Every finding on record at Spring Valley Care Center

Based on observation, interview, and document review the facility failed to provide a dignified dining experience for 1 of 1 resident (R9) observed for dignity. Findings include:Findings include:R9's face sheet dated 8/13/26, identified diagnoses of Alzheimer's disease (a progressive brain disorder that slowly destroys memory) and Parkinson's disease (a slow brain disorder that damages nerve cells and makes it hard to control movement).R9's annual Minimum Data Set (MDS) dated [DATE], identified R9 had severe cognitive impairment, had no behaviors, no rejection of cares, needed partial/moderate assistance for eating, and received hospice services. R9's activities of daily living (ADL) care plan dated 11/16/23, identified R9 had a self-care performance deficit related to weakness and confusion secondary to Alzheimer's disease and Parkinsonism. Corresponding interventions are as follows: Eating: needs supervision and assistance as needed with eating. During an observation and interview on 8/13/26 at 9:25 a.m., R9 was seated in the dining room with a tray of partially eaten food sitting in front of her. Hospice nursing assistant (HNA)-E was seated next to R9 typing on a cellular phone with a white back. R9 repeatedly looked at HNA-E, while picking up her silverware, and moving her napkin, however, HNA-E continued to type on the cellphone, did not look up from her phone, nor speak to R9. At 9:32 a.m. a different staff member entered the dining room and began assisting R9 out of the dining room. HNA-E reported she had been using a work cell phone and not her personal cell phone while sitting next to R9. However, HNA-E removed a black cell phone without a white back out of her left pocket then removed a second cellular phone with a white back out of her right pocket explaining the white backed cell phone was her personal cell phone. HNA-E stated she should not have been texting instead of communicating or giving attention to R9; she was supposed to provide her full attention to a resident during mealtime and not be on a cellular phone. During an interview on administrator in training (ADMIN-IT) stated all residents at the facility deserved to be treated with respect and dignity during mealtimes and staff should not be on their personal phone when they were supposed to be helping the resident eat. During an interview on 8/13/26 at 2:32 p.m., NA-B stated all residents deserved to be provided with respect and dignity during mealtimes and be given full attention by staff. NA-B explained it was the policy of the facility not to be on a personal cell phone while on the floor and hospice staff should be following the same policy. NA-B further explained R9 had dementia but would still interact with staff during meals. NA-B would feel bad if someone was supposed to be helping or talking to and did not talk or pay attention to her. During an interview on 8/13/26 at 3:11 p.m., family member (FM)-F stated R9 would have been upset if a staff member was on their phone instead of paying attention to her during a mealtime and would make her feel like she had no worth. FM-F further explained that all residents deserved to get full attention from staff during cares.Review of the facility's Dignity and Respect Policy undated, identified the facility will make sure that everyone is treated with dignity and respect and that every resident has the right to be treated with dignity and respect.

Based on observation, interview, and document review the facility failed to comprehensively assess and monitor 1 of 1 resident (R7) who exhibited a change in respiratory status.Findings include:Findings include:R7's face sheet dated 8/13/26, identified diagnoses of chronic obstructive pulmonary disease (COPD) and respiratory failure.R7's annual Minimum Data Set (MDS) dated [DATE], identified R7 had intact cognition, had no behaviors, not rejection of cares, was independent in transfers, and was on oxygen therapy. R7's care plan dated 6/2/22, identified R7 was at risk for ineffective airway clearance and infection due to bronchoconstriction, increased mucus, and ineffective cough. R7 had a diagnosis of COPD. Corresponding interventions are as follows:-Administer medications as ordered. Watch for side effects such as tachycardia or anxiety, inflamed pharynx with inhaled steroids.-Administer oxygen as ordered (dated 6/2/22).-During exertion resident does not become short of breath, ensure oxygen is in place and provide frequent breaks for resident (dated 8/20/25). R7's physician orders included Oxygen at 3 liters (L) at rest and 6L with activity.During an interview on 8/12/26 at 1:40 p.m., R7 was seated on the edge of her bed in her room with oxygen on. R7 explained to the surveyor that she has not been feeling well for the past couple of days and had a terrible cold. R7 had told the staff about her cold, however, they had not tested for respiratory illness such as COVID or FLU nor did staff come to check on her. R7's order administration progress note dated 8/11/26 at 1:14 p.m., identified R7 was not feeling well today and did not want to leave room when she is stuffed up. Although R7's progress note identified R7 was not feeling well there was no indication a comprehensive respiratory assessment had been completed.During an interview on 8/13/26 at 11:39 a.m., nursing assistant (NA)-C stated she had worked with R6 on 8/11/26 when she did not feel well and refused to come out of her room to eat due to having a cold. NA-C explained she had not told the nurse, however, informed trained medication aide (TMA)-A about R7's complaints. During an interview on 8/13/26 at 12:48 p.m., family member (FM)-G stated on 8/11/26 she had stopped in to visit R7 and noted she was not feeling well and was showing cold symptoms. R7 had told her she had informed the nursing staff about not feeling well, however, she had not been notified of any testing being completed. During return phone interview on 8/13/26 at 6:51 p.m., TMA-A stated on 8/11/26 at 1:14 p.m., she had placed a progress notes in R7's record that a weekly weight had not been completed due to R7 not feeling well and being stuffed up. TMA-A had reported R7's complaints to the nurse but was unaware if the nurse had followed up with assessing R7's respiratory status.During an interview on 8/13/26 at 2:50 p.m., NA-E stated she worked the evening shift on 8/11/26 when R7 reported to her that she was not feeling well. NA-E had heard R7 coughing and she reported this immediately to registered nurse (RN)-A. During an interview on 8/13/26 at 2:55 p.m., RN-A stated on 8/11/26 she had been informed by NA-E that R7 did not take her bath because she was not feeling up to it. RN-A explained after being informed of the refusal she did not investigate the rationale nor complete a respiratory assessment.During an interview on 8/12/26 at 2:03 p.m., registered nurse care coordinator (RN-CC) stated she had heard in morning report that R7 had refused to have her daily weights taken on 8/11/26 due feeling stuffed up, however, had not followed up to see if R7 had a comprehensive respiratory assessment completed. RN-CC reviewed R7's record from 8/11/26 through 8/12/26 up until 1:40 p.m., which did not identify a comprehensive respiratory assessment had been completed nor physician notification. During a follow up interview on 8/13/26 at 2:18 p.m., RN-CC stated her expectation would be for staff to perform a comprehensive respiratory assessment for any resident with a change in their respiratory status and notify the physician immediately to get further direction. Review of R7's electronic health record (EHR) on 8/11/26 through 8/12/26 ending at 1:50 p.m., did not identify a comprehensive respiratory assessment had been completed. R7's progress note dated 8/12/26 at 2:01 p.m., identified R7 complained of being sick for a couple of days. R7 has a history of COPD and prior to complaints of stuffiness yesterday, resident had not informed nursing of complaints and R7 told writer she is feeling better today. Assessment of non-productive wet cough, and wheezing to lobes of lungs. Tested for COVID and was negative and was given standing order nebulizer and respiratory precautions initiated and physician assistant will be notified when he arrives at the facility. R7's physician assistant (PA) note dated 8/12/26, identified R7 was seen due to feeling sick with an illness that began two days ago with new onset sore throat, followed by clear rhinorrhea (runny nose), and shortness of breath. R7 reported yesterday she coughed up purulent yellow sputum. Initial covid swab was negative. Pulmonary with diminished breath sounds diffusely. Feels like this may be most consistent with viral upper respiratory infection that trigged a COPD exacerbation of moderate severe dyspnea plus purulent sputum. Symptoms improving and hemodynamically stable. Orders written as follows:-Begin nebulizer four times per day as needed for 7 days.-Chest Xray.-Influenza A/B, RSV, and COVID test.-Begin Doxycycline (antibiotic) twice daily for 5 days for COPD exacerbation.-Prednisone (steroid) 40 mg daily for 5 days for COPD exacerbation. During an interview on 8/13/26 at 1:49 p.m., PA stated he had he had been asked by nursing staff to evaluate R7 on 8/12/26 due to complaints of not feeling well for the past few days, however, he had not been notified of a change in R7's respiratory status until he arrived at the facility on 8/12/26. PA stated it would be his expectation for nursing staff to perform a comprehensive respiratory assessment, notify the physician immediately to get next steps in treatment, and monitor the residents closely for any change in condition. R7 appeared to be in an COPD exacerbation beginning and is lucky he saw her on 8/12/26 to begin treatment or she may have had to be sent to the emergency department. R7's record from 8/12/26 through 8/13/26 did not identify any monitoring of respiratory status after being seen by a physician assistant on 8/12/26. Review of the facility's Change in Condition Policy dated 5/24, identified the facility shall promptly notify the resident, his/her attending physician, and resident/representative of changes in the resident's medical/mental condition and/or status. Prior to notifying the physician or healthcare provider, the nurses will make detailed observations and gather relevant and pertinent information for the provider, including information prompted by the situation, background, assessment, and response.

Based on observation, interview, and document review the facility failed to place a resident with respiratory symptoms on transmission-based precautions (TBP)in a timely manner to mitigate the risk of spread of an infectious disease for 1 of 1 resident (R6) reviewed for respiratory symptoms. Findings include:R7's face sheet dated 8/13/26, identified diagnoses of chronic obstructive pulmonary disease (COPD), respiratory failure, and history of transient ischemic attack.R7's annual Minimum Data Set (MDS) dated [DATE], identified R7 had intact cognition, had no behaviors, not rejection of cares, was independent in transfers, and was on oxygen therapy. R7's care plan dated 6/2/22, identified R7 was at risk for ineffective airway clearance and infection due to bronchoconstriction, increased mucus, and ineffective cough. R7 had a diagnosis of COPD. Corresponding interventions are as follows:-Administer medications as ordered. Watch for side effects such as tachycardia or anxiety, inflamed pharynx with inhaled steroids.-Administer oxygen as ordered (dated 6/2/22).-During exertion resident does not become short of breath, ensure oxygen is in place and provide frequent breaks for resident (dated 8/20/25).R7's progress note dated 8/11/26 at 1:14 p.m., identified R7 was not feeling well today and did not want to leave room when she is stuffed up. During an observation and interview on 8/12/26 at 1:40 p.m., R7 was seated at the edge of her bed when she informed surveyor, she had been sick for the past two days with a terrible cold. R7 told the surveyor to not get too close to her. R7 explained she had told staff she had not been feeling well but was confused why she had not been tested for anything since she had been sick. R7 did not want to leave her room to prevent getting other people sick. There was no signage on the outside of R7's room that would communicate any necessary personal protective equipment (PPE) to enter the room.During an interview on 8/13/26 at 11:39 a.m., nursing assistant (NA)-C stated when she worked with R7 on 8/11/26m, R7 had told her she was not feeling well and had a raspy voice and cough. NA-C had informed the trained medication aide (TMA) about R7's complaints but was unaware of what was done about her complaints. NA-C explained R7 had not been placed on any PPE and/or isolation. During an interview on 8/13/26 at 11:52 a.m., NA-D states she had worked with R7 during the day shift on 8/12/26 where she complained about not feeling well during the day and did not want to leave her room to try and prevent other residents from getting sick. NA-D further explained R7 had not been placed on TBP during her shift During an interview on 8/12/26 at 1:50 p.m., licensed practical nurse (LPN)-A stated if a resident was noted to have any respiratory symptoms they would be placed on TBP and tested for viruses, however, R7 had not been placed on any type of precautions nor tested due to not being aware she had any respiratory symptoms. During an interview on 8/12/26 at 2:03 p.m., registered nurse care coordinator (RN-CC) stated if a resident develops respiratory symptoms, they should be tested immediately and be placed on TBP to mitigate the risk of spread of disease. RN-CC stated she had heard during the morning report that R7 had refused her weekly weight on 8/11/26 due to not feeling well and being stuffed up but had not ensured R7 had been tested nor placed on TBP. During a follow up interview at 4:30 p.m., RN-CC stated R7 had been tested for COVID with a negative result and was placed on droplet precautions due to her respiratory symptoms. During an interview on 8/13/26 at 12:06 p.m., RN-CC stated it would be her expectation to have staff place a resident on transmission-based precautions immediately if they notice any type of respiratory symptoms to mitigate the spread of illness in the facility. Review of the facility's Isolation-Categories of Transmission Based Precautions policy dated 12/25, identified transmission-based precautions shall be used when caring for residents who are documented or suspected to have communicable diseases or infections that can be transmitted to others.

