.During an interview on 4/23/2026 at 11:31 a.m., R3's family member (FM) stated R3 utilized supplemental oxygen at night because she did not like wearing the CPAP mask. R3 was utilizing supplemental oxygen during a care conference on 4/21/26 but FM did not know why.During an interview on 4/23/2026 at 2:58 p.m., registered nurse (RN)-A stated R3 utilized supplemental oxygen at night and during the day when she was in bed because she did not like to wear her CPAP mask. RN-A would assess the resident, notify a provider, and write a nurse's note if a resident needed supplemental oxygen due to low oxygen saturations.During interview on 4/24/26 at 12:17 p.m., RN-C reviewed R1's progress notes and verified nursing documentation did not address the reason or assessment for R1's supplemental oxygen use on 2/11/26. RN-C stated staff should update the provider and use a house standing order or obtain a new order if R3 used supplemental oxygen during the day, in addition to the ordered nighttime use. RN-C reviewed R3's progress notes and stated they were not sure why R3 had supplemental oxygen use during the day.During interview on 4/24/26 at 3:58 p.m., the director of nursing (DON) expected staff to complete a respiratory assessment, use house standing orders, and contact provider as needed for changes in supplemental oxygen use. Staff were to document assessments and actions in a progress note. The DON stated documentation was important for resident safety, continuation of care, and provider review.The facility Skilled Documentation policy dated 4/2021, instructed staff to complete a daily skilled documentation progress note for residents who had a skilled nursing need on a skilled stay. The daily progress note was individualized and completed based on the primary diagnosis/reason for skilled stay and other pertinent diseases and conditions.

Based on observation, interview, and document review, the facility failed to ensure monitoring and timely removal of facility food stored in refrigerators and freezers was completed to reduce the risk of foodborne illness. This had the potential to affect approximately 20 residents who consumed meals from the third-floor kitchen, and all residents in the facility who received meals from the main facility kitchen. Findings include: During the initial tour with the assistant dietary director (DA)-A on [DATE] at 12:30 p.m., the following foods were found in the walk-in refrigerator and freezer of the main facility kitchen. -One opened container sealed with plastic wrap; ranch dressing labeled use by [DATE]. -One opened container of Chow Mein noodles with an expiration date of [DATE]. -One opened container of Pace salsa with a use by date [DATE]. -One single container of chocolate ice cream dated [DATE]. During the walk through DA-A removed the expired food. DA-A stated the cooks were supposed to go through the refrigerator and freezers daily. After the initial walk-through, evening cook (C)-A confirmed the cooks are suppose to check both the refrigerator and the freezer for expired dates daily. During a tour of the Crossway kitchen on [DATE] at 12:16 p.m., the following foods were found in the refrigerator. -One multi-use grape juice container for the unit dispenser which expired ,d+[DATE]. -Plastic container with dozens of single use cream cheese, undated. -Plastic container with dozens of single use creamers, undated. -Four packs of pancakes and two packs of waffles, unlabeled. -Cocktail sauce expired ,d+[DATE]. During an interview on [DATE] at 12:16 p.m., Crossway server (DA)-B stated the process was to check for expired foods daily, however was unsure about the process of pancakes, waffles, cream cheese, or creamer. The pancakes and waffles were brought up from the main freezer every day and kept for about two days on the unit. DA-B confirmed the pancakes and waffles in the refrigerator were unlabeled, and indicated servers were responsible for checking the snack cart. DA-B confirmed there was no process for documenting how or when the snack cart was checked for expiration dates. During an interview on [DATE] at 12:41, DA-A stated kitchen supervisors conducted audits on each floor. DA-A confirmed that DA-B did come down to ask what she should do with the unlabeled items. DA-A stated that DA-B should throw the unlabeled items away. During an interview on [DATE] at 12:49, DA-B stated no one told them what they should do with unlabeled food. During an interview on [DATE] at 12:54 p.m., kitchen supervisor (DA)-D confirmed the unit refrigerator had pancakes and waffles that were not labeled. The food was removed and placed on a cart to take back to the main kitchen. The expired juice was taken out of the garbage and the expired date was confirmed with the supervisor as ,d+[DATE] and placed on the cart. DA-D confirmed there was no process for single use cream cheese and creamers that are undated and placed on the cart. During an interview on [DATE] at 8:21 a.m., per-diem Crossway server (DA)-C stated the process was to take food from the main kitchen freezer, place a label with a use by date, and then bring food to the unit. The food should be used within three days. DA-C confirmed pancakes and waffles came from the main kitchen freezer. DA-C opened the refrigerator and confirmed 1.5 packages of pancakes were in the refrigerator. One package was opened, and both were unlabeled. DA-C brought up one package of pancakes that was on the counter opened without a date, but confirmed the package was taken from the freezer that morning and had a label completed and ready to be placed on the package. DA-C stated the packages in the refrigerator must have been there from the server on [DATE]. The facility's undated Labeling and Dating Policy indicated foods that are not marked will be discarded. The facility's Safe Food Storage Policy, dated ,d+[DATE] directed staff to label, date, and properly cover all foods items upon opening of package.

Based on interview and document review, the facility failed to notify the county (designated State Mental Health Authority - SMHA) for 1 of 1 resident (R11) with new onset of mental illness. Findings include: R11's 6/23/23, Initial Pre-Admission Screening (PAS), did not identify a diagnosis of mental illness and did not indicate the need for a Level II (PASARR) to be completed. R11's 8/31/23, Provider Order identified R11 was to receive olanzapine (treats schizophrenia and bipolar disorder) 1.25 milligrams (mg) at night and 1.25 mg as needed for anxiety/paranoia and lack of redirection. R11's 2/3/25, Significant change Minimum Data Set (MDS) assessment identified R11 was dependent on staff for cares and activities of daily living (ADLs). R11 had a diagnoses of dementia, anxiety, depression, and a psychotic disorder other than schizophrenia, and took antipsychotics on a routine and as needed (PRN) basis. R11 was severely cognitively impaired and had disorganized thinking that would come and go with change in severity, and had little interest or pleasure in doing things and felt down, depressed and hopeless two to six days during the 14-day assessment period. R11's undated, current diagnosis list identified R11 received a new diagnosis of unspecified psychosis not due to a substance or known physiological condition on 2/16/24. R11's medical record lacked any indication that the county (SMHA) had been notified since the new onset of R11's mental illness. Interview on 4/2/25 at 11:35 a.m., with social service designee identified she was aware R11 had a newly evident diagnosis of psychosis to support R11's dementia. She identified she was not directed to contact the designated-state mental health authority and never thought to do that. Interview on 4/3/25 at 10:09 a.m., with the administrator indicated it was expected the facility would file a Level I to the county for all admissions and if a Level II was needed the facility would follow the recommendations. If a resident was identified to have a newly evident diagnosis of a mental illness the facility would resubmit a Level I PASARR for recommendations. Review of July 2024 Pre-Admission Screening and Resident Review (PASRR) Policy identified the facility would evaluate mental disorders and/or intellectual disability upon admission to the facility. A Level II would be referred to the state-designated authority when a resident had a newly evident or serious mental disorder, exhibit behavioral, psychiatric, mood related, or had a significant change in status.

Based on interview and document review, the facility failed to ensure as-needed (PRN) antipsychotic medications (group of medications used to treat psychosis) were limited to 14 days of use or re-evaluated by the medical provider to ensure necessity and reduce the risk of complication for 1 of 5 residents (R26) reviewed for unnecessary medication use. Findings include: R26's admission Minimum Data Set (MDS) assessment, dated 3/9/25, indicated R26 had moderately impaired cognition with no hallucinations or delusions, no behaviors and no rejection of care. R26 required supervision from staff for activities of daily living (ADLs). The MDS indicated R26 diagnoses included: anxiety, depression, generalized weakness, and mild cognitive impairment of uncertain or unknown etiology, R26's Order Summary Report, printed 4/2/25, indicated R26 had an order for 50 milligrams (mg) quetiapine fumarate (antipsychotic medication) by mouth as needed for agitation started on 3/3/25. The report included a section titled End Date that did not include a date for this order. R26's Medication Administration Record (MAR) for the months of March and April, printed 4/1/25, indicated R26 received the PRN quetiapine with the order date 3/3/25, three times during this period. During an interview on 4/2/25 at 10:07 a.m., consulting pharmacist (CP)-A stated he reviewed resident's orders monthly, which included reviewing for 14 day end dates on PRN antipsychotic medications. CP-A stated he sent over a pharmacy recommendation on 3/11/25, for an end date on the PRN quetiapine order. Director of nursing (DON) verified the order for PRN quetiapine was active and did not have the required 14 day stop date. Both CP-A and DON acknowledged PRN antipsychotic medications were to be limited to 14 days. On 4/2/25 at 11:32 a.m., DON provided a copy of the pharmacy review. DON stated the doctor addressed it today and discontinued the medication. DON verified it had not been addressed prior to surveyor bringing to their attention. During a follow up interview on 4/3/25 at 10:03 a.m., DON stated the expectation was when the orders were put in for a PRN antipsychotic, a 14-day end date would be entered also as this was part of processing the order. A facility policy titled Psychotropic Medication Use Policy, dated 3/2025, indicated Anti-psychotics: may only be used for 14 days. If the prescribing practitioner wishes to write a new order for the PRN anti-psychotic the resident must first be evaluated.

Based on observation, interview, and document review the facility failed to ensure a sanitary and homelike environment for 1 of 1 residents (R34) who had dried feeding tube-like substance on their feeding tube pole, dresser, bed, and floor. Findings include: R34's quarterly Minimum Data Set (MDS) dated [DATE], indicated R34 had intact cognition and was diagnosed with cancer, heart failure, anxiety, and depression. The MDS indicated that R34 required moderate assistance with personal hygiene and maximal assistance with toileting, bathing, and lower body dressing. R34's order summary report dated 10/10/23, indicated that R34 received daily tube feedings over eight hours at night. During an observation on 1/8/24 at 1:24 p.m., R34 was observed lying in her bed on the right side of the room with a feeding pump on a pole between her and the drawered nightstand to the right of the bed. The nightstand was observed to have splatters of a light brown/yellow substance scattered over the left side, top, and front of the dresser. The light brown/yellow substance was also observed scattered over the bottom one-fourth of the feeding pump pole, the carpet on the right side of the bed, and on the right bed rail/frame of R34's bed. During an observation and interview on 1/9/24 at 1:03 p.m., the light brown/yellow substance was again observed as described above. R34's family member (FM)-A stated that he frequently observed the tube-feeding on R48's furniture as it was now and rarely observed it cleaned. R34 stated that the uncleanliness of her room frequently bothers her and she wished that staff would more frequently clean up the tube feed that covered her furniture. During an interview on 1/9/24 at 1:14 p.m., registered nurse (RN)-D stated that he thought the tube feeding had been on the furniture for at least a couple [sic] days but housekeeping would be in charge of cleaning it up. RN-D stated that nursing was in charge of cleaning the tube feeding off of the feeding pump and pole and acknowledged the presence of tube feeding on the pole. RN-D stated he had not seen it that morning because it was dark in R34's room when he disconnected her from the feeding. During an interview on 1/11/24 at 10:57 a.m., the director of nursing (DON) stated that she expected nursing staff to clean the resident furniture and tube feeding pole as the spills occurred and housekeeping should have been cleaning the furniture during daily housekeeping rounds. The DON stated that staff should have cleaned the dried tube feeding to ensure R34's dignity was maintained, she had a home-like environment, and infection control measures were practiced. The facility Cleaning Resident Rooms/ Apartment Units policy dated 3/12, indicated that resident rooms should be cleaned on a scheduled basis to ensure proper sanitization and cleanliness. The policy indicated that cleaning could have been completed either daily or weekly but gave no specific frequency for R34's unit. The policy indicated that wall and floor spot cleanings should be completed with this scheduled cleaning. The policy indicated that staff were to report any deep cleaning or floor care needs but did not indicate to whom these concerns were reported or when these would have been completed.