Based on observation and interview, the facility failed to properly label, store and dispose of refrigerated items. This had the potential to affect all residents served out of the kitchen.During the initial kitchen tour on 12/15/25 at 11:45 a.m., with dietary manager (DM)-A the following undated or expired items were observed in the refrigerator: Undated bin of sandwiches,Undated hot dogs,Undated onion, Undated oranges in syrupPumpkin puree dated 12/10Honeydew dated 11/8Chicken gravy dated 11/20During interview 12/15/25 at 12:01 p.m., DM-A confirmed the previous listed items. She stated the sandwiches and pumpkin puree were expired and should have been discarded. The policy directs them to discard all items after 3 days. DM-A confirmed the importance of dating food was to ensure residents don't become ill from the foods they were served. During interview on 12/18/25 at 12:11 p.m., the administrator stated the dietary staff were expected to follow the facility food safety policy to accurately date and dispose of food items.A facility policy titled Food Receiving and Storage dated August 2025, all foods stored in the refrigerator or freezer will be covered, labeled, and dated. After three days, leftover food should be disposed of.

Based on interview and document review, the facility failed to ensure advanced directives for emergency treatment were accurately reflected in all areas of the medical record to ensure the residents wishes would be implemented correctly in an emergent situation for 1 of 1 residents R39) reviewed for advanced directives. Findings include:R39's quarterly Minimum Data Set (MDS) dated [DATE], indicated R39 had severe cognitive impairment. R39 had diagnoses of non-traumatic brain dysfunction and dementia. The MDS also indicated R39 was receiving hospice care. R39's medication administration record (MAR) indicated unscheduled other orders DNR Do Not Resuscitate. The Advanced directives section indicated DNR Do Not Resuscitate/Comfort. The MAR also contained hospice weekly charting.R39's care plan indicated R39 was receiving hospice care.During record review on [DATE] the banner on R39's electronic medical record (EMR) indicated Code Status: DNR-Do not resuscitate/comfort. Also contained in the banner was a hyperlink connecting to a signed Provider Orders for Life-Sustaining Treatment (POLST). The hyperlink lead to a POLST dated [DATE] that indicated R39 wished for cardiopulmonary resuscitation (CPR) and full resuscitative treatment (implementation of all life sustaining measures). In a separate section of the medical record a POSLT dated [DATE] indicated R39 wished for comfort-focused treatment and no attempts at resuscitation (allow natural death). During interview on [DATE] at 6:23 p.m., RN-A stated if a resident was found unresponsive, she would verify code status before initiating interventions. RN-A stated the banner on the EMR contained the code status. She stated the information was also on the assignment sheet staff obtained at the beginning of the shift. RN-A stated she would not pay attention to the hyperlink as that was not part of the facility's process to verify code status. If the EMR banner had no code status listed, RN-A stated she would then use the hyperlink. RN-A stated the care coordinator was responsible for entering code status on the EMR upon admission and if code status changes. A blank 24-hour report sheet listed all residents assigned to the nurse. The form indicated R39 was DNR/comfort and also listed the hospice agency. A blank resident notes form used by the nursing assistants indicated H for hospice. During interview on [DATE] at 6:25 p.m., trained medication aide (TMA)-A stated she had been a TMA for 2 weeks. TMA-A stated if a resident was found without signs of life, she would look at the banner on the EMR to establish code status and immediately notify the nurse on duty. TMA-A did not know how to verify if the code status on the banner. During record review on [DATE] at 9:09 a.m., the banner on R39's electronic medical record continues to indicate Code Status: DNR-Do not resuscitate/comfort with the hyperlink connecting to the POLST dated [DATE]. During an interview on [DATE] at 7:53 a.m., licensed practical nurse (LPN)-A stated care coordinators and/or facility social workers were responsible for establishing and entering code status on the EMR. LPN-A stated they would use the EMR banner or 24-hour report sheet to verify code status. LPN-A also stated they might use the hyperlink that connected directly to the POLST. If there was a discrepancy between the EMR banner and the POLST attached to the hyperlink, LPN-A stated they would immediately call the resident's emergency contact, on-call provider, on-call social worker, or on-call registered nurse to verify code status. During interview on [DATE] 10:05 a.m., care coordinator (CC)-A stated the care coordinator was responsible for establishing code status. If the admission was after business hours, the admitting floor nurse was responsible. Code status was verified on the EMR banner or under the miscellaneous tab to find the most recent POLST. CC-A confirmed the banner on R39's EMR indicated DNR-do not resuscitate. CC-A clicked on the hyperlink and confirmed the attached POLST was dated [DATE] and indicated CPR-full resuscitative treatment. CC-A stated she was unsure how the POLST was attached to the hyperlink in the EMR.During interview on [DATE] at 1:29 p.m., the administrator stated the admitting nurse went over code status and upon admission. Code status was also reviewed annually. The admitting nurse entered the code status into the EMR. If a code status changed, the nurse or social worker was responsible for making changes in EMR. The administrator stated having the incorrect POLST linked to the code status was definitely a problem. An undated policy titled Advanced directives indicated Prior to or upon admission of a resident to our facility, the Social Services Director or designee will provide written information to the resident concerning his/her/their right to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment and the right to formulate advance directives. It continues Changes or revocations of a directive must be submitted in writing to the Administrator. The Administrator may require new documents if changes are extensive. The Care Plan Team will be informed of such changes and/or revocations so that appropriate changes can be made in the resident assessment (MDS) and care plan.

Based on interview and record review the facility failed to ensure proper side effect monitoring for potential orthostatic hypotension (sudden drop in blood pressure that occurs when a person changes position from lying to sitting and/or standing) was completed for 1 of 1 resident (R45) reviewed for unnecessary medications who received antipsychotics. R45's quarterly Minimum Data Set (MDS) dated [DATE] indicated R45 had severe cognitive impairment with wandering but no other behaviors. R45 required partial to substantial assist for activities of daily living and was independent with side-to-side bed mobility and sitting on edge of the bed. He required substantial assists for all other transfers and position changes. R34 has a history of traumatic brain dysfunction, and palliative care. The MDS also indicated R45 had a history of 2 or more falls with no injuries and 1 fall with minor injury. R45 received antipsychotic medications on a routine and as needed basis and receives hospice care R45's diagnoses list indicated brain bleed with loss of consciousness, encephalopathy (disease of the brain), disorientation, and palliative care. R45's care plan included hospice care, history of attempts to leave the facility, impaired cognitive function, transfers with stand lift, risk for falls related to deconditioning, incontinence, poor communication/comprehension, psychoactive drug use, unaware of safety needs, and previous falls. R45's care plan also included use of antipsychotic medications with interventions that included monitoring for target behaviors and side effects R45's medication administration record (MAR) indicated R45 received antipsychotic medications on a routine and as needed basis since admission to the facility on 7/1/25. The MAR did not contain orders to obtain monthly orthostatic blood pressures. R45's medical record indicated R45 had 5 falls in July; 2 in August; 6 in September; and 2 in October. The last documented fall was on 10/19/25. Orthostatic blood pressures were obtained once in July, September, and October with an associated fall. No orthostatic blood pressures were obtained in August or November. During an interview on 12/17/25 at 10:32 a.m., medical director (MD)-A stated residents receiving antipsychotic medications should have monthly orthostatic blood pressures obtained. MD-A stated she expected staff to perform as many steps of orthostatic monitoring as resident was physically able to perform, even if it was just lying and sitting. If a resident refused, she expected staff to attempt again. If a resident was actively dying, she would not expect orthostatic blood pressures. She would also expect the consultant pharmacist to request orthostatic blood pressure monitoring during monthly reviews. During an interview on 12/18/25 at 10:36 a.m., the consultant pharmacist stated she reviewed the record for an abnormal movement assessment, target behaviors, and if a resident can stand, orthostatic blood pressures. Her reviews do not change for a resident who was under hospice care. The pharmacist stated she does not always look for orthostatic blood pressure monitoring for hospice residents because hospice will discontinue them anyway. If a resident was on hospice but still able to ambulate or get up, the pharmacist stated she would request to have orthostatic blood pressure monitoring in place. The pharmacist confirmed she did not request orthostatic blood pressure monitoring for R45. During interview on 12/18/25 at 11:25 a.m., care coordinator (CC)-A stated residents who received antipsychotic medications were monitored for side effects, continued behaviors, and monthly orthostatic blood pressures. CC-A stated staff to not attempt orthostatic blood pressures for R45 because he was stand-lift transfer and can't stand long enough. CC-A stated she believed not doing orthostatic blood pressures was discussed with the providers however it was likely a conversation done in person. CC-A was unable to provide documentation the discussion occurred. CC-A stated R45's transfer status and overall health had declined. She confirmed R45 had a history of frequent falls with his last fall on 10/19/25. R45's transfer status changed 10/10/25 from a 1 assist with a walker to a stand lift transfer. During an interview on 12/18/25 at 1:33 p.m., the administrator stated residents started on antipsychotic medications were monitored for side effects and continued behaviors. A policy for antipsychotic medication monitoring was requested but not received.

Based on interview and document review, the facility failed to ensure a resident had accurate physician orders for medications for 1 of 5 residents (R11) reviewed order accuracy.Findings include:R11's comprehensive Minimum Data Set (MDS) dated [DATE], indicated R11 had no cognitive deficit.R11's diagnosis included: dementia with psychotic and mood disturbance, psychotic disorder with delusions, cognitive function decline, anxiety, and depression.R11's Medication administration Record (MAR) indicated Tylenol-give 1 tablet every 6 hours as needed for pain; the Tylenol order lacked a dosage.R11's Order summary reports, signed by the provider, dated 1/28/25 through 12/17/25 lacked a dosage for Tylenol.During interview on 12/17/25 at 10:32 a.m., medical director (MD) confirmed the current Tylenol order lacked a dosage. MD confirmed an accurate Tylenol order would contain a dosage. MD confirmed her provider team should have picked up the dosage discrepancy with his initial order summary sign off and with each sign off since.During interview on 12/18/25 at 10:36 a.m., pharmacist stated pharmacy reviews were conducted monthly per regulation. Pharmacist stated she reviewed medication orders for accuracy, side effect monitoring, target behaviors and vital signs. Pharmacist confirmed the current Tylenol order lacked a dosage. Pharmacist confirmed the provider team reviewed and signed off the order summary; medications that lacked a dosage should have been identified when the provider signed off on the order summary.A policy titled Consultant Pharmacist Reports-Medication Management dated April 2019, the attending physician/provider perform ongoing monitoring for appropriate, effective, and safe medication use.

Based on interview and document review, the facility failed to ensure facility staff appropriately transcribed physician orders for 1 of 5 residents (R11) reviewed for order entry.Findings include: R11 was admitted to the facility on [DATE], with orders from the sending facility for Tylenol 500mg, take 1 tablet by mouth every 6 hours as needed for pain. R11's comprehensive Minimum Data Set (MDS) dated [DATE], indicated R11 had no cognitive deficit. R11's diagnosis included: dementia with psychotic and mood disturbance, psychotic disorder with delusions, cognitive function decline, anxiety, and depression. R11's Medication administration Record (MAR) indicated Tylenol-give 1 tablet every 6 hours as needed for pain; the Tylenol order lacked dosage. R11's initial orders were transcribed into the medical record by the health unit coordinator (HUC). During interview on 12/18/25 at 12:11 p.m., the administrator stated the current process for ordering processing was the HUC entered the orders sent from the provider, a registered nurse (RN) double-checked the order was entered correctly, and the provider team reviewed and signed off on the order summary. The administrator confirmed the Tylenol order was inaccurately transcribed at time of admission. During interview on 12/17/25 at 10:32 a.m., medical director (MD) confirmed the current Tylenol order lacked a dosage. MD confirmed an accurate Tylenol order would contain a dosage. MD confirmed the process for entering orders was the responsibility of the HUC. The RN signed off on the order completion. MD stated it was important orders were transcribed accurately so the resident received the medication or treatment as the MD intended. During interview on 12/18/25 at 10:36 a.m., pharmacist stated pharmacy reviews were conducted monthly per regulation. Pharmacist stated she reviewed medication orders for accuracy, side effect monitoring, target behaviors, and vital signs. Pharmacist confirmed the current Tylenol order lacked a dosage. Pharmacist confirmed the facility staff were responsible for entering new orders from the provider. Pharmacist stated transcribing orders accurately was important, so residents received the care the provider ordered An undated facility policy titled Order Processing in the Skilled Nursing Facility, the purpose is to ensure that all physician orders are processed accurately, timely, and in compliance with federal and state regulations to promote resident safety and continuity of care.

Based on interview and record review, the facility failed to ensure the pharmacy consultant identified irregularities in monthly drug regimen reviews for 2 of 5 residents (R11 and R45) reviewed for unnecessary medications.Findings include: R11's comprehensive Minimum Data Set (MDS) dated [DATE], indicated R11 had no cognitive deficit. R11's diagnosis included: dementia with psychotic and mood disturbance, psychotic disorder with delusions, cognitive function decline, anxiety, and depression. R11's Medication administration Record (MAR) indicated Tylenol-give 1 tablet every 6 hours as needed for pain; the Tylenol order lacked a dosage. R11's pharmacy reviews dated July 2025 through December 2025, lacked a dosage for Tylenol. During interview on 12/17/25 at 10:32 a.m., medical director (MD) confirmed the current Tylenol order lacked a dosage. MD confirmed an accurate Tylenol order contained a dosage. MD stated she expected the pharmacist to question the Tylenol order during monthly pharmacy reviews. During interview on 12/18/25 at 10:36 a.m., pharmacist stated pharmacy reviews were conducted monthly per regulation. Pharmacist stated she reviewed medication orders for accuracy, side effect monitoring, target behaviors, and vital signs. Pharmacist confirmed the current Tylenol order lacked a dosage. Pharmacist confirmed she failed to notice the strength of Tylenol was missing. R45's quarterly Minimum Data Set (MDS) dated [DATE] indicated R45 had severe cognitive impairment with wandering but no other behaviors. R45 required partial to substantial assist for activities of daily living and was independent with side-to-side bed mobility and sitting on edge of the bed. He required substantial assists for all other transfers and position changes. R34 has a history of traumatic brain dysfunction, and palliative care. The MDS also indicated R45 had a history of 2 or more falls with no injuries and 1 fall with minor injury. R45 receives antipsychotic medications on a routine and as needed basis and received hospice care. R45's diagnoses list indicated brain bleed with loss of consciousness, encephalopathy (disease of the brain), disorientation, and palliative care. R45's care plan included hospice care, history of attempts to leave the facility, impaired cognitive function, transferred with stand lift, risk for falls related to deconditioning, incontinence, poor communication/comprehension, psychoactive drug use, unaware of safety needs, and previous falls. R45's care plan included use of antipsychotic medications with interventions of monitoring for target behaviors and side effects R45's medication administration record (MAR) indicated R45 received antipsychotic medications on a routine and as needed basis since admission to the facility on 7/1/25. The MAR did not contain orders to obtain monthly orthostatic blood pressures. R45's medical record indicated R45 had 5 falls in July, 2 in August, 6 in September, and 2 in October with the last documented fall on 10/19/25. Orthostatic blood pressures were obtained once in July, September, and October with an associated fall. No orthostatic blood pressures were obtained in August or November. Monthly drug regimen reviews from July 2025-December 2025 lacked monthly orthostatic blood pressure monitoring. During an interview on 12/17/25 at 10:32 a.m., MD stated residents receiving antipsychotic medications should have monthly orthostatic blood pressures obtained. MD expected staff to perform as many steps of orthostatic monitoring as resident was physically able to perform, unless the resident was actively passing away. If a resident refused, she expected staff to attempt again. MD also expected the consultant pharmacist to request orthostatic blood pressure monitoring during monthly reviews. During an interview on 12/18/25 at 10:36 a.m., the consultant pharmacist stated she reviewed the record for an abnormal movement assessment, target behaviors, and if a resident can stand, orthostatic blood pressures. The pharmacist stated she does not always look for orthostatic blood pressure monitoring for hospice residents because hospice will discontinue them anyway. If a resident was on hospice but still able to ambulate or get up, the pharmacist stated she would request to have orthostatic blood pressure monitoring in place. The pharmacist confirmed she did not request orthostatic blood pressure monitoring for R45. During interview on 12/18/25 at 11:25 a.m., care coordinator (CC)-A stated residents who received antipsychotic medications were monitored for side effects, continued behaviors, and monthly orthostatic blood pressures. CC-A stated R45's transfer status and overall health had declined. She confirmed R45 had a history of frequent falls with his last fall on 10/19/25. R45's transfer status changed 10/10/25 from a 1 assist with a walker to a stand lift transfer. CC-A stated staff do not attempt orthostatic blood pressures for R45 because he was stand-lift transfer and can't stand long enough. CC-A stated she believed she discussed with the providers not doing orthostatic blood pressure monitoring for R45 however was unable to provide documentation the discussion occurred. During an interview on 12/18/25 at 1:33 p.m., the administrator expected residents started on antipsychotic medications were monitored for side effects and continued behaviors. A policy titled Consultant Pharmacist Reports-Medication Regimen Review dated April 2019, the consultant pharmacist performs a comprehensive review of each residents' medication regimen and clinical records at least monthly; reporting findings and recommendations for improvement or correction.

Based on observation, interview, and document review, the facility failed to ensure the facility's state survey results were kept in a location that was readily accessible to all residents. This had the potential to affect all 42 residents and/or visitors who wished to review the information. R25's quarterly Minimum Data Set (MDS) dated [DATE], indicated R25 had intact cognition. During an interview with the facility resident council president on 12/17/25 at 2:43 pm., R25 (resident council president) stated the survey binder was usually at the front desk; it had been gone for some time though. R25 stated she would like to see it returned. During observation and interview on 12/18/25 at 10:31 a.m., social worker (SW) and administrator confirmed the facility had a survey binder; they were unsure why it wasn't in the designated spot at the front desk. A policy regarding posting survey results was requested and not received.

Based on interview and record review, the facility failed to submit complete and/or accurate data for staffing information based on payroll and other verifiable data during 1 of 1 quarter (Quarter 3) reviewed, to the Centers for Medicare and Medicaid Services (CMS), according to specifications established by CMS. Findings include: Review of the Payroll Based Journal (PBJ) [NAME] Report 1705D identified the facility had excessively low weekend staffing during the third quarter of the fiscal year 2024, which included dates between April 1st to June 30th. Review of daily staff schedules and facility staffing report during quarter three indicated adequate levels of staff on weekends. Therefore, the data submitted in the PBJ to CMS was inaccurate. During interview on 11/21/24 at 3:09 p.m. the administrator stated the facility staffing levels did not change from weekdays to weekends. Administrator stated the business office completed and submits the PBJ data based on information off the schedule and daily staff postings. Administrator stated it was important to ensure accurate data is submitted based on requirements. The facility Payroll Based Journal (PBJ) Reporting policy, dated 7/2024, indicated staff and census information will be reported electronically to CMS through the Payroll-Based Journal system in compliance with 6106 of the Affordable Care Act. Direct-care staffing information will include staff hired directly by the facility, those hired through an agency, and contact employees. Providers who are employed by the facility (including physicians) will be included in direct-care staffing information, providers who bill Medicare directly will not be included. For auditing purposes, reported staffing information will be based on payroll records, or other verifiable information.