Based on observation, interview and document review, the facility failed to ensure post-hospitalization narcotic medication orders were clarified and/or obtained to reduce the risk of potential unnecessary administration and associated complication (i.e., sedation, constipation); and failed to ensure non-pharmacological interventions were attempted and documented prior to administration of as-needed (PRN) narcotic medication for 1 of 5 residents (R33) reviewed for unnecessary medication use. Findings include: R33's quarterly Minimum Data Set (MDS), dated [DATE], identified R33 had dementia with severe cognitive impairment and required no physical assistance to complete transfers or ambulation. Further, the MDS outlined R33 was not on a scheduled or PRN pain medication regimen, and R33 had no pain symptoms. R33's care plan, dated 1/4/24, identified R33 sustained a hip fracture on 12/30/23, and had surgical repair. The care plan listed several interventions including dispensing pain medication as prescribed, evaluating the pain, and physical or occupational therapy as ordered. On 1/8/24 at 5:16 p.m., R33 was observed seated in a high-back wheelchair in the locked unit dining room. R33 appeared comfortable and had no obvious physical symptoms of pain (i.e., moaning, grimacing) present. R33's Interagency Transfer Form, dated 1/3/24, identified R33 was being discharged back to the care center from the acute hospital where they had been admitted for a left hip fracture due to a fall. A section labeled, Medication Review, outlined R33's hospital discharge orders which included oxycodone (a narcotic medication) and directions which read, Take 1 tablet (5 mg [milligrams]) by mouth every 4 hours as needed for severe pain. The note included dictation which read, Pain after surgery is normal and expected . symptoms will improve with time . several things you can do to help reduce your pain including: rest, cold compresses, elevation, and using pain medications as needed. R33's subsequent care center Provider Orders, dated 1/4/24, identified orders for Tylenol (a mild pain reliever) with orders for 650 mg scheduled three times a day, and an additional 650 mg dose by mouth every 24 hours as needed due to pain from the hip fracture. R33's Medication Administration Record (MAR), dated 1/2024, identified R33's care center' provided medications along with corresponding staff initials (or dictation) to demonstrate the administration status (i.e., given, refused). This included the post-hospitalization order for oxycodone with directions, Give 1 tablet [5 mg] by mouth every 4 hours as needed for severe pain, along with the following administrations recorded: On 1/3/24 at 10:34 p.m. for a recorded pain rating of 3, with the results being listed as effective. A corresponding progress note, dated 1/3/24, identified the medication was given, however, lacked evidence what, if any, symptoms R33 displayed to warrant the use of the narcotic medication (versus Tylenol) or what, if any, non-pharmacological interventions were attempted prior to the administration of the narcotic. On 1/4/24 at 8:30 a.m. for a recorded pain rating of 4, with the results being listed as effective. A corresponding progress note, dated 1/4/24, identified the medication was given with dictation present, . given before morning care, however, lacked evidence what, if any, symptoms R33 displayed to warrant the use of the narcotic medication (versus Tylenol) or what, if any, non-pharmacological interventions were attempted prior to the administration of the narcotic. On 1/4/24 at 12:30 p.m. for a recorded pain rating of 6, with the results being listed as effective. A corresponding progress note, dated 1/4/24, identified the medication was given, however, lacked evidence what, if any, symptoms R33 displayed to warrant the use of the narcotic medication (versus Tylenol) or what, if any, non-pharmacological interventions were attempted prior to the administration of the narcotic. On 1/5/24 at 10:13 a.m. for a recorded pain rating of 3, with the results being listed as effective. A corresponding progress note, dated 1/5/24, identified the medication was given with dictation present, . given before morning care, however, lacked evidence what, if any, symptoms R33 displayed to warrant the use of the narcotic medication (versus Tylenol) or what, if any, non-pharmacological interventions were attempted prior to the administration of the narcotic. On 1/6/24 at 8:00 p.m. for a recorded pain rating of 4, with the results being listed as effective. A corresponding progress note, dated 1/6/24, identified the medication was given with dictation present, . Resident show the s/sx [symptoms] of pain, however, lacked evidence what these symptoms were to warrant the use of the narcotic medication (versus Tylenol) or what, if any, non-pharmacological interventions were attempted prior to the administration of the narcotic. On 1/10/24 at 9:17 a.m. for a recorded pain rating of 4, with the results being listed as effective. A corresponding progress note, dated 1/4/24, identified the medication was given, however, lacked evidence what, if any, symptoms R33 displayed to warrant the use of the narcotic medication (versus Tylenol) or what, if any, non-pharmacological interventions were attempted prior to the administration of the narcotic. In total, 11 doses of the as-needed narcotic medication had been provided to R33. However, the MAR included the provider order (dated 1/4/24) for Tylenol with directions, Give 650 mg by mouth every 24 hours as needed for Pain related to (L) hip fracture with repair. The order had a listed start date recorded of 1/4/24 with a discontinue date outlined of 1/10/24, but there were no recorded doses given or recorded in the MAR spaces. R33's medical record was reviewed and lacked evidence the post-hospitalization orders for oxycodone and Tylenol had been clarified to ensure staff had consistent administration direction for which medication (i.e., oxycodone or Tylenol) should be given for which corresponding pain rating or physical symptoms despite R33 having a diagnosis for the oxycodone of 'severe pain' and staff only recording mild or, at most, moderate pain levels with each administration (i.e., 3 or 4). Further, the medical record lacked evidence in any of the provided doses' of what, if any, non-pharmacological interventions had been attempted prior to the administration of the narcotic medication despite R33 having consistently low(er) pain ratings where such interventions could have potentially helped or resolved R33's pain. On 1/10/24 at 12:47 p.m., registered nurse (RN)-F was interviewed and verified they had worked with R33 before and after the fall on 12/30/23, with a resultant hip fracture, and stated R33 had been more ambulatory and independent with cares prior to the fall. RN-F explained the administration of PRN medication, including narcotics, required the nurse to assess the patient and record any non-pharmacological interventions attempted or refused in the progress notes. RN-F stated the use of Tylenol or oxycodone would come down more on the nursing assessment as there were no established protocols or directions on which to give for a variable pain rating. However, RN-F stated if R33 demonstrated a lower pain rating, then it would be appropriate to then just give Tylenol and not a narcotic. RN-F stated the decision making, or rationale, of the intervention was supposed to be documented in the medical record. On 1/11/24 at 8:41 a.m., the director of nursing (DON) was interviewed and verified they had reviewed R33's medical record. DON acknowledged the oxycodone had a diagnosis listed for 'severe pain' and stated they had just yesterday, after being questioned about the medication use by the surveyor, had the nurses call the provider and obtain clarification on which medication to give for mild versus severe pain with new orders being obtained. DON stated a clarification for the medication use should have likely been obtained when R33 readmitted to the nursing home as there was not a facility' protocol, at least to their knowledge, to help nurses' determine which medications to provide without clarified orders. DON added, I probably should have caught that. DON stated it was important to ensure physician orders, if needed, were clarified to ensure consistent administration of medications so staff don't provide a medication that not necessary. The interview continued, and DON verified the lack of non-pharmacological intervention charting in the progress notes and expressed, They're [nurses] not charting it. DON stated they felt the staff had been doing non-pharmacological interventions with R33 but just not recording them. However, the DON verified non-pharmacological interventions should be attempted and recorded in the medical record with any as-needed narcotic administration. DON expressed this was important to do as, We need to know what's working and not working [for interventions]. A facility' policy on medication management, including order clarification, was requested. However, none was received.

Based on observation, interview and document review, the facility failed to provide adaptive equipment for 1 of 1 resident (R3) reviewed for adaptive equipment and observed with difficulty eating during dining observations. Findings include: R3's admission Minimum Data Set (MDS), dated [DATE], indicated R3 was cognitively intact, and required verbal cues or touching/steadying assistance to eat and received rehabilitation therapies including speech therapy. R3 diagnoses included cerebrovascular accident (damage to the brain from interruption of its blood supply) affecting right dominant side, hypertension(high blood pressure), hemiplegia (paralysis of one side of the body), hemiparesis (weakness or inability to move one side of the body), anxiety disorder, manic depression (or bipolar disorder is a mental illness that causes unusual shifts in a person's mood, energy, activity levels and concentration), and chronic obstructive pulmonary disease(lung disease that blocks airflow and make it difficult to breath). R3's Order Summary Report dated 1/11/24, included an order dated for Built up silverware with foam grips, plate guard, seated in recliner for all meals. R3's activities of daily living (ADL) care plan revised on 11/22/23, indicated R3 had a self care performance deficit related to physical weakness, cerebrovascular accident with right side weakness, anemia, hypertension, dementia, anxiety/depression, and bipolar disorder. R3's care plan interventions for eating indicated all foods should be cut up. I use built up/foam grip, plate guard and all liquids in insulated mug with lid. R3's room location was on the Gateway unit. The RA (resident assistants) Group sheet dated 1/10/24, indicated for R3 Regular (diet), plate guard, mugs with lids and handles, foam grips. R3's nutritional care plan dated 11/14/23, indicated I have a nutritional problem or potential nutritional problem r/t [related to] dysphagia (difficulty swallowing), GERD (gastroesophageal disease that causes stomach acids or bile to flow back into the tube connecting your mouth and stomach), HLD (hyperlipidemia defines high levels of lipids), COPD (Chronic obstructive pulmonary disease). The care plan failed to include R3's diagnosis of hemiplegia affecting the right dominant side, and the need for adaptive equipment to eat. During observation and interview on 1/8/24 at 6:59 p.m., a handwritten note was observed taped to R3's room door. The note read Please put pillows on each side when R3 is in chair to avoid tipping sideways, and Please put red utensils holders on fork and spoon when she is eating. R3 stated her son (FM)-C wrote the note hoping the staff would read it. R3 stated most of the time they [staff] forget to bring me the right silverware or forget to cut my food. My son has talked to different staff members but continues to be a problem. During interview on 1/9/24 at 7:15 p.m., (FM)-C, reported concerns about the staff not providing R3 with the adpative red handle silverware. FM-C stated he put the sign on the door hoping the staff would read it and make sure R3 would get the adaptive silverware and the plate guard. FM-C stated R3 received daily visits and sometimes more than two family members visited her every day and unfortunately, the staff have not been able to fix this problem. (FM)-C expressed concerns about potential weight loss and malnutrition. During observation on 1/10/24 at 12:29 p.m., nursing assistant (NA)-B brought R3's lunch tray. NA-B cut R3's food, asked if she needed any help and left the room. R3 was sitting in an upright position without the assistance of pillows. R3's flat plate had a plate guard, but the silverware was not adaptive silverware. R3 had a tablespoon on her right hand, her hand was not tightly closed and several times the spoon slipped out of her hand into the soup bowl or the tray. R3 was able to get soup into the spoon but approximately half of the soup fell on the cup or tray while she was bringing the spoon to her mouth. During interview on 1/10/24 at 12:28 p.m., dietary assistant (DA)-A stated, whoever sets up the trays is responsible to make sure the proper silverware, glasses and plates were provided. DA-A stated, we (dietary aids) were responsible to set up the trays. During interview on 1/10/24 at 12:29 p.m., nursing assistant (NA)-B who brought R3's lunch tray, stated the dietary department was responsible to set up the trays. When asked about the sign posted on the door, NA-B stated, I didn't pay attention to it. During interview on 1/10/24 at 12:36 p.m., nurse manager/registered nurse (RN)-C stated, adaptive silverware and adaptive equipment used by residents was on the nursing assistant's' RA Group Sheet and nursing assistants needed to read their RA Group Sheet to make sure resident's needs were met. RN-C checked the undated Gateway RA Group Sheet which indicated regular diet, plate guard, mugs with lids and handle foam grips. During interview on 1/10/24 at 12:43 p.m., the director of nursing (DON) stated the nursing assistants needed to look at the resident's care cards and assignments sheets and provide the proper adaptive silverware at each meal. DON stated a resident with decreased independence to feed themselves were at risk of decreased food intake resulting in weight loss. The facility policy titled Adaptive Feeding Equipment dated 1/31/11, indicated Residents will be provided with adaptive feeding equipment upon assessment by the nursing and therapy staff. The policy also indicated the use of adaptive feeding equipment is noted in the care plan and on the diet spreadsheet.

Based on interview and document review the facility failed to offer the influenza vaccine to 1 of 1 residents (R24) according to the Center for Disease Control and Prevention (CDC) guidelines. Findings include: R24's admission Minimum Data Set (MDS) dated [DATE], indicated R24 had intact cognition, required supervision to eat and extensive assistance for all other activities of daily living (ADLs). R24 was on palliative care and had diagnoses that included lung and prostate cancer, diabetes, stroke, heart disease, kidney disease, and a heart attack. R4's immunization record, undated, indicated R24 received the influenza vaccine on 10/6/20 and 10/4/21; however, the record lacked indication R24 received the influenza vaccine in 2022. R24's physician orders dated 2/10/23, indicated R24 may receive Influenza vaccine if not already received. R24's electronic medical record (EMR) lacked indicated R24 was offered and/or refused the influenza vaccine upon or after his admission to the facility. During an interview on 5/4/23 at 1:34 p.m., R24 stated he was not offered the influenza vaccine when he admitted to the facility in February. R24 stated he had received the influenza vaccine every year and would have wanted to get it had it been offered. During an interview on 5/3/23 at 3:00 p.m., the Infection Preventionist (IP) verified R24's immunization record and EMR lacked indication R24 had been offered, received or refused the influenza vaccine once he admitted to the facility in February 2023. The facility Influenza Vaccination policy dated October 2020, indicated residents were to be offered the influenza vaccine annually due to the serious risk influenza has on the elderly population. The policy indicated the influenza vaccine program was from early October to April 30 each year with flexibility according to the Center for Disease Control and Prevention (CDC) guidelines. In addition, all new admissions should be screened and given the influenza vaccine unless ordered otherwise by the provider. A record of the administration of the vaccine or the resident's refusal to receive the vaccine and education provided regarding the vaccine's risk and benefit was also to be included in the resident's EMR.

Based on observation, interview, and document review the facility failed to ensure baths were provided to maintain personal hygiene for 1 of 1 residents (R4) who were unable to perform their own activities of daily living (ADLs). Findings include: R4's Minimum Data Set d(MDS) dated [DATE], indicated R4 had intact cognition, required supervision for eating and extensive assistance for all other ADLs. The MDS also indicated bathing did not occur during the assessment period; however, R4 required assistance of one staff. R4's diagnoses included major depression, developmental disorder of scholastic skills (a learning disability), a history of falls, muscle wasting, dementia, epilepsy (seizures), anxiety, gout (inflammation in the joints, often the big toes), and cataracts (blurred vision). R4's Care Area Assessment (CAA) dated 4/6/23, indicated R4 triggered for vision, communication, ADL function, urinary incontinence, mood, falls, and psychotropic drug use. R4's care plan dated 5/5/20, indicated R4 had a self-care deficit due to physical weakness, morbid obesity, seizure disorder, depression, anxiety, and developmental delay with cognitive deficits. Interventions included requiring an assist of one staff for bathing. R4 had impaired cognition due to diagnosis of intellectual disability. Interventions included keeping R4's routine consistent and providing consistent care givers, if possible, to decrease confusion. The facility Bath Schedule undated, indicated R4 was to receive a bath on Sunday and Wednesday (including body audit) mornings. The nursing assistant care sheet undated, indicated R4 was to receive a bath on Sunday morning and Wednesday morning. R4's orders dated 9/1/21, indicated R4 was to have a body audit completed every Wednesday morning on bath day. R4's nursing assistant bath log from 4/3/23-5/2/23, indicated R4's bathing was not applicable for all shifts. No other documentation was provided to indicated baths/showers were completed on Sundays. R4's Body Audit log undated, indicated R4 received a shower as follows: -2/1/23 -2/8/23 -2/15/23-no body audit completed -2/22/23 -3/1/23 -3/8/23-no body audit completed -3/15/23 -3/22/23-no body audit completed -3/29/23-no body audit completed -3/31/23, (a Friday) Bath indicated other, no further documentation available. -4/5/23-no body audit completed -4/12/23 -4/19/23 -4/26/23 -5/3/23 Review of R4's progress notes lacked explanation for missed body audits and/or baths/showers. During an interview and observation on 5/1/23 at 6:50 p.m., R4 was in her room in a wheelchair. Her hair appeared oily but brushed in the front but dry and messy in the back. R4 stated staff did not wash her hair or give her a shower since her favorite nursing assistant left on vacation three weeks prior. R4 stated Just feel my hair. It's not right. During an interview on 5/2/23 at 9:08 a.m., registered nurse (RN)-A stated nursing staff charted resident baths once a week in a resident's Body Audit log. RN-A stated nursing assistants (NAs) would chart if a resident received or refused a second bath on the bath log in their electronic medical record (EMR). During an interview an observation on 5/2/23 at 9:14 a.m., R4 was sitting in her room in a wheelchair. Her hair appeared oily on the top and front and dry and unbrushed in the back. R4 stated her favorite NA was still not back, and therefore, staff didn't wash her hair or give her a shower. R4 stated she had a care conference the following week and wanted to look nice. R4 stated Touch my hair. During an interview on 5/2/23 at 9:12 a.m., NA-G stated NAs would document when they gave a resident a bath or if a resident refused a bath in their EMR bath log. During an interview on 5/3/23 at 1:11 p.m., NA-A stated NAs charted in the resident's bath log on the computer whenever they gave a bath or if a resident refused a bath. NA-A also stated R4 never refused her bath. During an interview on 5/4/23 at 8:55 a.m., RN-B stated R4 was supposed to receive a bath/shower on Sundays and Wednesdays. RN-B stated one bath would be documented in the resident's Body Audit log, but all baths should be charted in the resident's EMR bath log and verified R4's bath log lacked indication R4 had received any baths/showers from 4/4/23 to 5/2/23. RN-B further verified R4 did not have a Body Audit completed to indicate weekly showers were completed consistently since February. RN-B also stated R4 would let you know if she didn't get her bath or shower. During an interview on 5/4/23 at 10:26 a.m., the director of nursing (DON) stated body audits were to be completed every week during a resident's bath/shower and documented in the EMR. The DON also stated NAs should be documenting each time they give a resident a shower or bath in their EMR bath log and verified R4's bath log lacked documentation she had received any baths/showers. The DON further stated R4 would tell you if she didn't get it because baths were important to her. A facility ADL and/or Bathing policy was requested but not received.