Based on observation, interview, and document review, the facility failed to provide a dignified dining experience for 1 of 1 resident (R37) observed for dignity. Findings include: R37's quarterly Minimum Data Set (MDS) dated [DATE], identified R37 had severe cognitive impairment and required assistance with all activities of daily living (ADL)'s. R37's diagnoses included Alzheimer's disease, aphasia, dementia, depression, polyneuropathy ( is a condition in which a person ' s peripheral nerves are damaged, and low back pain. R37's care plan, indicated R37 needed assistance with eating, however lacked plastic silverware had been used for R37. During observation on 11/19/24, at 5:10 p.m., R37 was sitting in his wheelchair at a table in the middle of dining room with three other residents. Staff had placed regular silverware in front of the other three residents sitting at the table and placed a plastic spoon and fork on the table in front of R37. Staff assisted R37 with eating while staff utilizing a plastic fork. At 5:42 p.m., staff continued feeding R37 with plastic silverware. During observation on 11/20/24 at 12:07 p.m., R37 was seated at a table in the middle of dining room with three other residents. Staff assisted R37 with eating utilizing plastic silverware. During observation on 11/21/24 at 12:18 p.m., R37 was seated at a table in the middle of dining room with three other residents. Staff assisted R37 with eating utilizing plastic silverware. During interview on 11/19/24 at 2:30 p.m., family member (FM-A) stated R37 had a problem with collecting silverware due to his time in Vietnam where silverware was scarce. FM-A stated facility gave R37 plastic silverware to eat with due to the hoarding of silverware where R37 would take silverware and place in his shirt pocket where he would have six to eight pieces of silverware at a time. During interview on 11/20/24 at 10:02 a.m., nursing assistant (NA)-E stated R37 needed assistance with eating with staff having to feed him. NA-E stated R37 had been utilizing plastic silverware due to him collecting them. NA-E stated staff use plastic silverware when assisting R37 with eating. During interview on 11/21/24 at 10:54 a.m., licensed practical nurse (LPN)-A stated R37 had a history of stealing silverware. LPN-A stated R37 had worked as a jailor so not sure if that behavior correlated with his past occupation. LPN-A stated R37 had one incident in the past year, awhile ago, where he held a knife up to a nurse and due to that incident, R37 had been given plastic silverware ever since. LPN-A stated he is not aware of any other incidents regarding silverware. During interview on 11/21/24 at 11:39 a.m., registered nurse (RN)-A stated R37 was obsessed with collecting of silverware. RN-A stated R37 was a retired police officer, served in the army and also worked at a corrections facility where he would go and remove items from inmates. RN-A stated R37 had one incident a while ago where held a regular butter knife towards a nurse, so plastic silverware was initiated for R37 for the safety of the staff. RN-A stated she is not aware of any other incidents since. During interview on 11/21/24 at 12:59 p.m., assistant director of nursing (ADON) stated R37 liked to hold onto utensils and not give them up. ADON stated R37 previously attempted, within last year or so, to jab out with a knife towards staff so plastic silverware was initiated to make it less likely to cause injury to staff. ADON stated R37 had several episodes since then utilizing the plastic silverware but stated it had been quite a while since she was made aware or heard anything regarding incidents with silverware. ADON confirmed that R37 was assisted by staff with eating at all times due to R37's increased confusion. ADON stated she would expect behaviors to be assessed and characterized quarterly coordinating with MDS assessments. ADON stated an on-going quarterly assessment should have been completed for use of plastic silverware and behaviors and confirmed they were not completed. ADON stated a trial of regular silverware should have been completed to see if R37 was still demonstrating previous behaviors and confirmed trial had not been completed. ADON stated trial and reassessment were important as utilizing plastic silverware could affect R37's dignity and also how he eats and also percentage of how much R37 eats. The facility Dignity and Respect policy, dated 7/24, indicated facility will make sure that everyone is treated with dignity and respect. Every resident has the right to be treated with dignity and respect. Facility provides services and supports in a way that respects and considers personal preferences.

Based on observation, interview and document review, the facility failed to ensure residents were comprehensively assessed for self-administration of medications for 1 of 1 resident (R32) reviewed and observed for self-administration of medications. Findings include: R32's quarterly Minimum Data Set (MDS) dated [DATE], identified R32 had severe cognitive impairment and required assistance with all activities of daily living (ADL)'s. R32's physician orders included order for Ipratropium-Albuterol inhalation solution 0.5 - 2.5 (3) mg(milligram)/ml(milliliter) - 3 mL inhale orally two times a day related to mild intermittent asthma. R32's medical record was reviewed and lacked evidence of self-administration of medications order had been obtained for R32. During observation and interview on 11/18/24 at 3:17 p.m., R32 stated she used the nebulizer machine twice daily and has been on it for long-term management of asthma. R32 stated nurse will bring medication into room, pour medicated solution into the canister of the nebulizer mask, apply nebulizer mask to resident's face, will turn on nebulizer machine and will then leave her room. R32 stated the nurse will sometimes come back to her room, at a later time, to make sure nebulizer machine is turned off. Nebulizer mask with canister was standing up in nebulizer machine and contained approximately 1/4 inch of clear solution in canister. During observation on 11/19/24 at 12:49 P.M., nebulizer mask with canister was standing up in nebulizer machine and the canister was full of clear solution. During observation on 11/19/24 at 6:44 p.m., nebulizer mask with canister was standing up in nebulizer machine and contained approximately 1/4 inch of clear solution in canister. During observation on 11/20/24 at 8:47 a.m., nebulizer mask with canister was standing up in nebulizer machine and contained approximately 1/4 inch of clear solution in canister. During observation on 11/20/24 at 3:43 p.m., R32 was sitting in room with the nebulizer mask on her face and the nebulizer machine running. No staff were present in R32's room. During observation on 11/21/24 at 9:45 a.m., nebulizer mask with canister was standing up in nebulizer machine and contained approximately 1/4 inch of clear solution in canister. During record review on 11/20/24, the self-administration of medications (SAM) assessment was completed on 4/16/24, identified R32 was physically unable to self-administer medications and was not a candidate for self-administration of medication. During interview on 11/20/24 at 9:57 a.m., licensed practical nurse (LPN)-B stated there was only one resident that resided in facility who had an order to self-administer medications and confirmed R32 was not the resident. During interview on 11/20/24 at 10:02 a.m., nursing assistant (NA)-E stated the nurse sets the nebulizer up, applies fluid into canister, applies mask to R32's face and then leaves the room. NA-E stated nurse will come back at a later time to shut machine off. During interview on 11/20/24 at 10:16 a.m., LPN C stated there was only one resident who had a SAM order and LPN-C confirmed it was not R32. LPN-C stated if a resident had a SAM order, a little blue person with a circle around would be displayed in R32's electronic medication record (EMR). LPN-C reviewed R32's EMR and confirmed R32 did not have an order for self-administration of medications. During interview on 11/20/24 at 10:36 a.m., LPN-B confirmed R32 did not have an order to self-administer medications. LPN-B stated the nurse would take nebulizer solution into R32's room, set nebulizer up, apply mask and then would go back into R32's room [ROOM NUMBER]-20 minutes later to check on resident and shut machine off. When surveyor asked if R32 should have a self-administer order for nebulizer's, LPN-C stated, I don't know, this is just something we have always done. During interview on 11/21/24 at 10:48 a.m., LPN-A stated when a resident has a nebulizer treatment, the nurses set up the solution, apply the mask and would then leave room and come back later to check on resident. LPN-A stated R32 does her nebulizer treatment independently and confirmed had R32 had no SAM order. During interview on 11/21/24 at 11:39 a.m., registered nurse (RN)-A stated there was only one resident in the facility that had an order to self-administer medications and confirmed R32 did not have a SAM order. RN-A stated the nurse sets up the solution, signs it out in the MAR, fills canister in nebulizer mask with nebulizer solution, applies mask to resident's face and then would come back 15 minutes later to check on resident. When surveyor asked if a nebulizer treatment should be assessed for self-administration and an order obtained, RN-A stated she could understand and how it would be important to assess the resident for a self-administration order. RN-A stated if a resident was confused, the straps could be a safety risk if resident could not get the mask off their face and to also ensure the resident is able to self-administer medications safely. During interview on 11/21/24 at 12:59 p.m., assistant director of nursing (ADON) stated a resident should have a self-administration assessment completed to ensure the resident could reliably and accurately self-administer medications. ADON stated her expectation would be for nebulizer's to be assessed for self-administration of medication after set-up if staff are leaving the room during the treatment. ADON confirmed R32 did not have any SAM orders and stated an assessment should have been completed and an order should have been obtained. ADON stated it was important to ensure that the resident can correctly, accurately, and safely self-administer medications and that the provider agrees with the resident self-administering medications. ADON stated the resident should be reassessed quarterly to ensure there are no changes in resident's cognitive or physical status. The facility Self-Administration of Drugs policy, dated 7/24, identified residents in the facility who wish to self-administer their medications may do so, if it is determined that they are capable of doing so. As part of their overall evaluation, the RN and practitioner will assess each resident's mental and physical abilities, to determine whether a resident is capable of self-administering medications. In addition to general evaluation of decision-making capacity, the RN and practitioner will perform a more specific skill assessment, including (but not limited to) the resident's: 1. Ability to read and understand medication labels, 2. Comprehension of the purpose and proper dosage and administration time for his or her medications, 3. Ability to remove medications from a container and to ingest and swallow (or otherwise administer) them, and 4. Ability to recognize risks and major adverse consequences of his or her medications. If the RN determines that a resident cannot safely self-administer medications, the nursing staff will administer the resident's medications. The RN and practitioner review quarterly and as needed a resident's ability to continue to self-administer medications.

Based on interview and document review, the facility failed to provide the required written Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) and Notice of Medicare Non-Coverage (NOMNC) forms to 2 of 3 residents (R7 and R16) reviewed whose Medicare A coverage ended and then remained in the facility. Findings include: R7's undated Census Records listing identified on 7/9/24, R7's payer source changed from Medicare Part A to Private Pay, and remained in the facility. R7's medical records lacked evidence that a SNFABN and/or the NOMNC forms were completed and/or reviewed with resident/representative. R16's undated Census Records listing identified on 9/7/24, R16's payer source changed from Medicare Part A to Medicaid, and remained in the facility. R16's medical records lacked evidence that a SNFABN and/or the NOMNC forms were completed and/or reviewed with resident/representative. During interview on 11/20/24 at 2:09 p.m., social worker (SW) stated the facility could not locate any forms for R16. During interview on 11/21/24 at 11:22 a.m., SW stated the facility could not locate any forms for R7. During interview on 11/21/24 at 11:30 a.m., registered nurse (RN)-A stated forms are discussed at the facilities daily stand-up meetings and the MDS coordinator completed them. RN-A stated the MDS coordinator is on medical leave and the director of nursing (DON), assistant director of nursing (ADON) and herself have been splitting the MDS coordinator's tasks between the three of them and completes them. RN-A confirmed she could not locate any forms for R7 or R16. During interview on 11/21/24 at 12:59 p.m., ADON stated the facility could not locate any forms for R16. ADON stated it was important to complete and keep the notices to prove a discussion had been had with the resident and/or representative regarding the services and benefits that are ending. Important for the discussion and review of forms are completed with enough notice so the resident/representative could appeal if they do not agree with the discontinuation of services and they are aware of the daily rate they would be responsible for after coming off Medicare part A. During interview on 11/21/24 at 1:53 p.m., ADON stated the facility could not locate any forms for R7. ADON stated she could not confirm if they had been completed or not. The facility Beneficiary notices policy and procedure was requested but was not received.