Based on observation, interview, and document review, the facility failed to ensure significant bruising was comprehensively assessed and acted upon to develop potential treatment interventions, promote healing, and reduce the risk of complication (i.e., worsening) for 1 of 1 resident (R38) observed to have areas of significant bruising on their arm. Findings include: R38's admission Minimum Data Set (MDS), dated [DATE], identified R38 had intact cognition, required extensive assistance for most activities of daily living (ADLs), and had several skin concerns including an active unstageable pressure ulcer and skin tears. Further, the MDS identified R38 consumed anticoagulant medication during the review period. On 5/1/23 at 7:02 p.m., R38 was observed seated in a chair in their room on the transitional care unit (TCU). R38 had visible bruising on their left hand with several areas presenting as deep, dark purple in color, the areas being asymmetrical in shape, and a visible white-colored cotton ball was secured to R38's left anterior forearm with paper tape. R38 was interviewed, and they explained they bruised easily and attributed the bruising to several blood draws recently. R38 rolled up the long sleeve shirt they were wearing exposing more of their left arm. The same dark purple areas of bruising continued up R38's arm to nearly the elbow. R38 stated they were on an anticoagulant medication and the bruising looked about the same since they admitted to the TCU several weeks prior. R38 stated nobody from the nursing home had discussed the bruising, including potential options of treatment (i.e., heat application, lotion) or prevention (i.e., geri-sleeves), with him and added, No one has offered a solution to it. R38's care plan, dated 4/3/23, identified R38 had an ADL self-care performance deficit due to pneumonia, chronic kidney disease, and other medical complications. The care plan directed, SKIN INSPECTION: While providing care, I ask that you observe my skin for redness, open areas, scratches, cuts, bruises and report changes. The care plan outlined R38 consumed anticoagulant medication and directed to monitor for side effects of the medication including, . bruising, bleeding . In addition, the care plan identified R38 was at risk for skin impairments and had a history of pressure injuries. However, the care plan lacked information on R38's obvious, visible bruising or what, if any, interventions were being completed to promote healing (i.e., monitoring, lotion applied) or what, if any, approaches had been offered, attempted, or refused. R38's Body Audit - V4(s), dated 3/14/23 to 4/14/23, were reviewed in the medical record. These identified an anatomical human figure with a corresponding areas to record the site, type, and measurements of any identified skin alteration or impairment. These identified the following: On 3/14/23, R38 was identified to have an, Other type of alteration, and the form outlined several areas of bruising including, 30) Left hand (back), with, Bruising, being recorded. However, there were no other recorded characteristics of the bruising to help identify where in the healing process, if applicable, the bruising was at or if it was being monitored (i.e., coloration of the bruises, approximate sizing of them). On 3/17/23, R38 was identified to have an, Other type of alteration, and the form outlined several areas of bruising including, L [left] arm, hand, with, multiple bruises, being recorded. However, there were no other recorded characteristics of the bruising to help identify where in the healing process, if applicable, the bruising was at or if it was being monitored. On 4/3/23, R38 was identified to have an, Other type of alteration, and the form outlined several areas of bruising including, 30) Left hand (back), with, Bruising, being recorded. However, there were no other recorded characteristics of the bruising to help identify where in the healing process, if applicable, the bruising was at or if it was being monitored. On 4/7/23, R38 was identified to have an, Other type of alteration, and the form outlined several areas of bruising including, 30) Left hand (back), with, Bruising, being recorded. However, there were no other recorded characteristics of the bruising to help identify where in the healing process, if applicable, the bruising was at or if it was being monitored. On 4/14/23, the most recent audit was completed which again R38 was identified to have an, Other type of alteration, and the form outlined several areas of bruising including, both forearms, with Bruising, being recorded. However, there were no other recorded characteristics of the bruising to help identify where in the healing process, if applicable, the bruising was at or if it was being monitored. R38's corresponding Bowel, Bladder, and Skin Risk - V3 assessments, dated 3/18/23 to 4/28/23, identified an evaluation was completed on 3/18/23, 3/25/23, 4/7/23, 4/14/23, 4/21/23, and 4/28/23. These evaluations included review of a Braden scale (a tool used to help determine pressure ulcer risk), contributing factors and current skin condition, cognitive awareness, resident preferences, and a section labeled, Analysis and Summary . , which provide spacing to record the assessed issues and needs of the resident. However, each of these completed evaluations did not include or mention R38's bruising, or subsequent interventions to address them and prevent recurrence, despite R38 having obvious, dark-purple colored bruises present on their body which were also recorded on numerous Body Audit - V4 evaluations. On 5/3/23 at 10:34 a.m., nursing assistant (NA)-F was interviewed. NA-F explained they had worked with R38 in the past and expressed R38 had intact cognition and can remember things well. NA-F stated they were aware R38 had bruising on various parts of the body; however, were unable to recall how long R38 had the bruising or if it had been present since admission. NA-F stated they had never been told or directed to do any interventions for R38's bruising (i.e., apply cold packs, geri-sleeves). R38's medical record was reviewed and lacked evidence R38's developed bruising on their left arm was being monitored on a routine, ongoing basis (i.e., coloration, sizing) to ensure adequate healing. In addition, the medical record lacked evidence R38 had been comprehensively assessed for their bruising risk despite developing significant bruising on their left arm which had been present since first recorded on 3/14/23 (Body Audit - V4). There was no indication the facility had reviewed or assessed R38 for potential causative factors or interventions to help prevent recurrence of the bruising and ensure adequate healing of the developed areas. When interviewed on 5/3/23 at 11:16 a.m., registered nurse (RN)-C explained they had noticed R38 to have significant bruising which they recalled had been present since admission. RN-C added, [R38] keeps on bruising. RN-C attributed some of the repeated bruising to R38's ongoing blood draws and their subsequent pulling on the tape used to secured a pressure dressing (i.e., cotton ball). RN-C explained skin assessments, including for bruising, were typically completed by the clinical coordinator and expressed any developed skin alteration, including bruising, should be monitored in the skilled documentation of the medical record. RN-C reviewed R38's medical record, including the Treatment Administration Record, and verified there were no current, active treatments for R38's bruising on the left arm despite the area having several dark-purple colored bruises covering most of the skin surface. RN-C reiterated the clinical coordinator was responsible to assess the need, care plan any interventions, and pass the information down to the nurses for the treatments to be implemented. On 5/3/23 at 1:40 p.m., registered nurse clinical coordinator (RN)-D was interviewed, and explained R38 had admitted to the care center with multiple bruises present. RN-D stated when a new bruise was discovered, the area was reviewed and monitoring was implemented via the weekly body audit evaluations. RN-D explained appropriate monitoring for developed bruises would include observing the color of the bruise, shape of the site, and progress of the healing process. However, RN-D explained this process was more for bruises which develop after admission and not usually completed for bruising which is present upon admission to the care center. RN-D stated if R38's bruising had developed after admission, it would have likely been handled differently and monitored more closely adding interventions for bruising upon admission really depend[ed] on the extent of the condition. RN-D acknowledged the medical record lacked evidence R38's bruising, which had been present since admission, was being routinely monitored with characteristics; nor had anyone comprehensively assessed the bruising to ensure adequate interventions were in place to prevent decline or recurrence. A provided Skin Integrity Management Policy, dated 10/2022, identified the facility' policy was to properly identify, assess and monitor residents whose clinical conditions increase the risk of impaired skin integrity or pressure injuries and to implement preventative measures. The policy listed several steps and procedures to address pressure injuries, non-surgical wounds, and general preventative measures for skin health. However, the policy lacked specific information or procedures on how bruising would be triaged, assessed or managed at the care center.

Based on observation, interview, and document review, the facility failed to comprehensively reassess and develop interventions, and ensure ongoing efficacy of interventions, after the development of an in-house acquired deep tissue injury (DTI) for 1 of 2 residents (R24) reviewed for pressure ulcer care and services. Findings include: R24's admission Minimum Data Set (MDS), dated [DATE], identified R24 had intact cognition, required extensive assistance for most activities of daily living (ADLs), and was frequently incontinence of bowel. Further, the MDS outlined R24 was at risk for pressure ulcer development, however, had no current unhealed ulcers present. R24's most recent Bowel, Bladder, and Skin Risk - V3 evaluations, dated 3/7/23, identified R24 scored a 13 on the completed Braden scale (a tool used to determine pressure ulcer risk) which placed R24 at, High Risk. The evaluation outlined R24 had prostate cancer with metastasis, was on narcotic medication, and was, Full assist with cares, and bed bound. An alternating air mattress was in place along with routine wound care to R24's buttocks and skin prep to their bilateral feet. R24's care plan, dated 4/10/23, identified R24 was at risk for impaired skin integrity and outlined R24 developed a DTI on their left heel on 3/22/23, and a stage one pressure injury on their left left (big) toe on 4/5/23. The care plan listed several interventions for R24's skin management including assessment and evaluation of skin status per facility' policy, treatments as ordered, elevating R24's heels off the bed surface as needed. On 5/1/23 at 7:17 p.m., R24 was observed laying in bed in his room and positioned, via pillows, on his right side. R24's feet appeared raised up from the mattress, however, were covered with bed linen and not visible. R24 expressed they were in such pain and declined to interview with the surveyor at the time. R24 declined reproach later when not so uncomfortable but, again, declined to visit with the surveyor adding, I really don't want to talk to you. R24's medical record was reviewed. R24's Body Audit - V4, dated 3/23/23, identified an anatomical human figure with areas to record various observed skin impairments, including pressure injuries. This recorded R24 as having an, Other type of [skin] alteration, and recorded, See previously noted. Has pressure injury to L [left] heel, and redness to tip of L foot big toe. This was the first recorded entry identified in the medical record demonstrating a pressure injury had potentially developed on R24's toe. R24's subsequent Body Audit - V4(s), dated 3/30/23, 4/13/23, and 4/19/23, identified the developed area remained on R24's left toe. On 3/30/23, R24 was recorded with continued redness on left big toe. On 4/13/23, R24 was listed as having an, Other (specify), skin impairment on their left big toe. The audit recorded the type of injury as, Pressure. Further, on 4/19/23, the audit again recorded, . pressure injury to left tip on big toe and heel. On 5/3/23 at 10:38 a.m., nursing assistant (NA)-F was interviewed. NA-F explained R24 liked to remain in bed and staff would just assist R24 with changing their incontinence product, as needed. NA-F expressed staff to reposition R24 throughout the day as R24 has the sores on the legs. However, NA-F explained they had never seen R24's 'sores' so they could not describe them or provide further details on them. Later on 5/3/23, at 10:59 a.m., R24's feet and skin were observed with registered nurse (RN)-C present. RN-C removed several blankets from R24, who was laying in bed, which exposed R24's feet. R24 had a blue-colored heel protector soft boot in place on their left foot, and their left toes were all open and exposed to air and visible. R24's left great toe had an area present, measuring approximately .75 inches (in) in diameter, on the distal portion of the toe which was circular in shape, and was dark red in color with a visible, black-colored thin line extending around the perimeter of the area. The wound presented with no obvious depth but was unblanchable skin. RN-C explained staff had attempted to use a bed cradle (a device used to keep sheets from touching the feet and toes) in the past; however, R24 refused it. RN-C verified the area was pressure-related and attributed the cause of it to R24 using a lot of sheets on him while in bed and over their toes. RN-C expressed the area on R24's toe seemed to be healing in overall condition, however, was usually always just red when they observed it. During follow-up interview, on 5/3/23 at 11:10 a.m., RN-C explained they had worked with R24 several times over the past weeks and described R24 as someone who needs a log of help with repositioning and cares. RN-C stated they were not sure how long the pressure injury on R24's left toe had been there but felt was, at least, a few months now. RN-C reiterated the left toe ulcer was looking better lately, and they explained when someone develops a pressure injury the clinical coordinator was the person who usually assessed them and developed the treatment plan to be implemented. However, R24's medical record was reviewed and lacked evidence R24 had been comprehensively reassessed for their skin risk, including their risk of pressure ulcer development and subsequent causative factors or interventions to promote healing, despite R24 developing signs of a potential pressure injury (and subsequent ulcer) on 3/23/23 when they were identified to have redness to the tip of their left toe on the Body Audit - V4 (dated 3/23/23). On 5/3/23 at 1:49 p.m., registered nurse clinical coordinator (RN)-D was interviewed. RN-D verified R24 had not been comprehensively reassessed for their skin and pressure ulcer risk since 3/7/23, despite developing a pressure ulcer on their left great toe. RN-D expressed R24 should have been reassessed for their risk to help prevent additional pressure injuries, and because R24's skin was so fragile, it placed R24 at risk for infections, decreased comfort and on and on. Further, RN-D stated it was important to ensure a reassessment process occurred as part of overall effective wound care [management]. A provided Skin Integrity Management Policy, dated 10/2022, identified the facility policy' including the proper identification, assessment and monitoring of patients at risk for impaired skin integrity and pressure ulcers. The policy outlined several items which could be used to identify risk including a Braden scale, Skin Risk Assessment, and Tissue Tolerance Evaluation. A section labeled, Procedure: upon discovery of a non-surgical wound, directed several steps to be completed upon discovery of a potential pressure injury including, Initiate and complete Bowel, Bladder and Skin Risk Assessment with analysis and summary.

Based on observation, interview, and documentation the facility failed to comprehensively reassess, create and implement pain interventions for 1 of 1 residents (R17) whose pain medications were decreased resulting in worsening pain. Findings include: R17's quarterly Minimum Data Set (MDS) dated [DATE], indicated R17 had moderate cognitive deficits, was independent with eating and required extensive assistance for all other activities of daily living (ADLs). R17's diagnoses included a displaced left hip fracture, kidney failure, myocardial infarction (heart attack), rheumatoid arthritis, chronic pain, osteoporosis (low bone density), polymyalgia rheumatica (inflammation causing muscle pain and stiffness in the shoulders, neck, and hips that is usually worse in the morning), gout (pain, swelling, redness in joints, often the big toes), legal blindness due to macular degeneration (spondylosis of the cervical spine (a defect or stress fracture of the neck), spinal stenosis ( a narrowing of the spine causing compression on the spinal cord), heart failure, major depression, anxiety, and dementia. R17's Care Area Assessment (CAA) dated 6/28/22, indicated R17 triggered for cognitive loss/dementia, vision, ADL function/rehabilitation, falls, and pressure ulcer. The CAA did not indicate R17 triggered for pain. R17's care plan dated 7/20/21, indicated R17 had a self-care deficit due to physical weakness/impaired balance, gait, and range of motion (ROM) to both hands related to a hip fracture, depression/anxiety/dementia, heart failure, rheumatoid arthritis, spinal stenosis, chronic pain, visual impairment, and kyphosis (a curvature of the upper spine). Interventions included wearing palm guards on both hands at night, for comfort and ROM, and physical and occupational therapy evaluations and treatment as needed. R17 was also at risk for falls, and chronic pain. Interventions included administering pain medications as ordered and reviewing R17's pain needs with clinicians to ensure appropriate dosing, identifying, recording, and treating existing conditions which may increase pain and/or discomfort, and notifying the provider if interventions are unsuccessful, or a withdrawal or resistance to cares or change in usual activity attendance. R17's hospital discharge orders dated 4/4/23, indicated the following: -oxycodone (narcotic pain medication) 5 milligrams (mg) every six hours as needed for severe or breakthrough pain for a right hip fracture. Another medication with the same name was removed. The orders lacked acknowledgment of R17's historical use of oxycodone for chronic pain prior to her hip fracture. -Diclofenac gel (an anti-inflammatory) explain medication was to be stopped. No indication for reason. During an interview on 5/4/23 at 7:39 a.m., licensed practical nurse (LPN)-A stated she did not know why R17 no longer had scheduled oxycodone or diclofenac gel upon her return from the hospital. R17's medication administration record (MAR) dated April 2023, indicated R17 received diclofenac gel applied to all painful areas topically, twice a day and an additional twice a day, as needed, from 7/2/21 to 4/4/23. The diclofenac gel was not reordered after R17's return to the facility on [DATE]. The MAR indicated R17 received 20 mg of methotrexate (a chemotherapy and immune system suppressant used to treat rheumatoid arthritis that does not respond to other treatment) every Wednesday from 7/8/21 to 4/4/23. The MAR indicated R17's methotrexate was discontinued for the remainder of the month. The MAR further indicated R17 received 5 mg of oxycodone (an opioid) every four hours as needed (PRN) from 9/21/21 to 4/4/23 in addition to scheduled 5 mg of oxycodone three times a day for pain from 11/17/22 to 4/4/23. Upon R17's return from the hospital, R17 only received 5 mg of oxycodone every four hours as needed and no scheduled doses beginning 4/6/23. The MAR indicated there was no data available from 4/6/23 - 4/8/23 and R17 requested oxycodone once every day nine times, twice a day eight times, three times a day four times, and four times one day from 4/8/23 to 4/30/23. R17's Comprehensive Clinical assessment dated [DATE], indicated R17 had pain almost constantly during the previous five days and rated the pain 5 out of 10. R17 was unable to answer if the pain interrupted her sleep or limited her activities. R17 indicated the pain was an ache in her [left] hip. The assessment further indicated R17 had a fracture of the right hip; however, the Contractures box was unmarked although R17 had severe contractures. No further assessment was completed regarding R17's pain related to her chronic conditions. R17's nursing assistant care sheet undated, indicated R17 was to have palm guards on at night and off during the day. During an interview on 5/2/23 at 10:09 a.m., R17 was sitting in a wheelchair in her room with a soft neck brace on. R17 stated she received medications for pain relief but nothing else such as ice or heat packs. R17 stated the pain was constant and she would try anything to get some relief. During an interview and observation on 5/3/23 at 8:37 a.m., R17 was waking up in bed and did not have palm protectors on her hands. R17's hands were severely contracted causing her fingers to dig into her palms. R17 stated she wished she had palm protectors and would take anything to help the pain. R17 stated she had not slept well due to terrible pain in her toes and feet. R17's great toes pointed inward, causing her second toes to sit on top of her other toes on both feet. R17 stated her pain was 9 out of 10 but that the staff had stopped asking her what her pain level was because they already knew she was always in pain. R17 stated until recently, she would have relief with her pain medications, but the pain was constant, keeping her up at night and from being able to do activities because it just hurts to move. During an interview on 5/3/23 at 11:56 a.m., R17 was in her room, sitting in a recliner with a soft neck brace on. R17 stated although she received pain medication three hours ago, her pain was 8/10. During an interview on 5/3/23 at 1:11 p.m., nursing assistant (NA)-A stated residents could receive an ice pack for pain if they had an order for it and stated he referred to the resident care sheet for guidance on how to care for a resident. NA-A also stated R17 usually ate breakfast in the communal dining room, however, R17 did not want to come out of her room that morning, but NA-A did not know why. NA-A also stated he had not seen R17's palm protectors and did not know if R17 still had them. During an interview on 5/3/23 at 1:23 p.m., NA-B stated she had not seen palm protectors in R17's room recently, nor had she seen them on R17's hands upon waking her in the morning for a while. R17 also stated she would refer to the care sheet for instructions on how to care for a resident and verified R17's care sheet indicated she should have palm guards on at night and off during the day. During an observation and interview on 5/4/23 at 7:52 a.m., LPN-A entered R17's room to administer her morning medications. R17 was in her recliner, where she had slept, with a soft neck brace on and no palm guards. R17 stated the pain is so bad. LPN-A stated she was going to give her Tylenol and put lidocaine gel on her and if her pain was still bad, she would bring her oxycodone. R17 asked why she couldn't just get her the oxycodone now because it really hurts and her pain was 9/10. LPN-A stated she would return in 30 minutes to see if the other medications had relieved her pain and if not, LPN-A would give R17 the PRN oxycodone. R17 agreed reluctantly, stating, don't forget. LPN-A also stated R17 used to wear palm guards to protect her palms and help with contractions, but LPN-A had not seen them since R17 returned from the hospital a month ago. LPN-A verified R17's care sheet indicated she was to have palm guards on at bedtime and taken off during the day. During an interview on 5/4/23 at 9:26 a.m., LPN-A stated upon reassessment R17 indicated she was still in a lot of pain and LPN-A gave R17 her PRN oxycodone. During an interview on 5/4/23 at 8:15 a.m., registered nurse (RN)-B stated R17 used to have soft palm protectors and was unaware they were missing and R17 was not having them applied at night according to her care plan. RN-B verified R17 was using her PRN oxycodone daily and although the times were not always consistent, maybe having it on a regular schedule again would be appropriate. RN-B stated R17 would always have pain due to her diagnosis of RA but would expect the nursing staff to assess and document R17's pain and any changes and/or interventions including non-pharmacological that were offered. During an interview on 5/4/23 at 10:32 a.m., physical therapist (PT)-A stated R17 had been receiving PT after hip surgery to regain strength and balance during transfers and to return to using her walker. PT-A stated R17's hip pain had been managed pretty quickly but recently R17 had been complaining of pain in her back and knees and it was the main barrier for her progression, causing R17 to refuse or prematurely end some of her PT sessions. During an interview on 5/4/23 at 10:45 a.m., certified occupational therapy assistant (OT)-A stated R17 should have been wearing soft palm guards every night to decrease her pain and prevent skin break down due to her contractures; however, OT-A had not seen the palm guards in R17's room since she returned from the hospital. During an interview on 5/4/23 at 10:45 a.m., the facility medical doctor (MD) stated he was unaware R17 had been having increased pain. The MD stated R17's methotrexate was held to increase wound healing after her surgery; however, the MD did not know why her diclofenac gel was discontinued. The MD further stated he would have expected staff to offer R17 non-pharmacological interventions such as palm protectors and reassess her pain due to her medication changes and history of rheumatoid arthritis. The facility Pain Assessment and Management policy dated November 2022, indicated all residents were to be assessed for pain on admission, with a significant change in status, and with the new onset of potential pain or discomfort. Staff were to obtain as much information as possible and evaluate resident pain through all available means to indicated a resident's history of pain and its treatment including non-pharmacological and pharmacological treatments and if each has been effective, the impact pain has on the resident's quality of life, the resident's pain management goals and satisfaction with the current treatment plan, notifying the provider of pain management findings to start or change the pain management plan, and following the prescribed orders for pain.

Based on observation, interview, and document review, the facility failed to ensure required nurse staffing information was posted on a daily basis. This had potential to affect all 79 residents, staff, and visitors who could wish to review this information. Findings include: On 5/1/23 at 6:20 p.m., the survey team entered the nursing home for the recertification survey, and adjacent to the main reception area was a wall-mounted, wood-laminated board which contained two clear plastic sleeves for respective documents including, Nursing Hours. A single sheet posted under this heading was titled, PHS Bloomington Care Center, and listed posted, Daily Staffing Ratio, which included the actual and total hours worked by the licensed nursing staff and the census of the home. However, the posting was dated 4/28/23 (three days prior). There was no posted staffing information visible for 4/29/23, 4/30/23, or 5/1/23 (the current date). When interviewed on 5/1/23 at 6:27 p.m., the long-term care clinical coordinator (LTCCC)-A observed the posting and verified it was dated 4/28/23. LTCCC-A stated they were unsure who was responsible to update the posting on a daily basis with current, accurate information adding, I would have to check. On 5/2/23 at 10:14 a.m., the care center administrator was interviewed. They explained the nursing home had two staffing coordinators who were responsible to post the nurse staffing information during the weekday; and the weekend managers would post it over the weekends. The administrator stated they were unsure why the nurse staffing information was not updated for several days but expressed it should be current and accurate so visitors could review the information and be aware of the accurate care levels and staffing ratios the nursing home had in place. During subsequent interview, on 5/2/23 at 10:54 a.m., the administrator expressed they had visited with the staffing coordinators who acknowledged the posting wasn't updated and it was an honest mistake. Further, the administrator verified the nurse staffing information was not posted anywhere else in the building. A provided Nurse Hours Posting Policy, dated 10/2022, identified the nurse staff data would be posted in a designated public place by the staffing personnel. The policy included, The data will be posted on a daily basis at the beginning of each shift.