Based on observation, interview and document review, the facility failed to reassess behaviors and intervention of potential wandering to ensure safety and prevent possible elopement for 2 of 2 residents (R37 and R33) reviewed for accidents. Findings include: R37's quarterly Minimum Data Set (MDS) dated [DATE], identified R37 had severe cognitive impairment and required assistance with all activities of daily living (ADL)'s. R37's diagnoses included Alzheimer's disease, aphasia, dementia, depression, polyneuropathy, and low back pain. MDS indicated wandering was not exhibited. R37's initial Elopement Risk Assessment, dated 7/14/23, indicated R37 was an elopement risk. However, R37's medical record was reviewed and lacked evidence R37 had been comprehensively reassessed quarterly for wandering or a potential elopement risk. R37's order summary, indicated order to check placement of wander guard (alerts when attempting to leave an area or building) on left wrist every shift. R37's care plan, indicated R37 was at risk for eloping and wandering due to history of attempts at home and attempts at eloping rom facility since admission. R37's progress note, dated 10/16/24 at 10:30 a.m., identified wander guard in place due to history of wandering and elopement. R37's progress note, dated 6/11/24 at 5:26 p.m., indicated R37 wandered down hallway during dinner, pushed on the south emergency exit door, and exited the building. Door alarm and wander guard sounded alerting staff that R37 had exited the building. Staff were able to redirect resident back inside. During observation on 11/18/24 at 3:57 p.m., R37 was seated in his wheelchair in the common living room area and was self-propelling self around room reaching out for imaginary items. R37 had a wander guard device on his left wrist. During observation on 11/21/24 at 10:43 a.m., R37 was seated in his wheelchair in the common living room area and was self-propelling self around room. R37 was seated by the front door for several minutes before beginning to wander around area. During observation on 11/21/24 at 1:33 p.m., R37 was seated in his wheelchair in the common living room area and was self-propelling self around room. During interview on 11/20/24 at 9:57 a.m., licensed practical nurse (LPN)-B stated R37 wandered throughout facility. During interview on 11/20/24 at 10:02 a.m., nursing assistant (NA)-E stated R37 was very active and restless, wanders around facility, and requires one on one staff monitoring frequently for safety. During interview on 11/21/24 at 11:14 a.m., social worker (SW)-A stated wandering and elopement assessments are completed by either herself or nursing staff. SW-A stated she is usually the one responsible for completing these assessments. SW-A stated elopement assessments are completed quarterly along with the resident's quarterly assessments. SW-A confirmed R37's last elopement assessment was completed on 7/14/23. SW-A stated quarterly reassessments are important to ensure interventions in place are still appropriate, wander guard was still appropriate, and if there was still an elopement risk/concern. During interview on 11/21/24 at 12:59 p.m., assistant director of nursing (ADON) stated elopement/wandering assessments are to be completed quarterly. ADON confirmed R37 last elopement assessment was completed on 7/14/23. ADON stated it should have been reassessed quarterly. ADON stated it was important to reassess resident quarterly for safety reasons, to determine if resident was still at continued risk for elopement and ensure wander guard is still appropriate as it could be a dignity concern for a resident who no longer needs a wander guard. ADON stated the elopement assessment would help determine if the resident was having increased wandering and may need to be transferred to the memory care unit for their safety. 40938 R33's quarterly MDS dated [DATE], identified R33 had severe cognitive impairment, required extensive assistance with care, R33 wore a wander/elopement alarm. R33's medical diagnoses included parkinsons, dementia, post traumatic stress disorder (PTSD), anxiety, edema, repeated falls, cerebrovascular disease, visual hallucinations, and restless legs. R33's Wandering Risk Assessment done 8/22/23, identified R33 did not understand surroundings or what is being said and had a history of wandering. Wandering Risk Assessment score was 14 indicating R33 was at a high risk of wandering behavior R33's care plan dated 11/02/24, identified R33 was an elopement risk/wanderer due to history of attempts to leave facility unattended. Interventions included redirect from wandering by offering pleasant diversions, structured activities, food, and conversation and wanderguard on wrist. On 11/19/24, at 6:58 p.m. R33 was observed in common area watching television (tv) no attempts to wander. R33 was observed on 11/20/24, at 10:13 a.m. self propelling wheelchair in common area, no attempt to approach front door. on 11/20/24, at 1:43 p.m. R33 was observed self propelling wheelchair down hallway, no attempt to approach front door, no attempts to enter other resident rooms. On 11/21/24, at 9:16 a.m. R33 was observed self-propelling wheelchair from dining room to common area with no attempt to go towards front door. When interviewed on 11/21/24, at 9:20 a.m. nursing assistant (NA)-B stated R33 wandered down hallways, did not enter other residents rooms and had not attempted to leave the building in a long time When interviewed on 11/21/24, on 10:03 a.m. licesed practical nurse (LPN)-A stated in R33s head he has somewhere to go. He hasn't done any exit seeking in a very long time, he goes up and down the halls looking for something, never enters other rooms. During interview on 11/21/24, at 10:49 a.m. assistant director of nursing (ADON) stated wandering/elopment assessments were completed at admission and quarterly. ADON confiremd a wandering risk assessment was last completed on 8/22/23, the assessment should be completed quarterly to ensure the wanderguard is still an appropriate intervention. When interviewed on 11/21/24, at 11:14 a.m. social worker - A stated wandering and elopement assessment were completed between social services and nursing. Risk assessments are coordinated with the quarterly assessments. social worker confirmed that lastwandering risk assessment was completed on 8/22/23. Important to assess to determine interventions in place are still appropriate for them. The facility Wandering, Unsafe Resident policy, dated 7/2024, identified the facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for elopement. The staff will identify residents who are at risk for harm because of unsafe wandering (including elopement). Nursing staff will assess residents quarterly for risk factors related to unsafe wandering. If determined to be at risk, nursing will consult with social services. The resident's care plan will indicate the resident is at risk for elopement or other safety issues. Interventions to try to maintain safety will be included in the resident's care plan. If wander guard is determined to be needed, consent will be obtained from family for device use. Nursing staff will document circumstances related to unsafe actions, including wandering, by a resident. Staff will institute a detailed monitoring plan, as indicated for residents who are assessed to have a high risk of elopement or other unsafe behavior. Staff will notify the Administrator and Director of Nursing immediately and will institute appropriate measures (including searching) for any resident who is discovered to be missing from the unit or facility.

Based on observation, interview, and documentation review the facility failed to provide assistance with facial hair removal for 2 of 3 residents (R32 and R37) with grooming needs who was dependent upon staff for assistance. Findings include: R32's quarterly Minimum Data Set (MDS) dated [DATE], identified R32 had severe cognitive impairment and required assistance with all activities of daily living (ADL)'s. R32's diagnoses included heart failure, hypertension, orthostatic hypotension, renal failure, Alzheimer's disease, stroke, dementia, depression, and asthma. R32's care plan lacked evidence of resident's shaving preferences. During observation on 11/19/24 at 6:44 p.m., R32 was sitting in wheelchair in her room. R32 had white facial hair on chin approximately 1 inch long. During observation on 11/20/24 at 8:47 a.m., R32 continued to have facial hair on chin. During observation on 11/20/24 at 3:43 p.m., R32 continued to have facial hair on chin. During observation on 11/21/24 at 9:45 a.m., R32 continued to have facial hair on chin. R37 R37's quarterly Minimum Data Set (MDS) dated [DATE], identified R37 had severe cognitive impairment and required assistance with all activities of daily living (ADL)'s. R37's diagnoses included Alzheimer's disease, aphasia, dementia, depression, polyneuropathy, and low back pain. R37's care plan lacked evidence of resident's shaving preferences. During observation on 11/18/24 at 2:53 p.m., R37 had facial hair located on face located on his check extended down chin and neck approximately one fourth inch to one half inch long. During observation on 11/19/24 at 12:39 p.m., R37 continued to have facial hair on face. During observation on 11/20/24 at 1:04 p.m., R37 continued to have facial hair on face. During observation on 11/21/24 at 10:43 a.m., R37 continued to have facial hair on face. During interview on 11/19/24 at 2:25 p.m., family member (FM)-A stated R37 was very particular with being clean shaven and had detailed hygiene practices he had performed daily. During interview on 11/20/24 at 10:02 a.m., nursing assistant (NA)-E stated if a resident had facial hair and needed to be shaved, she would automatically shave resident with morning cares. During interview on 11/20/24 at 10:16 p.m., licensed practical nurse (LPN)-C stated nursing assistants perform shaving when doing morning cares with residents. LPN-C confirmed R32 and R37 had facial hair and should have been shaved. During interview on 11/21/24 at 10:48 a.m., LPN-A stated nursing assistants shave residents on bath days but if facial hair is noted, nursing assistants would shave residents when needed. LPN-A confirmed there was a few scruffy residents at this time who should be shaved. LPN-A confirmed R32 and R37 had facial hair and should have been shaved. During interview on 11/21/24 at 11:39 a.m., registered nurse (RN)-A stated when a resident is admitted , their shaving preference is asked. Shaving is performed by the nursing assistants on the resident's bath day or as needed or based on their preferences. RN-A stated staff should be asking R32 if she would like her chin hairs shaved and that R37 should be shaved daily. RN-A stated we encourage daily grooming for the residents. During interview on 11/21/24 at 12:59 p.m., assistant director of nursing (ADON) stated the nursing assistants should be assisting residents with shaving. ADON stated the resident's shaving preferences should be located on the resident's care plan. ADON stated her expectation is shaving should occur daily with grooming and for staff to ask the resident if they would like to be shaved if facial hair is noted. ADON stated it was a commonsense thing and is important for the resident to be shaved for the dignity of the resident and their sense of self. The facility Shaving the Resident Policy, dated 7/24, indicated shaving residents is to promote cleanliness and to provide skin care.