Based on interview and document review, the facility failed to respond appropriately to 1 of 1 residents (R1) when staff initiated cardiopulmonary resuscitation (CPR) 20 minutes after R1 was determined to have no pulse, had rigor mortis (stiffening of the muscles; considered a clinical sign of irreversible death) indicating CPR would not be effective or appropriate. Findings include: R1's Admission Record dated [DATE], indicated R1 admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 was admitted to the facility Transitional Care Unit (TCU) for cardiac rehabilitation after surgery on [DATE]. R1's Minimum Data Set (MDS) dated [DATE], lacked information due to R1's recent admission. R1's Interagency Physician Discharge Orders/Instructions dated [DATE], at 12:45 p.m. indicated R1 was a full code (wanted CPR initiated if R1 stopped breathing and had no pulse). R1's admission Progress Note dated [DATE], at 6:04 p.m. indicated R1 was alert and oriented with forgetfulness. R1 was able to stand and pivot and required an assist of one staff member for transfers. R1's care plan dated [DATE], indicated R1 had limited mobility and would be free from thrombus (blood clot) formation. Interventions included assistance of one staff with a gait belt for transfers. R1 had a POLST with advanced directives he wanted honored and wished to discharge from the facility by [DATE]. R1's POLST dated [DATE], indicated R1 wanted CPR performed in the event he was not breathing and had no pulse. R1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's progress note dated [DATE], indicated at approximately 6:50 a.m. licensed practical nurse (LPN)-A observed R1 was not breathing and did not have a pulse. Registered nurse (RN)-A confirmed R1 did not have a pulse, called 911 and began CPR. During an interview on [DATE], at 11:01 a.m. a police dispatcher stated 911 was called at 7:10 a.m.; 20 minutes after R1 was found without a pulse. A police officer arrived at the facility at 7:13 a.m. During an interview on [DATE], at 11:08 a.m. an emergency medical (EMS) dispatcher stated on [DATE], at 7:11 a.m. EMS was notified CPR was being started on an unresponsive resident at the facility. EMS arrived at the facility at 7:17 a.m. and pronounced R1 dead at 7:23 a.m. Review of RN-A's written statement dated [DATE], indicated on [DATE], at 6:50 a.m. LPN-A and RN-A found R1 lying in his bed with no pulse and not breathing. According to the written statement, LPN-A called the administrator to report the resident's death, then RN-A noted R1 was a full code, LPN-A and RN-A transferred R1 to the floor using a sheet. RN-A indicated R1's neck was stiff and did not drop during the transfer and his extremities were cool with some rigor. Despite the presence of rigor mortis, LPN-A called 911 and assisted RN-A in performing CPR on R1 until the emergency medical services (EMS) arrived. RN-A indicated EMS stopped life saving efforts shortly after arrival because R1 had levity [lividity] (pooling of the blood in the lowest parts of the body which is considered a clinical sign of death indicating CPR would not be effective or appropriate). During an interview on [DATE], at 3:13 p.m. LPN-A stated on [DATE], at 6:50 a.m. NA-A stopped her as she was leaving for the day and told LPN-A she didn't think R1 was breathing. LPN-A shook R1, called his name and gave him a very hard sternal rub which should have sent him screaming. When R1 did not respond, LPN-A called out for RN-A who took R1's temperature and assessed R1 did not have a pulse. LPN-A left R1's room to call the director of nursing (DON) and the administrator and RN-A left R1's room to read the procedure for a resident who died in the facility less than 24 hours after admission. After reading the procedure, RN-A checked R1's code status and found him to be a full code. LPN-A the two nurses returned to R1's room where they lifted him from his bed onto the floor. LPN-A then called 911 and texted the administrator who responded Good. We have to try. RN-A and LPN-A started CPR; however, they did not get the facility's automated external defibrillator (AED, a device used in conjunction with CPR for the best chance of survival during cardiac arrest). LPN-A stated nursing staff received training on how to perform CPR. During an interview on [DATE], at 11:42 a.m. RN-A stated she did not know if there was a facility procedure for how to take care of a resident in cardiac arrest (not breathing and without a pulse) and that there was no perfect process. RN-A stated on [DATE], at 6:50 a.m. she was alerted by LPN-A that R1 was gone. RN-A went to R1's room and found him lying in his bed with his arms at his side and his head tilted to the right with blankets pulled over his chest. R1's arm was cool but not ice cold, he was not breathing and did not have a pulse. LPN-A left to call the director of nursing (DON) and the administrator. RN-A stated after 7:00 a.m. she checked R1's code status and realized he was a full code. RN-A advised LPN-A and they returned to R1's room and transferred R1 onto the floor next to his bed. LPN-A then called 911 and RN-A started CPR. RN-A also stated they did not think to get the facility AED. RN-A stated it did not occur to her at the time, to check R1's code status immediately after assessing R1 had no pulse because R1 looked so gone; however, RN-A did not identify any obvious signs that indicated she should not have initiated CPR and used the AED. RN-A further stated when EMS arrived, they pronounced R1 dead at 7:23 a.m. stating R1 had signs of dependent levity [lividity]. RN-A stated she did not know what that was and responded, What is that?. Although RN-A's statement to the facility indicated R1 had rigor mortis, RN-A did not identify it as a reason for the delay in initiating CPR during the interview. Instead, RN-A stated, she did not go into the mode that R1 did not have a pulse, requiring her to check his code status. RN-A also did not identify rigor mortis as an irreversible sign of death, resulting in CPR being ineffective and unnecessary. During an interview on [DATE], at 11:34 a.m. RN-B stated she was agency staff and received CPR training through the American Red Cross and did not receive any CPR training from the facility. RN-B stated she would start CPR right away on a resident who had no pulse and was a full code. RN-B stated she would ask another staff member to bring the facility AED but applying an AED was not automatic and RN-B would not use it unless she felt it could help. RN-B was unable to specify circumstances she felt an AED would or would not be useful. During an interview on [DATE], at 9:14 a.m. LPN-B stated a few days ago she was instructed to review the facility policy on where to find a resident's POLST and to check a resident's code status immediately after finding them with no pulse and not breathing. LPN-B stated there was no training on the specific steps for providing CPR and did not know what the procedure was. LPN-B stated she would probably get on the Walkie talkie and ask for help and for someone to bring the resident's chart to her if she found a resident with no pulse and not breathing. During an interview on [DATE], at 9:29 a.m. RN-C stated they reviewed the facility CPR policy about an hour ago with the DON. RN-C was instructed if a resident was found without a pulse and was a full code, the staff were to start CPR right away, get the AED and continue CPR until EMS arrived. RN-C further stated EMS would then determine whether CPR should continue or be stopped based on an assessment for clinical signs of death including dependent lividity and/or rigor mortis. During an interview on [DATE], at 1:28 p.m. the director of nursing (DON) stated when staff find a resident who was not breathing and did not have a pulse, they should look at the resident's POLST in their chart and if they are full code, initiate CPR, call 911 and get the AED immediately. The DON stated if staff did not see obvious signs of clinical death, she would not expect them to roll a resident over and undress them to look for dependent lividity when determining whether to perform CPR on a resident who was full code. The DON further stated the facility Cardiopulmonary Resuscitation (CPR) policy dated [DATE], was the only facility policy she was aware of. During an interview on [DATE], at 8:54 a.m. the DON stated she did not know the content of the training the nursing staff received on [DATE], after R1 died , however, when she arrived at 6:00 a.m. today, she began reviewing the facility CPR policy with the nursing staff. The DON, also advised staff it was not their responsibility to determine whether a resident had dependent lividity or rigor mortis and they were to initiate CPR and continue until EMS arrived. The nursing staff were also to begin CPR immediately upon assessing a resident had no pulse, then call out for other staff to check the code status of the resident. If the resident had a do-not-resuscitate (DNR) order, staff were to stop CPR. The DON stated because that procedure was not in the facility policy, nursing staff were giving her some push back about not checking the resident's code status before initiating CPR. The DON stated although that was not in the policy, she did not want any delay in a resident receiving CPR. The DON stated there was no new or revised CPR policy or procedure created since [DATE]. During an interview on [DATE], at 4:07 p.m. the administrator stated staff were expected to review a resident's code status immediately after determining they were not breathing and had no pulse. The administrator also stated staff did not follow the facility procedure and should have initiated CPR and called 911 immediately after determining R1 had no pulse and was full code. The administrator further stated the facility Cardiopulmonary Resuscitation (CPR) policy dated [DATE], was the only policy on CPR that he was aware of. Review of the facility Cardiopulmonary Resuscitation (CPR) policy dated [DATE], indicated PHS (Presbyterian Homes and Services) provided American Heart Association CPR classes to nursing working in campuses located in Minnesota. The policy indicated if a resident was found in cardiac arrest, the facility must provide CPR, prior to the arrival of EMS, according to the resident's advanced directives, and in the absence of obvious signs of clinical death (e.g. rigor mortis, dependent lividity).

Based on interview and document review, the facility failed to ensure vaccination policies and procedures included additional infection control precautions for staff who were exempted from the COVID-19 vaccine. In addition, the faciltiy staff vaccination rate was 87%, which increases the potential of spreading COVID to the 80 resident in the facility. Findings include: On 2/2/2022, information provided by the facility employed 278 staff. Of those, 222 were vaccinated, three granted temporary delay, 37 partially vaccinated or unvaccinated, and 16 staff were granted a non-medical exemption. This was an 87% vaccination rate. This data was consistent with National Health Care Safety Network (NHSN) data for 1/23/2022, (85.6%). All workers in the facility are considered employees of the parent corporation, there were no contracted staff from outside agencies. There were no COVID positive cases among residents at the time of the survey and eight confirmed cases of COVID among residents during the four week period prior to the survey. On 2/2/22, at 10:20 a.m. Clinical Nurse Manager (CNM)-A stated was aware of the stipulations for staff members practicing in resident care areas who had been granted an exemption to receiving COVID vaccine. These included wearing an N-95 mask, not care for immunocompromised or unvaccinated residents, and required to undergo COVID testing twice a week. Stated would discuss these stipulations with employees as needed. There were no exempted employees on the unit at the time of the interview. CNM-A stated managers would be notified if an exempted staff member was assigned to their care areas. CNM-A stated information about vaccination policies has been readily available to all staff members including the process for requesting a medical or non-medical exemption. CNM-A identified all staff were undergoing COVID testing twice weekly because two employees were found to have positive COVID test results during the week of 1/17/2022. On 2/2/2022, at 11:05 a.m. the administrator and the director of nursing (DON) were interviewed and stated they have discussed expected stipulations to practice for employees who had been granted either a medical or religious exemption to receiving the Covid vaccine. Stipulations included communicating with the employee(s) informing them their vaccination status would be disclosed to their immediate supervisor, they will not be assigned to care for immunocompromised or unvaccinated residents, and they would be required to undergo COVID testing twice a week. Though discussed, these stipulations had not yet been memorialized into policy. Final discussions among department and corporate leaders were pending. On 2/2/22, at 12:10 p.m. Human Resources Manager (HRM) for Presbyterian Homes of Bloomington (HR) disclosed that 16 exemptions have been granted to employees for religious reasons and no medical exemptions have been granted. HRM further stated all personnel working in this facility are employees, there are no contracted staff. Employees who travel between campuses are fully vaccinated. For exempted employees, testing for COVID-19 must be done twice a week, PPE must be worn, they may not work with Immunocompromised or unvaccinated residents. Any employee who misses testing may not participate in their job until testing is done on site. Covid test kits are always available on site at each facility in the Presbyterian Homes system. HR stated these measures have been discussed with nursing leadership. The HRM stated these stipulations had not yet been added to policy. Discussions with corporate leadership would continue before a finalized policy would be published. The facility policy PRESBYTERIAN HOMES AND SERVICES COVID-19 VACCINATION POLICY, revised 1/27/2022, REASONABLE ACCOMMODATION, section entitled MEDICAL AND RELIGIOUS EXEMPTION FOR COVID-19 VACCINATIONS POLICY: Staff who have a medical contraindication or who object to being vaccinated on the basis of a sincerely held religious belief and practice may request and engage in an interactive process to determine if a reasonable accommodation or exemption from the application of this policy can be provided so long as it does not create an undue hardship for PHS and does not pose a direct threat to the health or safety of others in the workplace and/or to the employee. Staff may request an accommodation without fear of retaliation.

Based on interview and document review, the facility failed to implement interventions as directed by the care plan resulting in a fall from a mechanical lift for 1 of 3 residents (R1) reviewed for falls. Findings include: R1's admission Minimum Data Set (MDS) dated [DATE], noted R1 had intact cognition and required extensive assist of 2 staff for transfers. R1's fall Care Area Assessment (CAA) dated 10/20/21, noted R1 was at risk for falls due to a history of falls, weakness, limited range of motion (ROM), balance problems, urinary incontinence, medication side effects, hearing and visual deficits. R1's care plan dated 10/14/21, noted R1 had limited mobility and required assistance with her physical mobility due to frequent falls, weakness and unsteady gait. R1's care plan was updated on 12/3/21, to include R1 required the use of a Golvo (brand name) mechanical lift for all transfers due to R1 no longer being able to safely pivot transfer with assist. R1's care plan was revised again on 12/8/21, to include R1 required mechanical lift with assist of 2 staff and changed her toileting care plan to use of bedpan. R1's care plan was revised again on 12/13/21, to indicate a small sling size with mechanical lift. R1's progress note dated 12/3/21, noted the clinical coordinator (CC)-B and the physical therapist (PT)-C met with R1 at 4:10 p.m. to notify R1 that it had been determined she was not safe for pivot transfers with the assistance of two staff. The progress note indicated it was determined that R1 would require a Golvo lift for transfers and a bedpan for toileting. Further, they informed R1 that they were unable to place the Golvo sling to safely place resident on the toilet. R1's progress note dated 12/8/21, noted at 2:00 p.m. the nurse was told there was an emergency in R1's room. R1 was found on the floor in front of her toilet in her bathroom under the Golvo lift with the sling still attached. Nursing Assistant (NA)-A and NA-B stated they were transferring R1 off the toilet, they further stated R1 refused to use the bedpan and insisted the Golvo lift be used to place her on the toilet. R1's progress note further indicated R1 had suffered a [CONDITION(S)] that measured 6 centimeters (cm) x 4 cm and a hematoma. R1 was treated at the facility with an ice pack and steri strips placed over the laceration. R1's task care sheet on 12/8/21, noted R1 required a Golvo lift for transfers and further noted R1 required the use of a bedpan as she was not safe to transfer to the toilet at this time. R1's occurrence report dated 12/8/21, noted staff did not follow R1's care plan or care task sheet with R1's toileting plan. When interviewed on 12/15/21, at 10:05 a.m. registered nurse (RN)-A stated she was on her lunch break at the time of R1's fall. When she returned to the floor, the clinical coordinator (CC)-B and the two staff involved had already placed R1 back in bed. RN-A stated the Golvo slings the facility uses is not appropriate for toilet transfers for R1. When interviewed on 12/15/21, at 10:14 a.m. PT-C stated she had discharged R1 from services on 12/8/21. Further, PT-C stated nursing staff and R1 were informed of the change in transfer status on 12/3/21. PT-C stated she coordinated a meeting on 12/2/21, with leadership to discuss R1's case as the facility does not have a sling for the Golvo lift that is necessary for toilet transfers and thought it would be a difficult transition for R1 to have to use a bedpan for toileting. When interviewed on 12/15/21, at 11:56 a.m. NA-A stated on 12/8/21, in the morning she noticed R1's care sheet indicated R1 required a Golvo lift for transfers and a bedpan for toileting. NA-A stated R1 did not want staff to use lift or bedpan so NA-A went to CC-B for clarification. CC-B accompanied NA-A to R1's room to let R1 know that staff must use the lift and the bedpan for safety. NA-A stated in the afternoon R1 was complaining about feeling uncomfortable and wanting to be transferred to the toilet. NA-A and NA-B used the Golvo lift and transferred R1 onto the toilet removing the sling completely. R1 relieved herself on the toilet and NA-A and NA-B reapplied the sling under R1 and attempted to lift her using the Golvo lift when R1 slipped through the sling and fell to the floor. When interviewed on 12/15/21, at 12:18 p.m. NA-B stated she assisted NA-A on the morning of 12/8/21, to transfer R1 to her wheelchair. NA-B stated after lunch R1 stated she was uncomfortable and wanted to use the toilet. NA-B stated she attempted to find a nurse for clarification of toilet use but no one was available so she and NA-A transferred R1 onto the toilet using the Golvo lift. When attempting to lift R1 off the toilet, R1 slid through the sling and fell to the floor. When interviewed on 12/15/21, at 2:08 p.m. the director of nursing (DON) stated the root cause of the fall was that NA-A and NA-B were not following R1's care plan or care task sheet. The DON further stated it was an expectation that all staff follow a resident's care plan at all times. When interviewed on 12/15/21, at 2:26 p.m. CC-B stated NA-A and NA-B did not follow R1's care plan or care task sheets on 12/8/21. CC-B further stated she expects staff to follow a care plan for resident safety. A facility policy titled, Mechanical Lift Transfer Policy last revised in November of 2018 noted the policy purpose was to provide safe resident transfers for each resident to provide weight bearing support. The policy directed staff to refer to resident specific care plan and assessment for number of staff required for the transfer, as well as the type and size of the sling for each specific resident. The policy does not address use of full body mechanical lifts to transfer residents to and from toilets.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure information on resident rights was posted and provided during their stay for residents who lived on the second and third floors of the facility. This had the potential to affect 38 of 84 residents who resided on the second and third floor. Findings include: During the resident council interview on 10/27/21 at 10:35 AM Residents (R) 39, 61, 4 and 34 said they attended resident council meetings regularly and their resident rights were not always discussed. The residents said they did not know where the resident rights information was posted. The residents did not recall if they were given a copy of their rights upon admission. During on observation on 10/27/21 at 12:30 PM the resident rights information was posted in the first-floor lobby area. Residents on the first floor lived on a secured unit. Residents on the second and third floor must access the stairs or elevator to get to the first-floor lobby. Observations of the second and third floor revealed there were no postings of the resident rights information. During an interview on 10/27/21 at 12:46 PM the Administrator and Resident Services Specialists (RSS) 15 and 32 and Social Worker (SW) 31 and 33 were in attendance. RSS-15 said resident council meetings were held monthly with a staff person present and residents were verbally invited to attend. RSS-15 said the minutes from resident council meetings were not shared with residents who did not attend. The Administrator said one or two resident rights were reviewed before each resident council meeting. He also said the residents were not reeducated on their rights on a regular basis but could be if warranted. The Administrator said residents were given a copy of their resident rights upon admission, but he was unsure if residents retained those copies after years long stays at the facility. The Administrator said the resident rights were posted in the first-floor lobby and residents who went downstairs had access to them. RSS-15 said many residents were able to go down to the lobby and could see the resident rights posting. RSS-15 confirmed if residents were unable to go to the lobby and did not attend resident council, they would have no information regarding their rights unless they kept their admission packet. During an interview on 10/27/21 at 2:12 PM the Life Enrichment Coordinator (LEC) said the facility had no system in place to communicate information discussed in resident council with residents who were not able or did not attend. The LEC said one or two resident rights were discussed at each resident council meeting. The LEC said the activities staff did not provide any ongoing information regarding resident rights to the residents. She said she was unsure where the resident rights were posted but if a resident asked, they could provide them a copy. The LEC said she was sure the residents were given a copy of their rights upon admission but did not know how residents were educated about their rights during their stay. The LEC said she thought the social services department would be responsible for that. Review of Resident Council Minutes dated 09/21/21 indicated four residents attended and no resident rights were read during the meeting. Review of Resident Council Minutes dated 09/28/21 indicated three residents attended and Resident Rights Read: 1-2 Exercise of Rights 1-7 were covered during the meeting. Review of the Resident Rights Policy dated January 2020 indicated the resident services department or designee informs the resident of Resident's Rights at the time of admission and at periodic intervals throughout the resident's care period.

Based on observation, interview, and record review, the facility failed to post the list of pertinent state agencies, ombudsman information, and a statement on how to file a complaint with the State Survey Agency in a manner that was accessible to all residents of the facility. The posting was not readily available to 38 of 84 residents who resided on the second and third floor of the facility. Findings include: During the resident council interview on 10/27/21 at 10:35 AM Residents (R) 39, 61, 4 and 34 said they attended resident council meetings regularly. The residents said they did not know where the ombudsman and complaint information were located. The residents said if they had a complaint, they would have to fill out a grievance form with a facility staff person. The residents indicated they were unsure how to file a complaint without notifying the staff. During on observation on 10/27/21 at 12:30 PM the state agency, complaint and ombudsman information was posted in the first-floor lobby area. Residents on the second and third floor must access the stairs or elevator to get to the first-floor lobby. Observations of the second and third floor revealed there were no postings of the state agency, complaint and ombudsman information. During an interview on 10/27/21 at 12:46 PM the Administrator and Resident Services Specialists (RSS) 15 and 32 and Social Worker (SW) 31 and 33 were in attendance. The Administrator confirmed the state agency, complaint and ombudsman information was posted in the lobby on the first floor but not on the second or third floor. RSS15 said many of the residents were able to access the first floor with and without staff assistance. Both the Administrator and RSS15 confirmed a resident who needed assistance would not be able to confidentially find the state agency, complaint, or ombudsman information without asking a staff person. During an interview on 10/28/21 at 10:47 AM R54 said someone came in a few years ago and told her how to report something but she did not remember how to do it. She said she would have a hard time finding out how to report if she wanted it to be private. R54's room was located on the third floor. During an interview 10/28/21 at 10:51 AM R279 said I have no idea where the information is to report things to the state. R279's room was located on the third floor. During an interview 10/28/21 at 10:58 AM R34 said I don't know where to find the information about how to call the state, but I guess if I felt comfortable, I could go get the information from [sic] Clinical Coordinator 10. R34's room was located on the third floor. During an interview 10/28/21 at 11:03 AM R67 said I have no idea how to make a private complaint. R67's room was located on the third floor.

Based on observation, record review, and interviews, the facility failed to treat 1 of 30 resident (R16) with dignity during administration of medications in the Pathway Unit Dining Room. Findings include: Review of the facility's policy titled Dignity dated December 2014 directs that residents are cared for in a manner that and in an environment that promotes maintenance and enhancement of a resident's quality of life. [Facility] is committed to an atmosphere that humanizes and individualizes each resident and their experiences. Review of the facility's policy titled Medication Administration Procedures dated 01/27/19 directs Eye Drop Administration .Provide for resident privacy. Review of the Profile tab in the electronic medical record (EMR) revealed that R16 was admitted to the facility on [DATE] for long term care. Review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD of 08/11/21 revealed R16 had a Brief Interview for Mental Status (BIMS) score of 12 that indicated the resident had mild cognitive impairment. During an observation on 10/25/21 at 6:36 PM Licensed Practical Nurse (LPN) 36 approached R16 with medications and without asking administered a pill with a spoon and eye drops to R16, who was sitting in a wheelchair, in the Pathway Unit dining room; two other residents were still in the dining room. During an interview on 10/25/21 at 7:05 PM, R16 stated that she did not like receiving medication in a public area, she would rather get her medication in her room in private. She further revealed she often is given her medications in the dining room. During an interview on 10/25/21 at 7:17 PM LPN 36 acknowledged that he administered a Tylenol in applesauce using a spoon and eye drops to R16 in the Pathway Unit dining room. LPN 36 stated he normally administers the resident's evening medications in the dining room because most of the residents take their medication in the dining room; R16 was waiting for them that's why she took them there. During an interview on 10/28/21 at 2:38 PM, with both the Director of Nursing (DON) and Campus Administrator revealed the policy would not allow administration of eye drops or an injection in the dining room. The Campus Administrator stated any medication administration in the dining room should be addressed in the resident's care plan.

Based on observation, interview, and document review, the facility failed to ensure care planned fall prevention interventions were followed for 1 of 3 residents (R2) reviewed for falls. R2 sustained harm when the care plan was not followed, R2 fell and sustained a pelvic fracture. However, the facility took immediate corrective action, therefore this is being cited at past non-compliance. Findings include: R2's admission Minimum Data Set ((MDS) dated [DATE] included, severe cognitive impairment with [DIAGNOSES REDACTED]. R2 was unsteady with transfers and required 2 plus physical assist with transfers and ambulation. R2's fall Care Area Assessment (CAA) dated 7/1/20, included being at risk for falls related to a fall prior to admission which resulted in a left femur fracture. Other risk factors included, severe cognitive impairment, weakness, impaired balance, cardiac and respiratory impairments, incontinence, use of [MEDICAL CONDITION], cardiac and diuretic medications and behavior concerns. R2's progress note dated 8/1/20, included, Pt (patient) was found sitting on the floor with her back against the front of the reclining chair. Pt is unable to give specific data on what she was trying to do that caused her to fall. After assessment, pt was picked up from the floor using the full mechanical lift. An immediate intervention was, Pin call light on pt. An interdisciplinary note, dated 8/3/20, noted, Root cause analysis: Pt was trying to get comfortable when she slid out of the chair. Intervention based on root cause analysis. Ensure legs are elevated in recliner when not eating. Evaluation of intervention: Pt states she is more comfortable with her feet up. R2's Falls Follow Up Form dated 8/1/20, included R2 had fallen and the, Short Term Intervention was to, Clip call light on Pt (patient). This form was updated on 8/3/20, and included, Ensure foot rest of recliner is up, except meal times. Pt tends to lean back and slide he (sic) butt forward trying to get comfortable. R2's risk for falls care plan dated 8/21/20, directed staff to keep call light within reach, Check my O2 sats (oxygen level) before I get out of bed in the morning, and, Ensure my feet are elevated in the recliner except during meal times. R2's care plan also addressed sleep apnea and directed staff to use a [MEDICAL CONDITION] machine (continuous positive airway pressure machine that aides in breathing for obstructive sleep apnea) at night, but often refuses to use it. R2's Pathway RA (resident assistant) Group Sheet, dated 8/19/20, directed staff, Ensure legs elevated in recliner when not eating. Keep walker within reach. R2's progress note, dated 8/15/20, included, Resident observed on floor at 0840 (8:40 a.m.) after writer heard sound of fall and resident shouting for help. Resident states she hit her head, no swelling noted, resident denies tenderness to palpitation of entire head area. Resident able to move all extremities PR (pulse rate) BP (blood pressure) stable. Resident alertness and communication pattern at baseline for resident, PERRL (pupils equal, round, and reactive to light). Resident assisted from floor to recliner using Golvo lift (mechanical lift) A2 (assist of two staff). Resident tolerates transfer with no complaints of pain. Intervention based on root cause analysis: Foot rest elevated per care plan after transfer to chair. ST (short term) intervention: Leave walker adjacent to resident. and Describe Injury: Denies headache or tenderness. Moves all extremities. Resident pleasant with staff this shift. Writer attempted to assist resident to standing position and to ambulate before lunch. Resident demonstrates pain upon standing and is unwilling to take a step due to fear of pain. The note identified a nurse practitioner was notified and lab work for R2's blood thinner and an X-ray was ordered. R2's x-ray, dated 8/15/20, noted, Right superior and inferior pubic ramus (pelvic) fracture. R2's nurse practitioner progress note dated 8/17/20, identified, 8/15 had fall from recliner. Staff reports that usually they have legs elevated but recliner was left down and the patient attempted to self transfer. Oximeter initially read 75-85% but later was 90%. CXR (chest x-ray) done showed chronic lung findings with developing LLL (left lower lobe) infiltrate. 8/16 sent to Methodist ED (emergency department) for concerns of hip pain/right groin pain and not wanting to bear weight. Recent left [MEDICAL CONDITION] with repair 6/19. At Methodist-right pelvic fracture, no issues with hip replacement. COVID negative. CT (cat scan) head negative for acute changes. Returned to facility same day. R2's investigation report from the fall on 8/15/20, dated 8/21/20, included, RA (resident assistant) indicated that she did not elevate footrest of the recliner upon leaving VA's (vulnerable adult) room per the VA's previously stated preference and care plan. During the interview with the resident assistant (RA) on duty at the time of the fall, the RA described helping the VA with AM cares and toileting prior to assisting VA to recliner. The RA placed the tray table on the side of recliner and call light within reach. The RA then left to retrieve the VA's breakfast tray. The VA was heard yelling by the nurse on duty and was found on the floor between the bed and the recliner. The VA was unable to verbalize what she was trying to do at the time of the fall. The RA noted upon her return to the resident that she had been gone approximately 2 minutes. Medical record review and nurse interview indicated that the VA experienced a period of decreased saturations (75%-85%) (normal oxygen saturation level 95-100%) noted during vital signs check after the fall. The nurse verified with 4 different oximeters and was able to obtain a reading of 90% after a period of time. The Nurse noted 'they started low and slowly went up.' The On-call MD was updated and orders for chest x-ray and COVID-19 swab were given and carried out. The NP (nurse practitioner) indicated that the VA has a history of Obstructive Sleep Apnea and refusal of wearing [MEDICAL CONDITION] and that this may have been a contributing factor to the low O2 level (oxygen level) The Director of Nursing interviewed the NP and she assessed VA on 8/17/2020 and VA was not symptomatic for pneumonia or other respiratory illness. A review of the progress notes indicated that overnight VA had displayed confusion, restlessness and combative behaviors. [MEDICAL CONDITION] medication was increased after a failed GDR (gradual dose reduction) on 8/7/2020. The RA noted that VA was not wearing her [MEDICAL CONDITION] when she initiated AM (morning) cares. During RA interview, RA indicated that she did not elevate footrest of the recliner upon leaving VA's room per per the VA's previously stated preference and care plan. The RA also stated that when she left the room, the VA did not recall that her assistive device was in within (sic) reach. The RA stated, I didn't do it on purpose, It just escaped my mind. When asked if RA knew the VA's care plan, she responded yes. She also verbalized carrying the assignment sheet on the day of the fall and previously demonstrating the ability to adhere to the care plan. Upon return from the ER (emergency room ), the intervention implemented was to ensure assistive devices are within reach. After further investigation, root cause of the fall was determined to be low saturations due to VA refusal of [MEDICAL CONDITION] overnight. Intervention is for an overnight oximetry (oxygen level) study to be completed and staff to check oxygen saturations prior to assisting VA out of bed for morning cares. The RA was immediately placed on administrative leave and remains on leave while termination is in process. Facility education was completed on following the care plan. Random audits will be completed on each household on a weekly basis to ensure compliance with education. Oximeters were checked and are all functioning properly. The NP ordered an overnight oximetry study to be completed to determine the need for supplemental oxygen. The VA remains in the facility and is currently utilizing the stand lift with assist of one and is participating in therapy for rehab. When interviewed on 8/27/20, at 10:50 a.m. licensed practical nurse (LPN)-A stated, R2 needed to have her feet elevated when she was sitting in the recliner for her safety and comfort. Otherwise, R2 sat at the edge of her chair making her at risk for falling. When observed on 8/27/20, at 11: 56 a.m. nursing assistant (NA)-A was observed assisting R2 with transferring from her recliner to the toilet. NA-A lowered the feet to the recliner. R2 was seated on a cushion in the chair. With the foot of the recliner down, R2 stiffened up her body, with her feet and legs up and angled, pointed away from recliner and upper body leaning back, but not against recliner. R2 verbalized, oh, oh, oh. NA-A assisted R2 with transferring to the toilet and then back to the recliner. Upon returning to the recliner, R2 sat on the edge of the recliner with her feet off the floor and stiffened up again. NA-A prompted R2 to scoot back in the chair. NA-A did not scoot back in the chair. NA-A advised R2 he would put the recliner feet up and elevated R2's feet and legs. Once the foot rest was elevated R2 appeared to sit comfortably in the chair. When interviewed on 8/27/20, at 12:05 p.m. NA-A stated. R2 had to have the recliner legs up or R2 would think she could stand, R2 may also slide and was apt to fall out of the chair when the foot rest was down. Stating, R2 was evidently more comfortable with the foot rest elevated. When interviewed on 8/27/20, at 1:44 p.m. NA-B stated she had worked with R2 on 8/15/20. NA-B stated she had prepared R2 for her meal by placing the foot rest down and placed a tray table in front of her, then left the room to obtain the meal tray. She was gone for a couple minutes and when she returned, R2 had fallen out of the chair. NA-B stated R2's care plan directed the foot rest be elevated unless R2 was eating, but she had forgotten to make sure it was elevated when she left R2 alone. When interviewed on 8/27/20, at 2:59 p.m. Registered nurse (RN)-A stated she was working at the facility on the day of R2's fall, 8/15/20. RN-A stated she had assessed R2 after the fall on 8/15/20, and noted no injuries, but later in the day R2 was hesitant to stand up and reported groin pain. RN-A contacted the physician and received an order for [REDACTED]. When interviewed on 8/27/20, at 3:27 p.m. R2's registered nurse and nurse manager (RN)-B explained R2 had two falls. The first fall on 8/1/20, R2 slid out of the recliner as she was trying to get comfortable. RN-B explained R2 tended to like to lean back and adjust herself that way. R2's, butt was way too close to the end of the chair when she sat down. Following the fall on 8/1/20, an intervention was added to elevate feet when R2 was not eating. RN-B explained R2's recliner foot rest should be up unless she was eating, including when staff left room to get R2's meal trays. When interviewed on 8/28/20, at 8:58 a.m. the director of nursing (DON) reported the facility determined R2's recliner foot rests were not elevated at the time R2 fell on [DATE], and should have been. The DON stated R2's oxygen level related to her not wearing her [MEDICAL CONDITION] contributed to the fall. Immediately, the facility re-educated all nursing staff on ensuring each resident's care plan was being followed and started audits to ensure compliance. The audits were for any resident at risk for falls to ensure their care planned interventions were being followed. The facility fall prevention and management program policy, last revised, 10/2018, directed staff, Care plans will indicate the resident specific interventions to prevent falls. Nursing staff will implement interventions according to resident specific risk factors. The past non-compliance that began on 8/15/20, was verified during the 8/31/20 onsite visit and was corrected by the facility on 8/16/20. Verification of the corrective action was confirmed by interview with a variety of nursing staff who had received education on ensuring fall prevention interventions were always implemented. In addition facility documentation showed staff had been trained and audits were being completed to ensure fall interventions were being implemented.