Based on interview and document review, the facility failed to ensure proper treatment was provided to maintain hearing for 1 of 1 resident (R8) reviewed for hearing. Findings include: R8's annual Minimum Data Set (MDS) dated [DATE], identified R8 had intact cognition and required assistance with all activities of daily living (ADL)'s. MDS indicated R8 had minimal difficulty with the ability to hear and wore hearing aids. R8's Communication Care Area Assessment (CAA) dated 9/19/24, indicated R8 had the potential for communication deficits related to his hearing impairment. Identified R8 had poor hearing in both ears and R8 had a history of cerumen (wax) build up. R8's care plan, indicated R8 has a communication problem related to hearing deficit and he wore bilateral hearing aids. R8's electronic health record (EHR) lacked evidence R8 was offered an audiology appointment. R8's physician's orders identified an order to flush both ears until wax clears every 24 hours as needed for wax buildup. During observation on 11/18/24 at 3:20 p.m., R8 had hearing aid in the left ear but none in the right ear. During observation and interview on 11/18/24 at 3:21 p.m., R8 stated he took his hearing aides out as they are not working well. R8 stated if a new battery is replaced into hearing aids, his hearing improved for a couple of hours and then went back to him not being able to hear. During observation on 11/19/24 at 12:37 p.m., R8 did not have hearing aids present in ears. During observation on 11/19/24 at 7:53 p.m., R8 was sitting out in the common area playing cards with another resident. R8 did not have hearing aids present in ears. R8 was speaking very loudly to another resident. During observation on 11/20/24 at 8:44 a.m., R8 was sitting in common area talking loudly to another resident. R8 did not have hearing aids present in ears. During observation on 11/20/24 at 3:22 p.m., R8 was sitting in common area talking loudly to another resident. R8 did not have hearing aids present in ears. During observation on 11/21/24 at 9:21 a.m., R8 did not have hearing aids present in ears. During interview on 11/20/24 at 10:02 a.m., nursing assistant (NA)-E stated resident had hearing aids, but thought they were broken and she does not know what exactly is going on with them. NA-E stated R8 may have wax buildup in ears and may need his ears flushed as he has a history of wax buildup. NA-E confirmed she has noticed an increase in hearing impairment for R8. During interview on 11/21/24 at 10:48 a.m., licensed practical nurse (LPN)-A stated R8 wore hearing aids but thinks that they do now work very well. LPN-A stated staff assist R8 with changing the batteries. LPN-A stated nursing could check R8's ears for wax if resident has complaints of pressure or staff notices his hearing is worse. LPN-A confirmed R8's hearing has been notably worse in the past month or so. Confirmed R8 had an order to flush ears. During interview on 11/21/24 at 11:39 a.m., registered nurse (RN)-A stated R8 has difficulty hearing and wore hearing aids in both ears. RN-A stated if staff notice a decrease in hearing, nursing should assess R8's ears with an otoscope to check for wax buildup. RN-A confirmed R8 had an order for flushing ears due to wax buildup and stated since R8 had that order in place, it should have been done to see if his hearing would improve at all after flushing. RN-A stated the provider reviewed orders every 30-60 days so due to it being an order, it should be tried to check for hearing improvement. RN-A confirmed flushing of R8's ears had not been completed in the past 6 months as it would be documents on the mediation administration record (EMR). During interview on 11/21/24 at 12:59 p.m., assistant director of nursing (ADON) stated she would expect staff to process the standing order for Debrox (wax softening) ear drops and then to flush ears after drops were initiated. ADON stated she expects the nurse to check for wax buildup when there is an increase in hearing difficulty noted in a resident. ADON stated this was important for the resident to be able to communicate and for staff to be able to communicate with him as this could lead to dignity concerns for the resident. The facility Care of the Hearing-Impaired Resident policy, dated 7/24, indicated the purpose of this procedure is to provide guidelines when providing care to the resident with hearing impairment. The facility to evaluate resident's progress and adjustment at regular intervals.

Based on observation, interview, and document review the facility failed to comprehensively assess past trauma and implement care plan interventions utilizing a trauma-informed approach for 1 of 1 (R37) resident reviewed who had a history of past traumatic experiences. Findings include: R37's quarterly Minimum Data Set (MDS) dated [DATE], identified R37 had severe cognitive impairment and required assistance with all activities of daily living (ADL)'s. R37's diagnoses included Alzheimer's disease, aphasia, dementia, depression, polyneuropathy, and low back pain. R37's care plan, print date of 11/19/24, lacked individualized trauma-informed approaches or interventions and lacked identification of triggers to avoid potential re-traumatization. R37's trauma questionnaire dated 7/6/23, indicated R37 had trauma in his past. However, no additional information was obtained to determine triggers and/or coping mechanisms. During interview on 11/19/24 at 2:30 p.m., family member (FM)-A stated R37 had post-traumatic stress disorder (PTSD) and behaviors had gotten worse. FM-A stated R37 would see imaginary people coming out of the television and standing outside the windows, would take things apart and remove batteries from items as he disassembled bombs during his time in Vietnam, would sleep during the day and would be awake all night as he would stand in the bedroom or sit in chair in living room where he could see both doors on guard like he was on guard duty, and collected silverware due to limited silverware during his time in Vietnam. FM-A stated facility gave R37 plastic silverware to eat with due to R37 taking the regular silverware, putting them in his shirt pocket and would have six to eight pieces of silverware at a time. During interview on 11/20/24 at 10:02 a.m., nursing assistant (NA)-E stated she was not aware of any past trauma in R37's life. NA-E stated it would be important to know if a resident went to war or had certain triggers so if they exhibit behaviors we know how to respond. NA-E stated if resident had a history of trauma, it would be on resident's care plan. During interview on 11/20/24 at 10:25 a.m., social worker (SW) stated she is responsible for completing assessments for trauma, elopement, and mood/depression. SW stated on the trauma assessments, if a resident answers yes to a question, she would have to talk in detail about triggers and what interventions are effective and put triggers/interventions in the resident's care plan. SW stated she completed the assessments for all residents, no matter what the resident's cognitive level is. SW stated for a resident with severe cognitive impairment, she would interview the resident and may get family input at care conference. SW stated she would be notified by staff with any issues resident may be experiencing and would follow up with resident to determine what could be offered or what interventions could be implemented. During interview on 11/21/24 at 9:15 a.m., SW stated trauma assessments are completed upon resident's admission and uses the information from the assessment to implement in care plan. SW confirmed she completed trauma assessment for R37 when R37 was admitted in 2023. SW stated when a resident has a decline or a change, it is discussed at Tuesday staff meetings and then she would reassess resident and determine what to do next. SW stated if a resident displayed behaviors, they would watch and chart behaviors. Facility has offered small groups for veterans, cognitive bins, real babies, and coordination with therapy for tasks to keep resident busy. During interview on 11/21/24 at 10:45 a.m., licensed practical nurse (LPN)-C stated she was not aware of any past trauma in R37's life. During interview on 11/21/24 at 10:46 a.m., LPN-A stated he was not aware of any past trauma in R37's life. During interview on 11/21/24 at 10:31 a.m., SW confirmed she completed the trauma assessment with R37, who had a severe cognitive impairment, and put information on care plan. SW reviewed R37's record and confirmed trauma was not on care plan. SW stated she should have asked about possible triggers and implement interventions to support the resident the best the facility can. SW stated it was important to include trauma on resident's care plan so staff know how to care for the resident and can provide interventions when needed. During interview on 11/21/24 at 12:59 p.m., assistant director of nursing (ADON) stated that when a resident is admitted , they are asked about past trauma and trauma informed care questionnaire would be completed by the social worker. ADON stated trauma assessments should be assessed quarterly due to new or changing behaviors. ADON stated R37's care plan should have included behavior monitoring, PTSD/trauma triggers, how staff would avoid those triggers and interventions to be used if R37 was triggered. ADON confirmed R37 did not have behavior monitoring or a care plan that addressed R37's past trauma and the last trauma assessment completed was on 7/6/23. A facility Trauma Informed Care policy, dated 7/2024, indicated the facility would demonstrate a culturally competent and trauma informed practice; integrate residents' preferences into care plans and understand the three core principles of Trauma Informed Care. The impact of adversity is not a choice; understanding adversity helps us make sense out of a behavior and prior adversity is not a [NAME]. The facility is to ensure that all those involved in the organization understand the general impact of trauma; paths to recovery and identify signs and symptoms of trauma in resident, families, staff and to incorporate practices that prevents re-traumatization. The facility will incorporate the 4 R's of a Trauma Informed Approach: - Realization: Ensure that all those involved in facility comprehend that trauma can affect individual's families, staff, and the community. - Recognition: Staff will recognize signs and symptoms of trauma and have access to trauma screening tools. - Responding: Staff will respond by using the Trauma informed Approach. - Resisting Re-traumatization: Ensure that practices and behaviors do not create a disruptive environment and re-traumatize.

Based on observation, interview, and document review the facility failed to ensure side rails were assessed to determine appropriate and safe to use for 2 of 5 residents (R8 and R19) who were observed to have a side rail affixed to their beds. Findings include: R8's annual Minimum Data Set (MDS) dated [DATE], identified R8 had intact cognition and required assistance with all activities of daily living (ADL)'s. R8's diagnoses included dislocation of internal left hip prosthesis, coronary artery disease, GERD, obstructive uropathy, arthritis, presence of cardiac pacemaker, pain in right shoulder, pain in left shoulder, generalized muscle weakness and other abnormalities of gait and mobility. MDS did not identify use of side rails. R8's care plan, included R8 required limited assist of one staff for bed mobility (to go from lying to sitting/sitting to lying) but was able to turn and reposition in bed himself in bed. Care plan indicated R8 had two half upper side rails to assist with bed mobility and for staff to observe for injury or entrapment related to side rail use. During observation on 11/18/24 at 3:27 p.m., R8's bed had a 1/4 side rail affixed to the head of bed on both sides of bed. R8's medical record lacked evidence that an assessment had been completed timely to determine necessity and whether R8 could safely use side rails. Last side rail assessment was completed on 6/25/24. Additionally, R8s medical record lacked evidence alternatives were tried prior to installing the side rails. R19's annual Minimum Data Set (MDS) dated [DATE], identified R19 had moderate cognitive impairment and required assistance with all activities of daily living (ADL)'s. R19's diagnoses included stroke, hemiplegia following cerebral infarction affecting right dominant side, atrial fibrillation, coronary artery disease, heart failure, hypertension, thyroid disorder, depression, dysphagia following cerebral infarction and Barrett's esophagus without dysplasia. MDS did not identify use of side rails. R19's care plan, print date of 11/20/24, included that R19 required limited assist of one staff for bed mobility. Care plan indicated R19 had two half side rails on both sides of her bed to help her turn and transfer easier. During observation on 11/19/24 at 12:39 p.m., R19's bed had a 1/4 side rail affixed to the head of bed on both sides of bed. R19's medical record lacked evidence that an assessment had been completed timely to determine necessity and whether R19 could safely use side rails. Last side rail assessment was completed on 8/21/23. Additionally, R19s medical record lacked evidence alternatives were tried prior to installing the side rails. During interview on 11/18/24 at 3:27 p.m., R8 stated he used side rails to reposition himself in bed and to assist him with getting into bed. R8 stated the side rails were in my way when he had to get up to use restroom at night. R8 stated he told staff several times but the staff told resident that it is something I guess I have to have. During interview on 11/20/24 at 10:02 a.m., nursing assistant (NA)-E stated she has seen R8 utilize the side rails on his bed with turning and repositioning NA-E stated she has seen R19 utilize the side rails on her bed with repositioning and to assist her from sitting to standing. During interview on 11/21/24 at 10:48 a.m., licensed practical nurse (LPN)-B stated R8 utilized bed rails to aid in turning and repositioning in bed. LPN-B stated he was not aware R8 was having trouble getting out of bed at night due to the side rails and stated R8 is not supposed to get out of bed on his own anyway's as R8 tends to self-transfer. During interview on 11/21/24 at 11:39 a.m., registered nurse (RN)-A stated side rail assessments are completed quarterly and annually by the MDS nurse. RN-A stated the MDS nurse has been out of medical leave for the past several months and her duties were being completed by director of nursing (DON), assistant director of nursing (ADON) and herself. RN-A confirmed R8's last side rail assessment was completed on 6/25/24 and R8 should have had another assessment completed in September. RN-A confirmed R19's last side rail assessment was started on 8/28/24 but it was not started/completed and the last completed assessment was completed on 8/31/23. RN-A stated facility does not assess the resident for what type of grab bar/side rail would be appropriate for resident but for whatever device is on the bed in the room that the resident was admitted to is what the resident received. RN-A stated some residents get side rails and some get grab bars. RN-A stated she did not assess side rails based on the resident's condition or need, only assessed on if resident wanted them. RN-A was not aware of what alternative methods could be assessed and/or trialed regarding side rails. RN-A stated assessment of side rails is important to ensure resident still wanted to use side rails, determine if resident still needed them and that they are able to still use them safely. During interview on 11/21/24 at 12:59 p.m., assistant director of nursing (ADON) stated side rail assessments are competed quarterly. ADON stated whatever is on the bed in the room the resident was admitted to is what the resident was assessed for. ADON stated the facility treated grab bars and side rails the same. ADON stated assessment of side rails are important to ensure the resident has side rails for the right reasons, that they are still safe for the resident, and that the resident is not having ill effects from having side rails on bed. The facility Assessing the Safety of Side Rails policy, dated 8/2024, indicated staff will alert the RN if a client has any type of side rail or similar equipment and the RN will then evaluate whether the side rails appear to be safe for the client. The RN will educate the client, the client's representative and/or family members about the risks related to side rails, and if the client's side rail does not appear to meet FDA standards, the RN will recommend to the client, the client's representative, the client's involved family members that the side rail be removed and will recommend alternative options to reduce the risk of a fall out of bed. The RN will document these conversations and recommendations. 1. The RN will train staff to be alert for any side rail or equipment that resembles a side rail that a client may be using or considering using and to notify the RN immediately about the side rail or equipment. 2. When notified that a client has a side rail, the RN will assess and evaluate what the client's needs are and assess to determine if the client can safely utilize the side rail/equipment and determine whether the side rail/equipment meets the FDA standards for side rails. 3. The RN will provide for any client who has a side rail or is considering obtaining one and, if appropriate, the RN will educate the client's representative and/or the client's family regarding side rail safety and risks including potential death due to falls, entrapment, and asphyxiation. If the RN determines that the client is not able to safely use a side rail, or that the client's side rail does not meet the FDA or most current safety guidelines, the RN will recommend that the side rail should be removed and will document this recommendation, will document to whom the education was directed and will document the person who was given the recommendation to remove the side rail. 4. If the RN determines that the side rails are not a safe device for the client, the RN will provide options and alternatives for reducing fall or positioning self to the client, the client's representative and/or the client's family. The RN will document these recommended options and the response from the client, client's family, and client's representative to the RN's recommendations. 5. The RN may not remove a side rail that is the property of the client, the client's representative or the client's family. If the RN determines that a client's side rail is unsafe, and the client, the client's representative or the client's family does not remove it, the RN will notify the client's physician and consider whether to notify the Common Entry Point. Side rails can be very helpful in assisting individuals in transferring out of bed or repositioning in bed. It is important to recognize that the dangers exist regardless of the purpose for using the side rails. Nursing staff should assess an individual's capabilities for using side rails safely.