Based on observation, interview and record review, the facility failed to implement fall interventions and provide supervision to reduce the risk of accident hazards for 1 of 3 residents (R1) reviewed for accidents. R1 sustained harm when care planned interventions were not followed and R1 fell sustaining a hip dislocation. It was determined the facility had implemented corrective action prior to the survey, therefore this is an example of past noncompliance. Findings include: Family member (FM)-B was interviewed via telephone on 10/29/19, at 10:26 a.m. and stated in (MONTH) 2019, R1 fell and fractured (fx) her left hip. FM-B further stated two weeks later, R1 fell again, landing on the hip she had replaced, which required hospitalization to have the hip realigned because it was dislocated. FM-B stated R1 had dementia and would forget to use her call light and ask for help, and had experienced six falls in the past few months due to her forgetfulness. A Falls Care Area Assessment (CAA) dated 5/9/19, identified R1 was at risk for fall due to prior history, impaired cognition, incontinence, confusion, impaired balance, medication and [DIAGNOSES REDACTED]. R1's Urinary Incontinence CAA dated 5/9/19, indicated R1 had urinary incontinence and worked with therapy for strengthening and endurance. R1's Care Plan revised 10/8/19, identified R1 was at risk for falls due to a fall with a fx 9/11/19. The Care Plan directed staff to place a non-skid liner on R1's bedside table with desired items, reacher nearby, alert R1 to changes of environment, large signs on walker and bathroom door to remind her to use call light, assistance with toileting every two to three hours 24 hours a day, inform me and family about safety reminders, monitor for side effects of medications, scheduled and as needed medications for nausea and vomiting, observe for acute illness, offer R1 to bed at 7:00 p.m., call light within reach and answer promptly, emesis basin/ waste basket at bedside, therapy to eval and treat. R1's quarterly Minimum Data Set ((MDS) dated [DATE], identified R1 had severe cognitive impairment and [DIAGNOSES REDACTED]. The MDS indicated R1 required extensive assistance from staff with activities of daily living and was always incontinent of urine, frequently incontinent of bowel and no toileting program was used. R1's Occurrence Reports, Falls Follow Up Forms, progress notes and hospital discharge notes were reviewed from 6/11/19, through 10/14/19, and revealed the following: On 6/11/19, R1 was found on the floor in her room near her bed. The occurrence form listed an intervention for reminder signs to use call light placed in R1's room; On 6/17/19, R1 was found next to her bed. The occurrence form listed an intervention for staff to wake and offer toileting at 3:30 a.m. if R1 hadn't called yet; On 7/5/19, R1 was found on the floor in her room. The occurrence form listed an intervention for staff to offer toileting at 2:30 p.m.; On 8/8/19, R1 was found on the floor in her room with emesis next to her. The occurrence form listed interventions which included for staff to administer saline nasal spray to thin secretions, and leave emesis basin on bedside table; On 8/10/19, R1 was found next to her bed. The occurrence form listed intervention for staff to offer to help put R1 to bed at 7:00 p.m.; On 9/9/19, R1 was found on the floor next to her bed. The occurrence form listed an intervention for staff to toilet every two to three hours to regulate bowel and bladder; On 9/11/19, a progress note indicated R1 complained about left leg pain, x-ray revealed displaced left femoral neck fx, the provider was updated, pain medication was ordered until primary provider available on 9/12/19, family in agreement; On 9/12/19, a progress note indicated an order was obtained to send R1 to the emergency room for evaluation due to acute fx per family request; R1's Discharge Summary dated 9/16/19, identified R1 was admitted to the hospital for a closed left [MEDICAL CONDITION] which had an arthroplasty (joint replacement/ remodel) performed; On 10/5/19, R1 was found on the floor in her room. The occurrence form listed interventions for staff to educate on use of reacher, ensure bedside table within reach, non-stick material to table for all desired items; On 10/14/19, an occurrence report indicated at 12:00 a.m. R1 was found on the floor next to her bed with emesis on the floor, and R1's pants were soaked with urine. The report indicated R1 was last seen in bed sleeping at 11:00 p.m., and was last toileted at 8:00 p.m. The occurrence form listed interventions which included: coaching nurses and aids on care plan, provide emesis basin at bedside, monitor and assess for nausea/ vomiting, started on scheduled medication for acid reflux and sleep monitoring for one week; A Discharge Summary dated 10/15/19, identified R1 was admitted to the hospital for a left hip dislocation following a fall which required reduction of the dislocation. Nursing assistant (NA)-A was interviewed on 10/29/19, at 11:57 a.m. and verified she had worked with R1 on 10/14/19. NA-A explained before leaving her shift around 11:00 p.m., NA-A saw R1 in bed with her eyes closed. NA-A stated she did not get close to R1 as she appeared to have been sleeping. NA-A stated she did not receive report from NA-B when NA-B left at 10:00 p.m. NA-B was interviewed on 10/29/19, at 12:16 p.m. and explained she had put R1 to bed on 10/14/19, around 6:30 p.m. or 7:00 p.m. and had taken R1 to the bathroom at that time. NA-B further stated around 8:00 p.m., she checked on R1 who was in bed sleeping. NA-B confirmed she had not offered R1 to use the bathroom after she'd put her to bed, because she was sleeping. NA-B stated R1 normally would have woken up and asked if she needed to go to the bathroom. NA-B indicated her shift ended at 10:00 p.m., and verified she had not toileted R1 prior to leaving her shift. NA-B stated she had left her shift at 10:00 p.m. without reporting off to another staff member. When NA-C was interviewed on 10/29/19, at 12:38 p.m. she stated on 10/14/19, she'd begun her shift at 11:00 p.m. NA-C stated she had first seen R1 on 10/14/19, at 11:45 p.m. laying on the floor next to her bed. NA-C explained R1 had her pants half way down and they were wet from urine. Registered nurse (RN)-A was interviewed on 10/29/19, at 12:53 p.m. and stated around 11:45 p.m. on 10/14/19, she was called to R1's room and found R1 laying on the floor next to her bed in excruciating pain. RN-A stated R1 was not wearing her bedtime clothes, but had been put to bed in her regular clothing and had her pants down part way and the pants were wet from urine. RN-A stated she had called R1's provider and obtained an x-ray which came back showing a dislocation of R1's left hip. R1 was observed on 10/30/19, at 6:43 a.m. to be in bed with her eyes closed. Her body was positioned to the right side of the perimeter mattress on the bed, and the bed was in the low position. R1 was calm and not attempting to get out of bed. An attempt was made to interview R1 on 10/30/19, at 7:13 a.m. but R1 was unable to answer questions. The director of nursing (DON) and administrator were interviewed on 10/30/19, at 8:57 am. The DON stated R1's left hip dislocation was investigated and it had been determined there was a discrepancy between what staff did for residents who were to be toileted, versus what they did for residents who were checked and changed. The DON stated they'd identified staff needed further education, which they began providing on 10/21/19. During a subsequent interview with the DON at 9:54 a.m. that same day, the DON stated the facility occurrence report had indicated R1 was last toileted at 8:00 p.m. The DON stated R1 should have been woken up and toileted at 10:00 p.m., but no later than 11:00 p.m. because R1's care plan indicated she required assist to toilet every two to three hours 24 hours per day. The DON stated it had also been determined NA-B had not communicated with NA-A prior to leaving her shift on 10/14/19, so NA-A did not know when R1 needed to be offered toileting. NA-E was interviewed on 10/30/19, at 10:08 a.m. and verified there had been recent education regarding toileting, how often to toilet R1, that staff should follow a resident's care plan for toileting which would also indicate if we should wake up a resident to offer toileting. NA-F was interviewed on 10/30/19, at 10:24 a.m. and stated there had been recent education about following toileting care plans and to make sure residents were woken up depending on their care plan. NA-I was interviewed on 10/30/19, at 10:36 a.m. and stated there had been recent education regarding toileting resident's every two to three hours and to ensure and wake up resident's to offer toileting depending on their care plan. The administrator was interviewed on 10/30/19, at 11:09 a.m. and stated majority of the staff were re-educated about ensuring they would read and follow resident toileting care plans. The DON was interviewed on 10/30/19, at 1:16 p.m. and stated it was her expectation staff would follow and implement scheduled toileting per each resident's care plan. The facility's Fall Prevention and Management Program Policy modified 9/2018, indicated the policy was to provide procedure for resident at risk for falls which included all staff were responsible for implementing the intent and directives within the policy and creating a safe environment of care. The policy indicated care plan would include resident specific interventions to prevent falls and the nursing staff would implement interventions. Although R1 fell on [DATE], as a result of the staff not offering toileting every two to three hours per R1's care plan, it was verified the deficient practice had been corrected prior to the survey. Through record review and staff interviews, it was determined re-education of all staff had been completed to correct the deficient practice to ensure resident care plan interventions for falls were implemented, and residents were toileted per the care plan. The provider had provided re-education to the majority of non-licensed nursing staff prior survey began as of 10/21/19, and had a plan in place to complete any remaining staff re-education as staff reported to duty moving forward.

Based on observation, interview and document review, the facility failed to implement fall interventions and provide supervision to reduce the risk of accident hazards for 2 of 4 residents (R51, R54) who had repeated falls. This resulted in actual harm to R51, who sustained a femur fracture during a fall on 3/18/19. Findings include: R51's significant change Minimum Data Set ((MDS) dated [DATE], identified R51 [DIAGNOSES REDACTED]. R51 had severe cognitive impairment and required extensive physical assistance with activities of daily living. The MDS lacked evidence regarding history of falls, indication of fall with fracture and prior surgery. R51's Cognitive Loss/ Dementia Care Area Assessment (CAA) dated 4/4/19, identified R51 was at risk for falls and recently had a fall which resulted in right femoral neck fracture that required surgical repair and indicated R51 had further potential for falls related to history, pain, impaired mobility, cognition, communication, incontinence and medication side effects. Preventative measure included call light within reach encouragement to use, anticipate needs, toileting per schedule, manage pain, exercise and strengthening per therapy recommendation. R51's Falls Care Plan revised on 4/8/19, identified R51 was at risk for falls and directed staff to observe for acute illness and keep R51 up until 10:00 p.m. if possible to avoid being awake during the night and to assist in fall prevention. The care plan however lacked evidence of frequent checks and sleep patterns related to risk of falls. R51's Bridgeway nursing assistant assignment sheet dated 5/8/19, directed staff not to leave wheelchair (w/c) by bed when sleeping, bed at knee position, ensure resident had clear path to bathroom, night light on in room and keep up until 10:00 p.m. if possible. R51 was observed on 5/7/19, at 3:46 p.m. in his room with the door closed, room was dark no lights on, lying in bed with his eyes open, call light between the mattress and head board of bed and bed low to the ground. R51 was unable to actively participate in conversation, he would reply with unrelated and/ or non-sensible answers to questions. When asked about his call light he stated it's out there as he pointed to the door. R51 was observed on 5/8/19, at 7:20 a.m. lying in bed on his left side laying along the right side edge of the bed, eyes open, call light on the floor between bed and night stand. At 7:38 a.m. nursing assistant (NA)-A confirmed R51's call light was on the floor and explained R51 didn't understand what his call light was for. NA-A stated R51 use to be independent and ambulatory, however R51 had fallen a few months ago hurt his hip and hadn't walked since. R51's Resident Occurrence Reports, Falls Follow Up Forms, Mobility, Physical Devices and Fall Risk and progress notes (PN) were reviewed from 1/30/19, through 5/5/19, as follows: -The occurrence report dated 1/30/19, at 11:20 p.m. indicated R51 was observed on the floor near the bathroom door entrance and indicated he was trying to take a shower while wearing socks. Suggestions to prevent reoccurrence included frequent checks in room and reorientation; -The follow up form dated 1/30/19, identified R51 had a change in activity pattern regarding difficulty sleeping. Short term interventions included frequent reorientation and safety checks. Long term interventions included increase frequency of overnight safety checked to ensure resident was in bed and/ or asleep, however this was not initiated until 5/8/19. R51's medical record lacked evidence of care plan updated at the time of the fall and implementation of interventions by staff. In addition, R51's medical record lacked evidence of sleep pattern assessment even though they identified a change in sleep patterns on 1/30/19. -The fall risk assessment dated [DATE] indicated R51 had a history of [REDACTED]. Effectiveness of interventions was left blank; -The PN dated 3/18/19, identified R51 was observed laying on the floor between his bed and the bathroom door. R51 complained of right hip pain with range of motion, and order for x-ray was obtained; -The occurrence report dated 3/18/19, at 9:30 p.m. identified R51 was observed on the floor near the right side of his bed, between his bed and the bathroom, and indicated he was trying to get up to look for his son when he fell . Suggestions to prevent reoccurrence included staff to complete hourly rounding and anticipate resident needs; -The follow up form dated 3/18/19, identified extrinsic risk factors which included bed height not appropriate. Analysis and summary of causal factors included R51 was cognitively impaired, confused and often would self-transfer to toilet. Short term interventions included staff to do hourly rounding, anticipate resident needs and make sure the bed was at appropriate height knee high. Long term interventions included keep bed at knee position, night light, keep area between bed and bathroom free of chair, walker and all equipment; -The PN dated 3/19/19, identified x-ray noted non displaced right femoral neck fracture. Order to send R51 to the hospital for evaluation and treatment; -The PN dated 3/23/19, identified R51 returned from the hospital following surgical repair of right hip; -The fall risk assessment dated [DATE], identified root cause of prior falls and successful interventions included unsafe self-transfers and [DIAGNOSES REDACTED]. Effectiveness of interventions was left blank; -The PN dated 3/28/19, identified R51 began sleep study on 3/27/19, for 7 days; -The fall risk assessment dated [DATE], identified root cause of prior fall included unsteady gait and interventions listed were to follow the same plans. Effectiveness of interventions indicated to monitor for changes; -The PN dated 4/4/19, identified R51 had not been sleeping well at night, obtained happy light and placed in R51's room. -Additional falls included 4/26/19, 4/27/19, and 5/5/19, R51 was found on the floor between his bed and bathroom. Suggested interventions included perimeter mattress and frequent checks, however it was indicated continuous pressure pump on bed not compatible with perimeter mattress and lacked further assessment regarding R51's bed and/ or positioning. -The fall risk dated 5/5/19, identified root cause of prior fall unsteady gate and unsafe transfer forgetful due to [DIAGNOSES REDACTED]. Effectiveness of interventions indicated to monitor for changes; -The PN dated 5/6/19, identified to sleep study initiated; -The PN dated 5/7/19, identified group sheet and care plan changed to reflect ongoing sleep study and keep resident awake until 10:00 p.m. if possible. Registered nurse (RN)-A interviewed on 5/8/19, at 12:16 p.m. explained when a resident fell the nurse would complete an occurrence report and falls follow-up form. The nurse would make a recommendation regarding a fall intervention on the follow-up form. Then the following business day the interdisciplinary team would evaluate the fall to see what the realistic intervention should be and at that time the care plan and group sheet would get updated. RN-A stated sometimes the nurse would implement an immediate intervention when it was obvious which included clear path to the bathroom and/or frequent checks, however these interventions would not be updated on the care plan and would be communicated by verbal report. RN-A identified R51 was in the process of having a sleep study and also was to have a night light in his room and frequent checks. RN-A explained frequent checks meant someone to check on the resident every two to three hours during the night after toileting. R51 was observed on 5/8/19, at 2:11 p.m. lying on his left side on the edge of the right side of his bed with his eyes closed and a pillow behind his back. RN-A interviewed on 5/8/19, at 2:36 p.m. reviewed R51's Fall Care Plan revised on 4/8/19, and verified the care plan identified R51 was at risk for falls and directed staff to observe for acute illness and keep R51 up until 10:00 p.m. if possible to avoid being awake during the night and to assist in fall prevention however lacked frequent checks during the overnight. RN-A explained that she would resolve the old interventions and they would not remain on the care plan. RN-A confirmed she was unable to locate the falls follow-up form for R51's fall on 1/31/19. RN-A verified that form was where the long term fall prevention intervention would have been listed and then added to the care plan and group sheet. RN-A could not identify what long term interventions were put into place after the fall on 1/31/19. NA-C interviewed on 5/9/19, at 8:52 a.m. verified R51 was at risk for falls and they were to encourage him to stay in the common areas where staff could see him due to continued attempts to self-transfer while awake. Licensed practical nurse (LPN)-A interviewed on 5/9/19, at 9:16 a.m. explained when a resident had a fall the nurse on duty would implement short term interventions which included keep room door open, frequent monitoring, remove w/c from resident's sight. LPN-A identified the nurse on duty was not the one to update the resident's care plan that management would do that the following business day. LPN-A indicated she was unaware that R51 had fallen prior to his fall 3/2019, and identified R51 had been independent with use of a walker when in his room. Rehabilitation manager (RM) interviewed on 5/9/19, at 10:27 a.m. stated R51 had been treated in therapy and was unable to return to his baseline of independent with ambulation following his [MEDICAL CONDITION]. RM identified therapy had been discontinued on 4/29/19, due to lack of progression. RM indicated R51's main mode of mobility was now the use of a w/c and needed to use a stand lift for transfers. NA-D interviewed on 5/9/19, at 10:35 a.m. stated she was not aware of any falls and/ or fall interventions for R51 prior to his fall 3/2019. NA-D stated R51 was a falls risk now and needed to be checked on when in bed. NA-D explained she would occasionally visually check on R51 between assisting other residents. Nurse practitioner (NP) interviewed on 5/9/19, at 12:03 p.m. explained R51 had been independent with ambulation with the use of a walker then he had a fall which resulted in a [MEDICAL CONDITION] and surgical repair. NP stated R51 had therapy, however had difficulty with standing and that his new baseline was w/c level. NP stated she was not aware of any changes in sleep pattern prior to the fall with fracture. NA-A interviewed on 5/9/19, at 1:20 p.m. stated R51 had not fallen prior to his fall 3/2019. NA-A stated they now keep an eye on R51 when he's in his w/c and when in bed they leave the call light by him. Medical director (MD) interviewed on 5/9/19, at 1:41 p.m. stated it was his expectation for staff to evaluate the cause of the fall and make recommendations for interventions and updates to the care plan within one to two days following the fall. MD stated the interventions should have been developed and implemented immediately to prevent further falls. MD could not speak specifically regarding R51 as he was not familiar with him. During an interview on 5/9/19, at 2:10 p.m. with the administrator and DON, the administrator verified they were unable to find the falls follow up form with completed long term interventions from 1/30/19, and explained the back of the form regarding long term interventions and the care plan were not completed or updated until 5/8/19, after survey began. DON and administrator confirmed the group sheet dated 5/8/19, did not include frequent checks during the overnight so the NA would not be aware. DON confirmed the falls follow up form dated 1/30/19, indicated difficulty sleep, however was unable to find that this had been assessed and/ or addressed in R51's care plan. DON and administrator reviewed the falls follow up form dated 3/18/19, which indicated bed height not appropriate and to keep bed a knee position. DON was unaware of the bed height at the time of the fall and was unable to find additional information regarding investigation of the bed height. DON and administrator reviewed falls follow up form dated 4/26/19, when the nurse suggested a perimeter mattress, DON stated R51 would not have tolerated a perimeter mattress due to potential for skin breakdown and need for an alternating pressure mattress. DON stated it was decided to implement more checks during the overnight, however the intervention did not get added to the care plan. Administrator stated it was his expectation that the care plan would be updated following the development of the long term intervention along with the group sheet as both should match. DON stated the interventions should be added to the care plan and the group sheets the same day they were developed. DON explained the root cause analysis was decided in the interdisciplinary daily meetings, however they did not keep notes of those discussions. The facility Fall Prevention and Management Program Policy modified 9/2018, indicated nursing staff will implement interventions according to resident specific risk factors. Care plans will indicate the resident specific interventions to prevent falls. The staff nurse would assess all factoring contributing to the fall event and which interventions were in place at the time of the fall using Falls Follow Up Form and recommend interventions and changes to plan of care to prevent a repeat fall. For the 48 hours following the fall observe for effectiveness of the interventions to prevent further incidences of falls. R54's Admission Record dated 5/9/19, indicated [DIAGNOSES REDACTED]. R54's quarterly Minimum (MDS) data set [DATE], identified R54 had severe cognitive impairment and required extensive physical assistance with activities of daily living. R54's Falls Care Area Assessment (CAA) dated 10/24/18, identified R54 had potential for fall related to history of falls and self-transfers and directed staff to call light within reach, transfer with assist of two staff and stand lift, get him up between 7:00 a.m. to 8:00 a.m., monitor for acute illness, ensure appropriate foot wear and grab bars on bed. R54's Falls Care plan revision date 4/2/19, identified R54 was at risk for falls and directed staff to alert resident of changes to environment, allow me to sleep in the morning until I naturally wake up if up early morning during change dress and take to nurses station for observation, complete fall risk assessment quarterly and as needed, encourage participation in activities that promote exercise, physical activity for strengthening and improved mobility, ensure wearing appropriate footwear, unable to utilize call light due to dementia, monitor for medication side effects, observe for acute illness, pharmacy medication review monthly, physical therapy eval and treat as needed, review information on past falls and attempt to determine cause of falls record possible root causes and alert/ remove any potential causes. R54 was observed on 5/9/19, at 9:10 a.m. seated in his wheelchair (w/c) self-propelling around the common area. R54 did not respond to surveyor interview questions. R54's Resident Occurrence Report, Falls Follow Up Form, Mobility, Devices and Fall Risk and Progress Notes (PN) were reviewed 11/20/18, through 4/5/19: -The occurrence report dated 11/20/18, indicated at 8:30 a.m. R54 had fallen out of bed suggestions to prevent reoccurrence indicated turn down the volume of the stereo and check resident to see if he needed to be changed. The follow up form dated 11/20/18, identified R54 had a change in medication during the past 7 days and the environment was noisy/ busy short term intervention music volume lower in dining room and check to see if toileting was needed. The long term intervention dated 11/27/18, identified educate kitchen staff to keep music volume down in the dining room and to offer toileting/ changing when awake; The PN dated 11/22/18, indicated fall from 11/20/18, was reviewed and effectiveness of intervention was blank; -The occurrence report dated 12/18/18, identified at 8:00 a.m. R54 was found on the floor suggestions to prevent reoccurrence indicated to change R54 and bring to nurse's station after to be monitored; The follow up form dated 12/18/18, identified short term interventions was to check and change R54 around 6:00 a.m. if awake and take to the nurses station to be watched. The long term intervention was to change R54 between 6:00 a.m. to 7:00 a.m. and bring to the nurse station for observation; -The fall risk assessment dated [DATE], identified R54 had made frequent attempts to get out of bed without assistance interventions included keep door open at all times when he was sleeping in order to monitor frequently. 4. Interventions (including devices) on care plan or updated on care plan: see chart. 5. Effectiveness of interventions: TBD (to be determined); -The occurrence report dated 1/16/19, identified at 11:45 a.m. R54 had fallen out of his w/c due to being in a raised position suggestion to prevent reoccurrence indicated lower w/c after meals; The follow up form dated 1/16/19, identified short term intervention to recline w/c after meals. The long term intervention dated 1/21/19, indicated recline w/c after meals to prevent R54 from attempting to stand; -The occurrence report dated 1/20/19, identified at 7:45 a.m. R54 had fallen out of bed onto the floor and indicated analysis of cause included soaker pad saturated in urine suggestion to prevent reoccurrence frequent checks at night to observe for wetness. The follow up form dated 1/20/19, identified short term intervention keep R54 clean and dry all of the time and get up by 7:00 a.m. if awake. The long term intervention dated 5/8/19, indicated if awake change pad dress for the day and situate at nurse station. The PN dated 1/22/19, indicated fall from 1/20/19, was reviewed and the effectiveness of interventions was continue monitoring for changes; -The follow up form dated 1/24/19, identified at 6:05 a.m. R54 had fallen due to being awake after diaper change at 5:45 a.m. short term intervention indicated assess wakefulness after changing/ activity when fully awake bring him out of room to the nurse station. The long term intervention dated 5/8/19, indicated check if awake early AM if awake bring to nurse station after dressing. The PN dated 1/24/19, indicated R54 was observed seared on the floor next to his bed. Interventions included assess wakefulness during diaper change, transfer to w/c if fully awake, keep bed at lowest height, call light within reach and medication review. The PN dated 1/25/19, indicated fall reviewed from 1/24/19, effectiveness of interventions noted as will continue to monitor for changes; -The PN dated 2/28/19, indicated at 7:45 a.m. R54 was found on the floor near his bed. R54 was noted to have a wet pad. Intervention included frequent checks and green briefs at night. A subsequent PN dated 2/28/19, identified R54 was in the livingroom and was heard falling near the nurse desk. Intervention included raise chair for meals only and lower to reclining position after meals. However, R54's medical record lacked evidence of occurrence report and/ or falls follow up form completed for noted falls on 2/28/19; -The occurrence report dated 3/15/19, identified at 6:50 a.m. R54 was found on the floor suggestions to prevent reoccurrence check R54 more frequently get a night light if awake get up. However, R54's medical record lacked evidence of completed falls follow up form regarding this fall. The PN dated 3/16/19, indicated fall follow up, interventions based on root cause analysis was left blank and effectiveness of intervention was left blank. The PN dated 3/18/19, indicated fall from 3/15/19, reviewed and effectiveness of interventions to be determined; -The fall risk assessment dated [DATE], identified R54 was at risk for falls related to unable to verbalize and need to change brief interventions included check him at 6:00 a.m. and during the night if awake, night light, care plan updated. Effectiveness of interventions indicated to be determined; -The occurrence report dated 4/1/19, identified at 8:25 a.m. R54 was found on the floor suggestions to prevent reoccurrence R54 should be changed around 6:00 a.m. to 7:00 a.m. to prevent R54 from attempting to go to the bathroom. The follow up form dated 4/1/19, identified R54 was wet with urine at time of fall and he was attempting to get up to go to the bathroom short term intervention indicated change around 6:00 a.m. to 7:00 a.m. The long term intervention indicated to educate overnight staff to check R54 to determine if he needs to be changed and to always check and change at 6:00 a.m The PN dated 4/2/19, indicated fall from 4/1/19, reviewed and effectiveness of interventions will continue to monitor. R54's medical record lacked evidence of development and implementation of interventions to prevent further falls. The Administrator interviewed on 5/9/19, at 10:12 a.m. and verified R54's fall intervention to change between 6:00 a.m. to 7:00 a.m. was never updated on his care plan and/ or group sheet. Nursing assistant (NA)-A was interviewed on 5/9/19, at 1:18 p.m. and stated R54 had a history of [REDACTED]. The licensed practical nurse (LPN)-A was interviewed on 5/9/19, at 1:22 p.m. and stated R54 had fallen out of bed due to attempting to get himself up without assistance. LPN-A explained once R54 was awake they get him up for the day and he would stay in his w/c. The director of nursing (DON) and Administrator were interviewed on 5/9/19, at 2:10 p.m. and during review of R54's medical record they were unable to find occurrence report dated 1/24/19, and follow up form dated 3/15/19. Administrator confirmed the care plan and group sheet had not been updated to reflect checking and changing R54 around 6:00 to 7:00 a.m. until today. DON stated it was her expectation to review the fall in the interdisciplinary daily meeting to assess for the root cause and develop interventions. DON further stated it was her expectation for the care plan and group sheets to be updated the day the follow up form is signed and the long term intervention developed. The facility Fall Prevention and Management Program Policy modified 9/2018, indicated nursing staff will implement interventions according to resident specific risk factors. Care plans will indicate the resident specific interventions to prevent falls. The staff nurse would assess all factoring contributing to the fall event and which interventions were in place at the time of the fall using Falls Follow Up Form and recommend interventions and changes to plan of care to prevent a repeat fall. For the 48 hours following the fall observe for effectiveness of the interventions to prevent further incidences of falls.