Based on interview and document review, the facility failed to ensure the services of a registered nurse (RN) were available onsite for 8 consecutive hours seven days a week. This had the potential to affect all 41 residents who reside at the facility. Review of the facility staffing schedules dated 4/1/24 through 6/30/24, identified there was not eight consecutive hours of RN coverage for 6/2/24, 6/15/24 and 6/16/24. During interview on 11/21/24 at 12:59 p.m., the assistant director of nursing (ADON) verified there was no RN on for eight consecutive hours on 6/2/24, 6/15/24 and 6/16/24. The ADON stated the facility policy and practice was to have a RN on duty in the building eight consecutive hours but had call-ins for those dates and not sure what happened. The facility Departmental Supervision policy, dated 7/2024, indicated the nursing services department shall be under the direct supervision of a Registered or Licensed Practical/Vocational nurse at all times. 1. A Registered or Licensed Practical/Vocational Nurse (RN/LPN/LVN) is on duty twenty-four hours per day, seven days per week, to supervise the nursing services activities in accordance with physician orders and facility policy. 2. A Registered Nurse (RN) is employed as the Director of Nursing Services (DNS). The DNS is on duty during the day shift Monday through Friday. During the absence of the DNS, the Assistant Director of Nursing (ADON), then a RN Care Coordinator (RNCC) is responsible for the supervision of all nursing department activities including the supervision of direct care staff. During the absence of those Registered Nurses (Weekends and holidays), a registered nurse will be scheduled to be on duty, in the facility, 8 hours out of every 24 hour period.

Based on observation, interview and record review the facility failed to conduct a thorough analysis to determine the causative factor of resident's falls; develop appropriate patient-centered interventions; implement appropriate fall interventions; and evaluate the effectiveness of interventions to prevent and/or reduce the likelihood of future falls for 2 of 2 residents (R28 and R38) reviewed for falls. This resulted in actual harm when after five prior falls, R28 fell on [DATE] and sustained a right [MEDICAL CONDITION] and underwent surgical repair, and since R28 experienced 7 additional falls. Findings include: R28's admission record, indicated the resident had [MEDICAL CONDITION], repeated falls and unspecified dementia without behavioral disturbance. R28 record review of fall incident reports from (MONTH) 2019 included 5 falls from 1/1/19 to 1/23/19 with minor injuries. 1. R28's fall incident report dated 1/1/2019 indicated R28 had an unwitnessed fall at 8:30 p.m. Resident states she reached for something and fell out of her chair. No obvious injuries noted. R28's medical record lacked documentation of a root cause analysis or an interdisciplinary team meeting review of this fall. No new intervention was implemented after the fall. 2. R28's fall incident report dated 1/9/2019 indicated R28 had an unwitnessed fall at 12:15 a.m. Resident Description: I was going to the bathroom and got mixed up. She said she lost her balance and fell backwards. She said she hit her head. She said she hurt her knees trying to get up. Immediate action taken: There was a goose egg forming on her back of her head. Ice pack gotten immediately. VS (vital signs) taken, taken to the bathroom and put in bed. Intervention: New N.O. (nursing order) to change batteries to motion detector routinely. R28's medical record lacked documentation of a root cause analysis or an interdisciplinary team meeting review of this fall. 3. R28's fall incident report and progress notes dated 1/20/19 indicated R28 had an unwitnessed fall at 12:02 a.m. nurse was alerted to lobby and observed resident laying on left side. Resident unable to describe. Immediate action taken: ROM (range of motion) checked WNL (within normal limits) Observed small bruise to left ear 1.0cm (centimeters) x 0.5cm. Intervention: OT (occupational therapy) order for wheelchair positioning. R28's medical record lacked documentation of a root cause analysis or an interdisciplinary team meeting review of this fall. 4. R28's fall incident report dated 1/22/19 indicated R28 had an unwitnessed fall at 9:50 p.m. res (resident) in seated position on her bathroom floor. Res (resident) denies pain; states she was trying to use the bathroom. R28's medical record lacked documentation of a root cause analysis or an interdisciplinary team meeting review of this fall. No new intervention was implemented. 5. R28's fall incident report and progress notes dated 1/23/19 indicated R28 had an unwitnessed fall at 11:10 a.m. in the activity room. Resident was observed laying on right side with wheelchair perpendicular to her. R28's medical record lacked documentation of a root cause analysis or an interdisciplinary team meeting review of this fall. No new intervention was implemented. R28's fall risk assessment completed 1/23/19 indicated R28 was at high risk for falls. 6. On 2/10/19, R28's Fall Incident Report, indicated R28 had an unwitnessed fall at 12:30 a.m. bed chime was activated, staff on way to room, crash heard. R28 was found on the floor on her right side. Small skin tear on her right elbow, skinned knee (not abrasion, no blood). VSS (vital signs stable), alert says hip hurts. Gotten up, placed in wh (wheel) chair. Unable to bear wt (weight). R28's first reaction to staff was, I did it again. Then I don't think I hit my head, but I hit my arm on the floor. Immediate action taken: Vs (vital signs), skin assessment completed. Seated in her wheelchair. She cried out in pain when right hip side was palpated. Unable to bear wt (weight). R28's medical record lacked documentation of a root cause analysis or an interdisciplinary team meeting review of this fall. No new intervention was implemented upon R28's return to the facility on [DATE] following hospitalization and surgery for [REDACTED]. R28 was observed 7/30/19, at 9:55 a.m. sitting in her wheelchair in the common area of the facility. R28 had gripper socks on her feet and a lap tray attached to the right arm of her wheelchair. R28's care plan last revised on 7/31/19, indicated the resident was at risk for falls due to poor balance. She has a [DIAGNOSES REDACTED]. R28 has history of falls. Interventions/Tasks for care included: Fall intervention 5 day sleep diary with sleep assessment to follow (initiated 10/29/18), wheelchair seat to be wedged. R28 will continue to be able to move out of chair with the chair wedged. Therapy assessed (initiated 11/19/18), Change Tylenol administration to increase resident rest (initiated 4/3/19), related to fall and need for Tylenol. 5 day pain assessment (initiated 4/3/19), anti rollback breaks (initiated 3/5/18), Anticipate and meet needs. Gripper socks on, TV off at bedtime (initiated 7/31/17), Assist R28 assistance with HS (evening) cares in-between 7:30pm-8:30pm (initiated 6/22/18), Assist R28 to use the toilet in between 5:15am-5:45am (initiated 6/28/18), Be sure call light is within reach and encourage to use it for assistance as needed. Prompt response to all requests for assistance (initiated 7/5/17), Desk/table to keep items at eye level in room (initiated 8/22/18), Do not leave resident alone in bathroom (initiated 10/31/18), Do not leave resident unattended in the dining room per IDT team (initiated 9/19/17), During sleeping hours observe every hour resident quietly and if she is restless and/or awake encourage her to use toilet (initiated 9/20/18), Dycem to w/c cushion to prevent slipping (initiated 9/25/17), Ensure HS (evening) snack is supervised to avoid her picking up dropped items off the floor (initiated 12/10/18), ensure personal belongings are within arms reach (initiated 1/20/18), Ensure resident is to wear black dr. Scholl's shoes/ gripper socks when ambulating or mobilizing in w/c. Monitor for compliance (initiated 7/5/2017), Fall mat while resident is in bed (initiated 3/23/19), R28 has a lap tray in her wheelchair, which she is able to remove. Ensure this is applied when she is in her chair, she is able to remove it independently. This helps to support her as she leans to the side when she is fatigued. If resident is observed leaning to the side or forward, assist her to lay in bed (revised 4/15/19), R28's room door should be left open (initiated 5/30/2018), Keep clothing in closet rather than at bedside (initiated 4/26/18), Keep written reminder near resident to remind her to ask for help picking items up etc (initiated 4/19/18), med review for fall 9/18/18 (initiated 9/19/18), Offer resident assistance to use the toilet every 1 1/2 to 2 1/2 hours while awake. Have resident ambulate from room to south tub room to use the toilet for toileting (initiated 6/22/18), Soft touch call light at edge of bed when in bed (initiated 7/2/18), Standby resident in bathroom while toileting (within arms length) due to self transfers off toilet unexpectedly while being assisted by staff (initiated 10/31/18), Use assertive and suggestive statements when offering(NAME)to use the toilet. She will often say 'no' if asked if she needs to use the toilet (initiated 7/8/18), Wheel chair foot rests to be used when staff are propelling Ilene's wheelchair. The feet rest have a heal loop. Resident is able to remove feet from foot rest (initiated 9/25/17), PT/OT and follow recommendations (initiated 5/2/18), use weighted blanket when in wheelchair and in bed (initiated 5/18/18). R28 record review of fall incident reports included R28 continued to fall after [MEDICAL CONDITION]. 7. R28's fall incident report dated 3/22/19 indicated R28 had an unwitnessed fall at 10:20 a.m. Resident was observed laying on right side perpendicular to bed. Immediate action taken: fall mat next to bed when resident is in it. R28's medical record lacked documentation of a root cause analysis or an interdisciplinary team meeting review of this fall. 8. R28's fall incident report dated 3/22/19 indicated R28 had an unwitnessed fall at 8:40 p.m. resident was found next to table in lobby where she had been folding washcloths on the floor, face down. She had been earlier leaning forward in wheelchair and was repositioned several times during the evening. Resident was examined and found to have no obvious injury. She was rolled over, gait belt applied and assisted into wheelchair with assist of 3. Again, resident was assessed for any obvious injury. Resident only c/o (complaint of) right wrist pain, but no obvious injury was noted to the wrist. She was able to move it without difficulty. Resident was toileted and placed into bed. Immediate Action Taken: See above. R28's medical record lacked documentation of a root cause analysis or an interdisciplinary team meeting review of this fall. No new intervention was implemented. 9. R28's fall incident report dated 4/3/19 indicated R28 had an unwitnessed fall at 6:50 a.m. Resident was observed laying on the floor perpendicular to her bed, with wheelchair facing the bed. Immediate action taken: Tylenol administration times changed to promote sleep. R28's medical record lacked documentation of a root cause analysis or an interdisciplinary team meeting review of this fall. During an interview on 8/01/19, at 12:42 p.m. the interim director of nursing (IDON) stated the fall 4/3/19 happened at 6:50 a.m. The IDON stated why are we worried about giving her Tylenol at 3:00 a.m. when the fall was at 6:50 a.m. R28 was not falling at 3:00 a.m. The IDON stated she would have expected staff to look at her toileting. The IDON stated this was R28's third time falling related to the bathroom and it was a pattern. The IDON stated interventions needed to correlate with the root cause of the fall. 10. R28's fall incident report dated 4/14/19 indicated R28 had a witnessed fall at 5:05 p.m. Resident sitting in lobby in her wheelchair her lap table was not on at 1525. Heard screaming from residents as this writer was down the south hallway. Looked toward lobby desk and saw resident laying on floor in front of her wheelchair. Witnessed by several residents. Resident denies pain other than her general pain. No obvious injuries noted. Gait belt placed and was assisted by 4 staff back into her wheelchair. Intervention: Keep lap tray on at all times when resident is in her chair. Resident is able to remove. R28's medical record lacked documentation of a root cause analysis or an interdisciplinary team meeting review of this fall. 11. R28's fall incident report dated 5/15/19 indicated R28 had an unwitnessed fall at 10:20 a.m. Resident was observed laying on the floor with her head against her side table. Immediate action taken: Refer to IDT (interdisciplinary team). R28's medical record lacked documentation of a root cause analysis or an interdisciplinary team meeting review of this fall. No new intervention implemented. R28's progress note dated 5/15/2019 included resident was observed laying on the floor with her head resting against her side table, feet pointing towards the door. Resident has no injuries. Resident stated she had been trying to take herself to the bathroom. Resident had been laid down after breakfast due to fatigue, toileted beforehand by 35 minutes. Resident had call light within reach and motion detector was on and functioning. Resident was not incontinent at time of fall grippy socks were also on. Resident was assisted to wheelchair via Hoyer and brought to the bathroom where she had stated she needed to go, but did not have bowel movement or void. Neuros checks completed and resident was observed to be at her baseline. Refer to IDT (interdisciplinary team) for fall intervention at this time. During an interview on 8/01/19, at 12:46 p.m. the IDON stated this was fourth time R28 fell related to going to the bathroom. The IDON stated we should keep reviewing her toileting program to get on top of it, because it seems likes toileting was the driving factor to R28's falls. The IDON stated I would go in and see where her toileting trends are related to falls times and I would schedule specific toileting times for her prior to those instances. 12. R28's fall incident report dated 7/3/19 indicated R28 had an unwitnessed fall at 10:05 p.m. Night CNA (certified nursing assistant) was going down hallway for report and saw resident laying on her left side in front of her bed. Immediate action taken: Resident able to move all extremities. She was assisted onto her back and sling placed for mechanical lift into bed. Staff offered to take the resident to the bathroom and resident declined having to go. Motion detective alarm found tucked at front desk and was turned off. Intervention: Staff education to ensure motion detecting alarm was turned on. R28's medical record lacked documentation of a root cause analysis or an interdisciplinary team meeting review of this fall. 13. R28's fall incident report dated 7/19/19 indicated R28 had an unwitnessed fall at 10:44 a.m. Resident was observed laying on the floor in her room next to wheelchair. Immediate action taken: family request eval of tools on tray table to keep her busy. R28's medical record lacked documentation of a root cause analysis or an interdisciplinary team meeting review of this fall. On 7/30/19, at 3:04 p.m. registered nurse (RN)-B stated Monday through Friday during IDT (interdisciplinary) meeting all falls were reviewed and together as an IDT team they discuss interventions to put into place, then we add it to the care plan. RN-B stated they do not document their IDT discussion on falls. RN-B stated we have a verbal discussion of a root cause analysis. RN-B verified R28's medical record lacked documentation of a root cause analysis or interdisciplinary team meetings review of her falls. On 8/01/19, at 12:51 p.m. the interim director of nursing (IDON) stated she responded to the fall on 7/19/19. The IDON stated R28 had her pants down to her knees, pull up was still up and she was trying to get around her wheelchair to take herself to the bathroom. IDON verified this information was not on the fall incident report. The IDON verified no documentation of root cause analysis, and stated the tools on the tray would not have addressed the root cause of the fall; the tools are not going to prevent her from trying to go to the bathroom. The IDON stated I am going to go and gather information on when R28 was most often incontinent, so we can have a more specific toileting program. I am going to change the process of how we review as a team resident falls. The IDON stated current process was we review falls at the 9:00 a.m. meeting, one of the care coordinators was on a computer during the meeting and as we are talking they are supposed to be adding interventions to the care plan in real time. The IDON stated we should also be putting in an IDT progress note stating what the root cause of the fall was and the intervention that was implemented. The IDON stated we talk about the root cause analysis but we are missing the documentation of that. The IDON stated we need to be looking at why they are falling and comparing to previous falls to determine appropriate interventions. The IDON stated 6 out of 13 falls reviewed did not have a new intervention. The IDON stated R28 had 4 falls prior to the fall with the fracture, two were related to going to the bathroom and no new interventions were implemented after the falls except to ensure batteries were in the motion detector. The IDON stated she understood this was a serious concern. The IDON stated the interventions implemented after R28's falls did not always match the reason for the fall. The IDON stated this was not going to continue on my watch. The IDON stated I am concerned about the lack of detail in charting. I am going to teach them other methods to organize their charting to be more specific and detailed. The IDON verified R28's medical record lacked documentation of a root cause analysis or interdisciplinary team meetings review of her falls. R38's Minimum Data Set (MDS), dated [DATE], identified R38 had severe cognitive impairment, was independent with ambulation, required supervision with transfers and extensive assist with toileting. R38's Admission Record, included [DIAGNOSES REDACTED]. During observation on 7/29/19, at 7:36 p.m., R38 sat in her wheelchair in the living room area sleeping. R38 had a cast on her left lower arm, had gripper socks on both feet and had automatic locking wheelchair brakes on her wheelchair. R38's care plan, revision date 7/3/19, included at high risk for falls related to limited mobility, incontinence, cognitive impairment, and gait deficits. Interventions included anticipate and meet needs, be sure call light is within reach and encourage to use it for assistance as needed, prompt response to all requests for assistance, check room during night rounds, if awake and/or restless offer resident assistance to use toilet. Check on the resident between 4:00 and 5:00 and if she is awake get her up and dressed for the day. Educate about safety reminders and what to do if a fall occurs. Ensure is wearing appropriate footwear when ambulating. Ensure bedding is free from extra linens. Follow facility fall protocol. If the resident is observed wandering, set up with cognitive bin. Keep wheelchair by the bed with the brakes locked so that it is available if she attempts to self transfer. Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter remove any potential causes if possible. Has an activities of daily living self care performance deficit related to cognitive Impairment, limited mobility, ambulation. Interventions included assist time two with bilateral platform wheeled walker, cues to maintain non weight bear status on left upper extremity. Transfers: requires assist of two staff for transfers. Toilet use: requires assist of two for toilet transfers and assist of one for toileting hygiene. R38's Fall Risk Assessment, dated 7/19/19, had a score of 17 (high risk falls). R38's Fall Incident Reports and progress notes identified: -6/23/19, at 23:30 (11:30 p.m.) nurse walking down hall and heard a fall. On entering room resident was laying on walker face down on the floor with blood noted near left forehead. Laceration on left eyebrow. R38 was sent into the hospital for evaluation. Call placed to hospital, resident is being taken back for outpatient surgery to do a washout on an open left wrist fracture. -7/2/19, at 0630 (6:30 a.m.) observed sitting on floor in front of bed, noted a folded flat sheet laying over flannel removed flat sheet that hs a more slippery texture, no injuries. -7/7/19, at 0505 (5:05 a.m.) found laying on the floor in front of wheelchair (w/c). Intervention keep w/c by bed with brakes locked so that it is available if attempts to self transfer. 7/7/19, at 1610 (4:10 p.m.) laying on left side in bathroom with pants and dry pad down with nothing observed on toilet. Intervention if resident observed wandering set up with cognitive bin. -7/15/19, at (0400) 4:00 a.m.) found laying flat on back near bedroom door feet facing doorway, no injuries. Resident was dry and was changed 45 minutes prior to fall. Intervention check on resident between 4-5 a.m. and if awake get her up and dressed for the day. Although the falls above had interventions implemented after each fall, there were no root cause analysis documented to determine if the interventions implemented were appropriate to prevent further falls and risk for injury. During interview on 7/31/19, at 10:41 a.m., RN-B stated the IDT team discuss interventions to put into place, then we add it to the care plan. RN-B stated they do not document their IDT discussion on falls. RN-B stated we have a verbal discussion of a root cause analysis. RN-B verified R38's medical record lacked documentation of a root cause analysis or interdisciplinary team meetings review of her falls. During interview on 8/1/19, at 1:51 p.m., the IDON stated the root cause of the fall should be first documented by the nurse documenting the fall. If the nurse was unable to come up with the root cause or intervention, the nurse would then go to the IDT team to determine the root cause and interventions to implement. The Falls and Falls Risk, Managing policy updated 1/21/19 included Based on previous evaluations and current data, the staff will identify interventions to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling.