Every finding on record at St Luke Living Center

The facility reported a census of 26 residents. The sample included 12 residents. Based on interviews, observation, and record review, the facility failed to ensure a safe, clean home-like environment in all areas of the facility including the resident rooms. Findings included:- Observed on 10/06/25 at 10:56 AM, several areas of Resident (R) 1's room walls had missing paint with exposed sheetrock. The bathroom door had multiple areas of missing paint with exposed wood and the metal door frame to the bathroom had missing paint with exposed metal.Observed on 10/06/25 at 11:28 AM, multiple areas on walls in R17's room had chipped and missing paint with exposed sheetrock. The bathroom door had paint missing in multiple areas with exposed wood and the bathroom door frame had missing paint with exposed metal.Observed on 10/06/25 at 11:36 AM, R2's bathroom door had multiple areas with exposed wood and the door frame had missing paint with exposed metal.Observed on 10/06/25 at 11:48 AM, R19's bathroom door had multiple areas of exposed wood, and the door frame had paint missing with exposed metal.Observed on 10/06/25 at 12:08 PM, R16's bathroom door and R4's bathroom door had multiple areas with exposed wood and the door frame had exposed metal.Observed on 10/06/25 at 12:32 PM, R5's bathroom door and door frame had multiple areas with exposed wood and metal.Observed on 10/07/25 at 09:00 AM, the public bathroom door had a large area of missing paint with exposed wood.Observed on 10/08/25 at 08:30 AM, during the facility walkthrough with Administrative Staff A and Administrative Nurse E, several areas of the walls had missing paint with exposed sheetrock. There were numerous ceiling tiles throughout the hallways that had brown water stains, and many were breaking and flaking, several were bulging and created open access to the drop-ceiling space above the tiles.Observed on 10/08/25 at 08:43 AM, the clean utility room had ceiling tiles around the ceiling A/C unit that had water stains, and several tiles were flaking and breaking. The wall molding of the countertop was pulling away from the wall and the wall by the sink had a large area that was scraped and had several exposed areas of sheetrock.Observed on 10/08/25 at 08:50 AM, a handrail on the Sunflower hallway had a large area, approximately one foot by four inches, that was scraped and had exposed wood and the ceiling tiles around the ceiling A/C unit at the Sunflower hallway intersection had large water spots and broken/flaking areas.On 10/08/25 at 08:45 AM, Administrative Staff A and Administrative Nurse E stated that he was unaware of the ceiling tiles, wall and molding issues in the clean utility room. They further stated that he was unaware of the ceiling tile issues in the resident apartments and hallways. Administrative Staff A then stated that maintenance repair/remodeling of resident apartments occurred when an apartment became vacant. Administrative Staff A then stated that he expected staff to be vigilant and report any maintenance or environmental concerns immediately.On 10/08/25 at 09:00 AM, Maintenance U stated that the wall and counter problem in the clean utility room had not been reported and he was unaware. He further stated ceiling tiles were replaced on a spot-check basis as they were noticed. Maintenance U also stated that apartment painting and remodeling occurred as apartments became vacant, other repairs occurred as they were reported, maintenance reports occurred through LIMBLE (a cloud-based CMMS computerized maintenance management system that functions as a maintenance reporting system by allowing users to submit work requests via a web portal or email, track work order status in real-time, and generate automated reports on asset performance, maintenance costs, and work order completion rates) that created a work order repair [NAME], this system also created a monthly preventative maintenance (PM) list.On 10/08/25 at 09:19 AM, Certified Medication Aide (CMA) R stated that maintenance and environmental concerns were reported to the charge nurse and submitted through LIMBLE. She further stated that concerns that would be submitted included light problems, bed problems, resident care equipment issues and plumbing problems.The facility policy Facility Repairs, dated 06/08/24, documented that all buildings, equipment, and infrastructure owned or managed by St. [NAME] Hospital and Living Center would be maintained in a safe, functional, and efficient condition. The policy further documented that plant operations would complete monthly rounds to identify any problems or concerns and to complete preventative maintenance.The undated facility policy Resident Rooms, documented that resident room spaces should reflect comfort, personal choice, accommodate and incorporate features of home.

The facility identified a census of 26 residents. The sample included 13 residents with five residents sampled for unnecessary medications. Based on observation, interview, and record review, the facility failed to inform R18 or her representative about the risk and benefits of taking an antianxiety (a class of medications that calm and relax people).Findings included:- R18's Electronic Medical Record (EMR) revealed the following diagnoses: Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), psychotic disorder (a type of mental health illness characterized by a dissociation from reality, often involving symptoms such as delusions and hallucinations), and major depressive disorder (major mood disorder that causes persistent feelings of sadness).R18's 07/09/25 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) of four, indicating severely impaired cognition. The MDS documented R18 had no delusions, or hallucinations. R18 did wander one to three days during the seven days prior to the assessment. The MDS recorded R18 took antipsychotic, antidepressant (a class of medications used to treat mood disorders), antianxiety and opioid (a class of controlled drugs used to treat pain). R18's Psychotropic Drug Use CAA documented R18 took Buspar (an antianxiety medication) for the treatment of anxiety. R18's Care Plan documented R18 took Buspar three times a day for anxiety on 04/16/24.R18's Physician's Orders documented R18 took Buspar five milligrams three times a day for anxiety disorder; ordered on 01/23/25.Review of R18's Drug Regimen Reviews noted no requests for staff to obtain an informed consent from the resident's representative.R18's clinical record lacked evidence of informed consent regarding the Buspar. On 10/08/25 at 9:56 AM, R18 sat at the table eating a snack in the common area. Staff walked by and observed and addressed her as they walked by.On 10/07/25 at 11:37 AM, Licensed Nurse (LN) G stated that when residents received psychotropic medication, Administrative Nurse D got the consents from the resident and/or their resident representative. On 10/07/25 at 3:12 PM, Administrative Nurse E stated she looked everywhere and could not find an informed consent for the Buspar, and confirmed it was not documented in the notes that the Buspar was discussed with the resident or the representative.On 10/08/25 at 11:44 AM, Administrative Nurse D stated she got the informed consent from the resident/resident representative. She was unable to find the consent for R18's Buspar and could not find a note that it was discussed.The facility policy for Psychotropic Medication, undated, documented residents will be obtained prior to administration of any nonemergent psychotropic medications.

The facility identified a census of 26 residents. The sample included 13 residents with five residents sampled for unnecessary medications. Based on observation, interview, and record review, the facility failed to attempt a gradual dose reduction (GDR) for Resident R)18's antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality), medication. Findings included:- R18's Electronic Medical Record (EMR) revealed the following diagnoses: Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), psychotic disorder (a type of mental health illness characterized by a dissociation from reality, often involving symptoms such as delusions and hallucinations), and major depressive disorder (major mood disorder that causes persistent feelings of sadness).R18's 07/09/25 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) of four, indicating severely impaired cognition. The MDS documented R18 had no delusions, or hallucinations. R18 did wander one to three days during the seven days prior to the assessment. The MDS recorded R18 took antipsychotic, antidepressant (a class of medications used to treat mood disorders), antianxiety (a class of medications that calm and relax people), and opioid (a class of controlled drugs used to treat pain). The MDS documented no GDR for the antipsychotic was attempted, and the physician had not documented a GDR was contraindicated.R18's Psychotropic Drug Use CAA documented R18 took Seroquel (an antipsychotic medication) for the treatment of depression and mania. R18's Care Plan documented R18 took Seroquel at supper for anxiety and restlessness on 04/16/24.R18's Physician's Orders documented R18 took Seroquel 25 milligrams (mg) by mouth in the evening for psychotic disorder with delusions due to a known physiological condition; ordered on 05/11/24.Review of R18's Drug Regimen Reviews noted no requests for a GDR for the Seroquel.On 10/08/25 at 9:56 AM, R18 sat at the table eating a snack in the common area. Staff walked by and observed/ and addressed her as they walked by.On 10/07/25 at 11:37 AM, Licensed Nurse (LN) G stated that when residents received psychotropic medication, Administrative Nurse D got the consents from the resident and/or their resident representative. LN G stated Administrative Nurse D addressed the pharmacy recommendations.On 10/07/25 at 3:12 PM, Administrative Nurse E stated she looked everywhere and could not find that the pharmacist ever requested a GDR for R18's Seroquel. Administrative Nurse F confirmed there was no request for a GDR, no attempt for a GDR, and no risk versus benefits statement for the Seroquel.On 10/08/25 at 11:44 AM, Administrative Nurse D stated the pharmacist recommended GDRs when he completed his reviews but verified there was no recommendation for R18 to reduce the Seroquel. She said she was aware that it was a regulation to attempt GDRs unless it was contraindicated.The facility policy for Psychotropic Medication, undated, documented residents who were prescribed an antipsychotic medication shall receive gradual dose reductions per CMS requirements.

The facility reported a census of 26 residents. The sample included 13 residents with one resident reviewed for hospitalization. Based on interview and record review, the facility failed to provide Resident (R) 6 a written notification of transfer to the resident and/or his representative as soon as practicable and failed to send a copy of that notification to the ombudsman. The facility also failed to provide R6 or the responsible party with a bed hold. Findings included:- R6's Electronic Medical Record (EMR) revealed a diagnosis of heart failure (a condition where the heart muscle is weakened and cannot pump blood effectively enough to meet the body's needs) and dementia (a progressive mental disorder characterized by failing memory and confusion).R6's EMR documented a Health Status Note dated 09/07/25 at 07:57 AM that documented R6 was short of breath with walking to the bathroom. R6 had wheezing and diminished breath sounds.R6's Health Status Note dated 09/07/25 at 11:05 AM, documented R6 was admitted to the hospital for observation. The hospital planned to take fluid off.R6's EMR lacked documentation of written notification to the resident and/or her representative, which explained the reason for the transfer to the hospital. The EMR lacked documentation that the bed hold was explained and given to R6 or her representative.On 10/07/25 at 11:37 AM, Licensed Nurse (LN) G stated that Social Services X gave the resident or the responsible party the bed hold when a resident went out to the hospital and the nurse verbally notified the family of transfers to the hospital.On 10/07/25 at 11:40 AM, Social Services X stated that she was the person that goes over the bed hold with the resident's representative. Social Services X noted that she forgot to do it on R6's transfer to the hospital. Social Services X said she was unaware of the regulation to notify the resident in writing and notify the ombudsman.On 10/07/25 at 11:48 AM, Administrative Nurse D stated the bed hold should be completed and signed by the next business day when a person transferred out of the facility. Administrative Nurse D said she was unaware of the regulation to notify the resident's representative in writing of a discharge or transfer and the facility had not been notifying the ombudsman.The facility's Resident Bed Hold for Admission policy dated 10/06/15 documented if there was a desire to hold the room the family would sign a bed hold agreement at the time of transfer.

The facility identified a census of 26 residents. The sample included 13 residents with two sampled for baseline care plan. Based on observation, interview, and record review, the facility failed to complete a baseline care plan for Resident (R) 29.Findings included:- R29's Electronic Medical Record (EMR) documented a diagnosis of dementia (a progressive mental disorder characterized by failing memory and confusion), failure to thrive, hypertension (HTN-elevated blood pressure), and atrial fibrillation (rapid, irregular heartbeat).R29 admitted on [DATE] so the 10/03/25 admission Minimum Data Set (MDS), was not completed.R29's Baseline Care Plan dated 09/25/25, was unsigned by R29 or his responsible party. It documented R29 was a full code (term used to indicate the desire to receive resuscitative measures in the event of cardiac arrest). It did not have the fall risk section completed. R29's Baseline Care Plan documented he had a behavior of wandering, including a previous incident of wandering outside of the house. It did not have the elopement section completed, which included a question on if he had a WanderGuard (a bracelet that helps monitor residents who are at risk of wandering). The Social Service portion of the care plan was not completed, which included his plans for discharge or to stay long term. The care plan indicated he took an antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication) which was not correct.On 10/06/25 at 12:19 PM R29 sat at the dining room table in his wheelchair with a WanderGuard around his left ankle. R29 pushed himself backwards and wheeled himself back to his room.On 10/08/25 at 9:26 AM R29 laid diagonally on his bed with his feet hanging ff the bed. R29's left foot was on the mattress on the floor beside his bed. R29's bed was in a low position.On 10/07/25 10:40 AM, Certified Nurse Aide (CNA) M stated staff followed the care plans to know how to care for a resident.On 10/08/25 at 8:33 AM, Administrative Nurse F stated usually the charge nurse goes over the baseline care plan with the residents and the family, or the Assistant Director of Nursing (ADON) does it. Administrative Nurse F said R29's representative left early on the admission day, so staff were unable to do that with R29's representative. Administrative Nurse F confirmed staff did not call or attempt to do it another way.On 10/08/25 at 8:34 AM, Licensed Nurse (LN) G stated usually the nurse completed the baseline care plan and the charge nurse or the ADON went over it with the resident and/or the resident's representative.On 10/08/25 at 11:44 AM, Administrative Nurse D stated that the baseline care plan is part of the admission packet; the charge nurse fills it out and goes over it with the resident and the resident representative at the time of admission.The facility policy for Nursing Care Plan, undated, noted the facility will ensure that each resident has an individualized current care plan.

The facility reported a census of 26 residents. The sample included 12 residents. Based on interviews, record reviews and observation, the facility staff failed to implement adequate and acceptable infection control practices when staff did not disinfect a glucometer (an instrument used to calculate blood glucose) after use.Findings included:- Observed on 10/07/25 at 11:22 AM, Licensed Nurse (LN) G perform a blood glucose check on Resident (R) 2 after performing hand hygiene and donning gloves. Upon completion of the blood glucose check LN G returned to the nurse's office and did not clean or disinfect the glucometer.On 10/07/25 at 11:30 AM, LN G verified that she did not clean the glucometer and further stated that she did not usually clean it unless there was blood on it, or it was dirty.On 10/08/25 at 11:44 AM, Administrative Nurse A stated that the facility educated staff on measuring blood glucose using glucometers every year as part of the yearly competencies, and she expected staff to clean and disinfect the glucometers after each use.The undated facility Infection Control for Living Center Residents documented that the policy was to establish and maintain an infection control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection.

The facility reported a census of 26 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to ensure the posted daily nurse staffing sheets included accurate and identifiable information to include the daily licensed and unlicensed staff actual hours.Findings included:- Daily Staffing sheets reviewed for the following dates did not list the actual hours worked, the total hours worked for nurses and CMA/CNA were listed: 08/01/25, 08/02/25, 08/03/25, 08/04/25, 08/05/25, 08/06/25, 08/07/25.Observed on 10/06/25 at 10:05 AM, the daily staffing sheet was not posted. Observed on 10/07/25 at 10:11 AM, the daily staffing sheet was posted on door frame of the nurse's office and only listed the total hours worked, the actual hours were not listed.ON 10/07/25 at 10:26 AM, Licensed Nurse (LN) G reported that the 3PM to 3AM shift was responsible for filling out the daily staffing sheets based on the weekly staffing schedule; that nurse then taped the staffing sheet to the door frame of the nurse's office.On 10/07/25 at 10:42 AM, Administrative Nurse A stated that the actual hours worked were not recorded at the end of each shift on the staffing sheet, she figured up the actual hours for the daily staffing sheets and did so once she received the invoices from the agency company the facility utilized for staffing needs. The facility policy St. [NAME] Living Center Staffing, dated 01/08/15, documented that the facility would designate a licensed nurse to serve as a charge nurse on each tour of duty and that the facility would staff licensed personnel 24/7 using Registered Nurses (RN) and Licensed Practical Nurses (LPN).

The facility reported a census of 29 residents. Based on observation, interview, and record review, the facility failed to ensure foods were stored, prepared, and distributed in a manner to prevent foodborne illness to the residents. Findings included: - Observation on 02/21/24 at 01:30 PM, during the environmental tour with Dietary Staff CC and Administrative Staff A, revealed the following areas of concern: 1. The food preparation and serving areas contained 18 approximately two feet by three-foot ceiling tiles which contained black dust like substances and grime. Several tiles contained brown discolorations resembling handprints. 2. The ceiling light in the food preparation area contained a black dust like substance and white dust like substance. The ceiling light in the kitchen entrance area also contained black and white dust like substances. 3. The front two stove vents contained an accumulation of grime. 4. Three large cookie sheets contained an accumulation of a black substance around the perimeter and extending into the mid area. 5. Two small skillets contained scratches and build up of grime over the entire interior surface. 6. One large and one small cutting board contained multiple deeply grooved scratches, making sanitation difficult. 7. The bottom shelf of the True Freezer contained food debris. 8. The dishwasher top contained an accumulation of a lime like substance. Interview on 02/21/24 at 02:00 PM, with Administrative Staff A confirmed the above areas of concern. Observation, on 02/21/24 at 02:50 PM, revealed the refrigerator freezer in the family room contained shelves with debris and food particles. Observation on 2/21/24 at 03:00 PM, revealed the dining room activity area contained a popcorn machine with a yellow substance dripping down the interior walls. Interview, at that time with Activity staff Z, stated she used the machine approximately seven days ago and it should be cleaned after each use. The facility policy Cleaning the Reach in Refrigerator dated 09/17/14, instructed staff to wipe up spills and thoroughly clean the interior of the refrigerator to reduce the risk of food borne illness and cross contamination. The facility policy Pots and Pans dated 06/2005, instructed staff to remove heavy soil from pots and pans before washing. The facility failed to ensure staff-maintained food storage, preparation and serving area were maintained in a sanitary manner to prevent food borne illness amongst the residents of the facility.

The facility reported a census of 29 residents. Based on interview and record review the facility failed to electronically submit to Centers for Medicare and Medicaid Services (CMS) with complete and accurate direct staffing information, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS (i.e., Payroll Base Journal (PBJ), related to licensed nursing staffing information, when the facility failed to accurately report Licensed Nurse Coverage for 24 hours a day on 12 days during the third quarter 2023. Findings Included: - Review of the 'Payroll Base Journal (PBJ) Staffing Data Report for fiscal year (FY) Quarter 3, 2023 (April 1-June 30) revealed lack of Licensed Nurse for the following 12 days: On 04/01 Saturday (SA). On 04/23 Sunday (SU). On 05/06 SA. On 05/07 SU. On 05/14 SU. On 05/27 SA. On 05/28 SU. On 06/20 SA. On 06/11 SU. On 06/17 SA. On 06/24 SA. On 06/35 SU. Review of the Staff Posting and Schedule revealed Licensed Nurse coverage for the above days. Interview, on 02/22/24 at 01:30 PM, with Administrative Nurse D, confirmed the finding that the facility provided 24-hour licensed nurse coverage for the above dates and stated the PBJ was submitted by the business office staff, and did not know how the error occurred. The facility did not furnish a policy for PBJ submission. The facility failed to electronically submit to Centers for Medicare and Medicaid Services (CMS) with complete and accurate direct staffing information, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS (i.e., Payroll Base Journal (PBJ), related to licensed nursing staffing information when the facility failed to accurately report 24 hour per day Licensed Nurse coverage on 12 dates between 04/01/23 and 06/30/23 as required.

The facility reported a census of 29 residents. Based on interview and record review, the facility failed to maintain an infection prevention and control program to proactively monitor infections in the facility to help prevent the spread among the residents of the facility. Findings included: - The facility lacked a surveillance plan for identifying, tracking, monitoring and reporting infections among residents. On 02/22/24 at 01:15 PM, Administrative Nurse D stated the facility did not currently use any criteria for tracking and trending infections. The facility lacked a policy for infection control surveillance. The facility failed to maintain an infection prevention and control program to proactively monitor infections in the facility to help prevent the spread of infections among the residents of the facility.

The facility reported a census of 29 residents with 14 residents sampled, including one resident reviewed for dignity. Based on observation, interview, and record review, the facility failed to show respect and dignity to one Resident (R)25, while transporting the resident in a sit to stand mechanical lift from her bed to the bathroom with the blinds partially open. Findings included: - Review of Resident (R)25's electronic medical record (EMR) revealed the following diagnoses: hemiparesis/hemiplegia (weakness and paralysis on one side of the body) and dementia (progressive mental disorder characterized by failing memory, confusion). The Annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of six, indicating severe cognitive impairment. She required extensive assistance of two staff for toileting and had impairment on one side of her upper and lower extremities. The Activity of Daily Living (ADL) Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 06/28/23, documented staff used the sit to stand lift (a mechanical device designed to assist individuals in moving from a sitting to a standing position and vice versa) to transfer the resident. The Quarterly MDS, dated [DATE], documented the resident had a BIMS score of 14, indicating intact cognition. She required substantial to maximum staff assistance for transferring to the toilet. The revised care plan for mobility, dated 01/17/24, instructed staff the resident had limited physical mobility and required two staff for transfers using the sit to stand lift. On 02/21/24 at 08:34 AM, Certified Nurse Aide (CNA) O and Certified Medication Aide (CMA) R transferred the resident with a sit to stand mechanical lift from her bed to the bathroom to the toilet. The window blinds in the resident's room, which looked out to the facility's patio area, were pulled up approximately 12 inches (in). The resident's brief hung down low, that exposed most of her buttocks to anyone outside on the patio. On 02/21/24 at 08:34 AM, CNA O confirmed the blinds in the resident's room were not completely closed and should have been while the staff gave cares to the resident to ensure the resident's dignity. On 02/21/24 at 08:34 AM, CMA R confirmed the blinds in the resident's room were not fully closed while staff gave cares to the resident. On 02/22/24 at 09:15 AM, Licensed Nurse (LN) G stated the staff should close resident's window blinds while giving cares to residents. On 02/22/24 at 09:03 AM, Administrative Nurse D stated it was the expectation for staff to close the window blinds in a resident's room when giving cares to protect the resident's dignity. The facility policy for Resident Rights, effective 2023, included: The facility will treat each resident with dignity and respect in full recognition of their individuality. The facility failed to show respect and dignity to this dependent resident while giving cares.

The facility reported a census of 29 residents, with 14 residents sampled. Based on observation, interview and record review, the facility failed to develop an individualized baseline plan of care for one Resident (R)130 regarding an indwelling urinary catheter (tube placed in the bladder to drain urine into a collection bag). Findings included: - Review of Resident (R)130's electronic medical record (EMR) revealed the resident admitted to the facility on [DATE] with a diagnosis of urinary retention (the inability to pass urine). Review of the resident's admitting orders to the facility revealed the following physician's order: Urinary catheter, ordered 02/08/24. On 02/21/24 at 09:02 AM, Certified Nurse Aide (CNA) O entered the resident's room to provide catheter care. On 02/21/24 at 09:06 AM, CNA O stated the resident admitted to the facility with the urinary catheter. On 02/22/24 at 09:15 AM, Licensed Nurse (LN) G stated staff would look at the resident's care plan in order to find instruction on caring for the urinary catheter. On 02/22/24 at 09:03 AM, Administrative Nurse D stated it was the expectation for staff to include a urinary catheter on the resident's baseline care plan, including the size of the catheter. The facility policy for Nursing Care Plan, revised July 2003, included: The nursing care plan is a personalized plan outlining the care of an individual resident with specific needs, desires and goals. The plan should indicate long-term and short-term goals in a measurable time frame for the resident and all members of the care team. The facility failed to develop a baseline care plan for this resident with an indwelling urinary catheter.

The facility reported a census of 29 residents with 14 residents included in the sample. Based on observation, record review, and interview, the facility failed to review and revise the care plans for one Resident (R)4, regarding the use of an anti-depressant (medication used to treat depression) medication. Findings included: - Review of Resident (R)4's electronic medical record (EMR) revealed a diagnosis of major depressive disorder ([MDD]major mood disorder which causes persistent feelings of sadness). The Significant Change Minimum Data Set (MDS), dated [DATE], documented the staff assessment for cognition revealed the resident had severe impairment. The resident received anti-depressant medication during the assessment period. The Psychotropic Drug Use Care Area Assessment (CAA), dated 11/29/23, documented the resident received an anti-depressant medication for MDD. The Quarterly MDS, dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of seven, indicating severe cognitive impairment. She received an anti-depressant medication during the assessment period. The care plan, revised 02/07/24, lacked staff instruction regarding the resident's use of an anti-depressant medication. Review of the resident's EMR revealed the following physician's order: Wellbutrin (an anti-depressant medication), 100 milligrams (mg), by mouth (po), twice daily (BID), for MDD, ordered 01/19/24. On 02/22/24 at 11:00 AM, Administrative Nurse D stated it was the expectation for staff to include anti-depressant medication on a resident's care plan. Administrative Nurse D confirmed the resident's care plan lacked staff instruction regarding the use of the anti-depressant medication. The facility policy for Nursing Care Plan, revised July 2003, included: The nursing care plan is a personalized plan outlining the care of an individual resident with specific needs, desires and goals. The plan should indicate long-term and short-term goals in a measurable time frame for the resident and all members of the care team. The facility failed to review and revise this resident's care plan to include staff instruction regarding the use of anti-depressant medication.

The facility reported a census of 29 residents with 14 selected for review, which included two residents reviewed for activities of daily living. Based on observation, interview, and record review, the facility failed to provide one Resident (R) 21, with shaving opportunities in the manner of his preference. Findings included: - Review of Resident (R)21's medical record revealed diagnoses that included unspecified dementia (progressive mental disorder characterized by failing memory, confusion) cerebral vascular accident (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), chronic kidney disease and diabetes (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin). The Admission Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of 15, which indicated normal cognitive function. R21 had impairment in both lower extremities and no impairment in upper extremities. The resident required partial/moderate assistance with personal hygiene. The Activity of Daily Living (ADL) Functional/Rehabilitation Care Area Assessment (CAA), dated 10/10/23, assessed the resident as dependent on others for assistance. The Care Plan, revised 01/24/24, instructed staff the resident received a shower on Monday and Thursdays. The care plan lacked instructions for shaving. Observation, on 02/20/24 at 09:00 AM, revealed the resident with several days of facial hair growth beneath his chin and on his neck area. The resident revealed he had an electric shaver, and staff assisted him with set up for shaving, but he could not shave the area under his chin and neck area as he preferred. Interview, on 02/21/24 at 09:11 AM, with Certified Medication Aide (CMA) R, revealed the resident could shave himself, but needed set up assistance and supervision. Interview, on 02/21/24 at 03:17 PM, with Certified Nurse Aide (CNA) P, revealed the resident usually shaved himself when propped up in bed and he used his electric razor. CNA P stated occasionally the resident may need staff assistance and staff should ensure his electric razor has a full charge. Interview, on 02/22/24 at 01:53 PM, with Administrative Nurse D, revealed she would expect staff to assist the resident as needed and he would let staff know his needs by manually ringing the jingle bells attached to his bed or chair. The facility policy Resident Rights, reviewed 04/19/22, instructed staff the residents have a right to a dignified existence. The facility must care for the resident in a manner that enhances the resident's quality of life. The facility failed to ensure this resident received assistance to shave beneath his chin and neck region in the manner he preferred to enhance his sense of wellbeing.

The facility reported a census of 29 residents with 14 residents selected for review, which included two residents reviewed for hydration. Based on observation, interview, and record review, the facility failed to provide one Resident (R) 21, with access to fresh water throughout the day. Findings included: - Review of Resident (R)21's medical record revealed diagnoses that included unspecified dementia (progressive mental disorder characterized by failing memory, confusion) cerebral vascular accident (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), chronic kidney disease and diabetes (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin). The Admission Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of 15, which indicated normal cognitive function. R21 had impairment in both lower extremities and no impairment in upper extremities. The resident was independent with eating. The Activity of Daily Living (ADL) Functional/Rehabilitation Care Area Assessment (CAA), dated 10/10/23, assessed the resident as dependent on others for assistance. The Care Plan, revised 01/24/24, instructed staff to ensure the resident had access to fresh ice water whenever possible. Observation, on 02/21/24 at 09:11 AM, revealed the resident seated in his wheelchair in the family room. Certified Nurse Aide (CNA) M and Certified Medication Aide (CMA) R transferred R21 from his wheelchair to the recliner in the family room. R21 did not have water available to him. Interview, at that time with CNA M, revealed the resident would be able to manually ring his jingle bells if he wanted anything and CNA M or CMA R did not obtain water for him. Observation, on 02/21/24 at 02:30 PM, revealed the resident seated in his wheelchair feeding himself lunch. The resident stated he was not hungry earlier and CNA M warmed his food up for him. The resident drank 240 cubic centimeters (cc) of milk and 240 cc of juice. Observation, on 02/21/24 at 03:17 PM, revealed the resident seated in the recliner in the family room. The resident did not have water available but did have an over the bed table beside the recliner with a box of Kleenex on it. Interview, on 02/21/24 at 03:17 PM, with Certified Nurse Aide (CNA) P, revealed the resident had two water containers, one for in his room and one for when he was out, and he should have a water container within reach when he was sitting in his recliner. CNA P obtained the water container for the resident, and he accepted a drink of water. Observation, on 02/22/24 at 09:07 AM, revealed the resident seated in the family room in the recliner. The resident did not have water available to him and did not have his jingle bells. Interview, on 02/22/24 at 09:15 AM, with Licensed Nurse G, revealed the resident notified staff of his needs by ringing the jingle bells. LN G did not know the Care Plan instructed staff to provide fresh water to the resident whenever possible. Interview, on 02/22/24 at 01:53 PM, with Administrative Nurse D, revealed she would expect staff to assist the resident as needed and he would let staff know his needs by manually ringing the jingle bells attached to his bed or chair. The facility policy Hydration and Fluids dated 2022, instructed staff the residents' hydration needs are addressed in the individualized care plans. Staff to ensure fluids to prevent dehydration. The facility failed to ensure R21 had access to water when seated in his wheelchair and recliner as care planned to ensure adequate hydration.

The facility reported a census of 29 residents with 14 residents selected for review. Based on observation, interview, and record review, the facility failed to ensure one Resident (R)9 received antibiotics appropriately for a urinary tract infection. Findings included: - Review of Resident (R) 9's medical record, revealed diagnoses included cerebral vascular accident (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), Alzheimer's disease ((progressive mental deterioration characterized by confusion and memory failure) with dementia (progressive mental disorder characterized by failing memory, confusion). The Annual Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status Score (BIMS) score of nine, which indicated moderate cognitive impairment. The resident was frequently incontinent of urine. The Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA) dated 03/15/23, assessed the resident with mild stress incontinence (leakage of urine during coughing, sneezing laughing or exercise). The Quarterly Minimum Data Set , dated 10/11/23, assessed the resident with a Brief Interview for Mental Status score of 12, which indicated moderate cognitive impairment. The resident was frequently incontinent of urine. The Care Plan, reviewed 01/18/23, instructed staff to check the resident every two hours for toileting. On 11/24/23, the physician instructed staff to obtain a urine specimen for analysis and send for culture and sensitivity. The physician instructed staff to administer Keflex (an antibiotic), 500 milligrams, twice a day, for seven days. The physician instructed staff to administer Pyridium, 100 milligrams, three times a day, for bladder discomfort. Review of the medical record revealed the lack of culture results. Interview, on 02/22/24 at 03:25 PM, with Licensed Nurse (LN) G, revealed the original urinalysis was done by a manual method and staff failed to properly process the urine for culture and sensitivity to determine and verify the antibiotic was appropriate for the causative organism. Interview, on 02/22/24 at 10:15 AM, with Administrative Nurse D, confirmed the culture results were not available, due to a glitch in the registration of the laboratory order. The facility policy Antibiotic Stewardship dated 10/18/23, instructed staff when applicable, cultures will be obtained prior to the first dose of antibiotics. The facility failed to ensure this resident's urinalysis was processed in a manner to obtain culture results to ensure proper antibiotic use.

The facility reported a census of 29 residents. Based on interview and record review, the facility failed to ensure one Residents (R)13 was offered the influenza vaccine. Findings included: - Review of Resident (R)13 electronic medical records (EMR) revealed she lacked the influenza vaccine. On 02/22/24 at 09:03 AM, Administrative Nurse D stated the facility failed to offer the influenza vaccine to the resident. The facility policy for Immunizations, revised 2023, included: The facility will provide education to residents regarding the health risks associated with influenza and pneumococcal pneumonia and COVID-19 and will offer ever resident the opportunity to receive immunizations unless contraindicated. The facility failed to offer the influenza vaccine to this dependent resident.

The facility reported a census of 29 residents. Based on interview and record review, the facility failed to post the Direct Care Staff Nursing Hours in a manner to reflect the scheduled hours and actual hours worked by staff as required. Findings included: - Review of the Direct Care Staff Nursing Hours for December 2023, January 2024, and February 2024, revealed the document lacked indication of the actual hours worked by staff at the end of the shift. Interview, on 02/22/24 at 01:30 PM, with Administrative Nurse D, revealed the night shift nurse filled in the document with the scheduled hours worked, but did not update the document upon completion of the shift to reflect the actual hours worked. The facility did not provide a policy for updating the Direct Care Staff Nursing Hours. The facility failed to update the Direct Care Staff Nursing Hours to reflect the actual hours worked by nursing staff as required.

The facility reported a census of 19 residents. Based on interview and record review, the facility failed to provide direct care staff annual evaluations/performance reviews to determine strengths and weaknesses in providing resident care. Findings included: - Review of five Certified Nursing Assistant (CNA) personnel files revealed the following: Review of CNA M, with hire date of 07/05/19, revealed lack of an annual review. Review of CNA N, with hire date of 05/21/14, revealed lack of an annual review. Review of CNA O, with hire date of 12/18/20, revealed lack of an annual review. Review of CNA P, with hire date of 09/09/20, revealed lack of an annual review. Review of CNA Q, with hire date of 12/01/21, revealed lack of an annual review. On 06/21/22 at 10:49 AM, Administrative Staff A stated the facility did not complete individualized staff evaluations. On 06/21/22 at 10:49 AM, Administrative Nurse D stated, annual staff evaluations should be completed, but were not. The facility policy for Employee Annual Performance Evaluation, revised February 2021, included: The purpose of the policy was to ensure the competency of the staff of St. Luke Living Center, to be completed at the end of the conditional period and in January of every year. The facility failed to provide direct care staff an annual evaluation to determine strengths and weakness.

The facility reported a census of 19 residents. Based on observation, record review and interview, the facility failed to store food under sanitary conditions to prevent the spread of food borne illnesses to residents of the facility. Findings included: - During an environmental tour on 06/20/22 at 10:00 AM, with Housekeeping/Maintenance Staff U, revealed the following concerns in the kitchenette area in the resident area on the 500 hall: 1. The resident's common microwave had a large amount of dried food on the inside. 2. The residents' refrigerator had dried food and food debris that littered the bottom shelf of the refrigerator on the bottom shelf. 3. There was a plate of raw vegetables, dated 06/13/22. 4. There was an unopened bag of kale and turnips, undated. 5. There was an unopened bag of spinach, dated 05/27/22. 6. An opened, undated bag of baby carrots, contained slime and had a strong odor. On 06/21/22 at 10:12 AM, Administrative Nurse D stated, the night shift staff were responsible for cleaning out the resident refrigerator. Any staff who put food into the refrigerator should ensure the food items are dated. The facility policy for Refrigeration of Food, Storage, Disposal and Cleaning--Resident Use, undated, included: Food placed in the resident refrigerator by residents will be dated. Food will be thrown out after three days. If no date is present on the food, it will be thrown out immediately. Personnel in the work area will clean the refrigerators and/or freezers every three days and as necessary. The facility failed to store food under sanitary conditions to prevent the spread of food borne illnesses to residents of the facility.

The facility reported a census of 30 residents. The sample included 14 residents, with 2 reviewed for nutrition. Based on observation, interview, and record review, the facility failed to ensure that one (#23) of the two residents reviewed maintained within acceptable parameters of nutritional status, when the resident experienced a significant weight loss of 10.8%, or 13.7 pounds, of his/her body weight, in the four months following his/her admission, and when the facility failed to implement nutritional interventions in response to the resident's significant loss of weight. Findings included: - Resident #23's signed physician's orders [REDACTED]. The resident admitted to the facility on a reduced-calorie diet, for his/her diabetes. The admission MDS (minimum data set), dated 1/9/19, assessed the resident with a BIMS (brief interview for mental status) of 1, indicated the resident experienced severly impaired cognition. The resident required limited assistance from staff with eating his/her meals, and required extensive assistance in order to complete his/her other ADLs (activities of daily living). The resident was free of swallowing issues, and had no dental issues. The resident was free of weight loss, and weighed 138 lb (pounds) at the time of the admission MDS. The CAA (care area assessment) for nutrition documented that the RD (registered dietician) would monitor the resident's weight. The resident was overweight, and required encouragement and assistance with eating his/her meals. The resident's quarterly MDS, dated [DATE], documented that the resident weighed 125 lb (a 13 lb/9.42% loss), experienced a weight loss, and was not on a physician-prescribed weight loss program. Review of the resident's care plan, dated 1/8/19, documented that the resident had a potential nutritional problem related to his/her [DIAGNOSES REDACTED]. Facility staff were to administer the resident's medications as ordered, obtain and monitor lab work as ordered, and report results to the resident's physician as indicated. Facility staff were to provide and serve the resident's diet as ordered, and the facility's RD must evaluate the resident and make diet change recommendations as needed. The resident's care plan lacked any further nutritional interventions for the resident. Review of the RD's nutrition assessment, dated 1/9/19, assessed the resident as being on a reduced-calorie diet. The assessment identified the resident's IBWR (ideal body weight range) as being between 131 lb and 143 lb. The RD recommended that the resident receive a regular diet, instead of a reduced-calorie diet. On 1/13/19, the resident's physician changed the resident's diet to a regular diet. Review of the resident's weights revealed that on 1/2/19, the resident weighed 139.9 lb. On 2/8/19, the resident weighed 131.8 lb, a 8.1 lb (or 5.8%) loss from admission, in one month. On 3/1/19, the resident weighed 128.2 lb. On 4/5/19, the resident weighed 124.8 lb. The resident's three month loss following admission, from 139.9 lb on 1/2/19, to 124.8 lb on 4/5/19, was 15.1 lb, or 11.8%, a severe loss of weight. Review of the facility's weight tracking log, dated 3/22/19, 3/29/19, 4/5/19, 4/22/19, and 4/26/19, revealed that facility staff documented that the resident experienced a change of -10% in his/her weight, but that his/her weight was stable, and that the resident's last RD consult was on 1/10/19. The weight tracking log failed to contain documentation of any nutritional interventions for the resident, in order to prevent continued weight loss. Review of nursing notes, following admission on 1/2/19, to 4/30/19, lacked documentation of the resident's weight loss, and lacked documentation that facility staff notified the resident's physician of the weight loss. On 4/29/19 at 12:42 PM, the resident received his/her lunch, consisting of one slice of ham steak with gravy, mashed potatoes, mixed vegetables with lima beans, orange Jell-o salad, and baked apples. Facility staff cut up his/her ham steak for him/her. The resident fed him/herself lunch, and at 1:19 PM, consumed 100% of his/her meal. Facility staff did not ask the resident if he/she was still hungry, or wanted anything additional to eat. On 4/30/19 at 10:35 AM, the resident received his/her breakfast, consisting of a bowl of oatmeal, a slice of toast with butter and jam, a banana, a glass of orange juice, and a glass of water. Facility staff assisted the resident to eat his/her breakfast at times, and at other times, the resident fed him/herself without difficulty. The resident consumed all of his/her breakfast at 11:00 AM. Facility staff did not offer the resident anything additional to eat. On 4/30/19 at 3:15 PM, direct care staff H confirmed that the resident experienced weight loss since being admitted to the facility. On 4/30/19 at 3:53 PM, licensed nursing staff C could not recall if the resident had lost weight, but stated that administrative nursing staff B tracked residents and their weights, and discussed them in weight tracking meetings. Staff C stated that if a resident did experience a weight loss, then facility staff must notify the resident's physician. On 4/30/19 at 4:15 PM, administrative nursing staff B confirmed that he/she reviewed resident's weights every Monday, and oversaw the weight tracking program. Staff B confirmed that he/she knew the resident experienced weight loss. Staff B recalled that on 1/13/19, the resident's physician changed his/her diet from reduced-calorie to regular, but stated that the facility failed to implement any other interventions to prevent the resident from losing further weight. Staff B confirmed that the facility failed to notify the resident's physician of the resident's severe weight loss. On 5/1/19 at 9:29 AM, office staff D, with the resident's physician's office, confirmed that the facility failed to notify the physician of the weight loss, and that the resident's physician would have immediately initiated nutritional interventions for the resident upon knowing of the weight loss. On 5/1/19 at 11:40 AM, direct care staff I confirmed that the resident experienced a weight loss, following his/her admission to the facility. Staff I explained that the charge nurses were aware of the resident's weight loss. On 5/1/19 at 12:29 PM, direct care staff I and direct care staff J weighed the resident, and obtained a weight of 126.2 lb. The difference in weight from admission on 1/2/19, to the weight obtained on 5/1/19, constituted a severe weight loss of 10.8%, or 13.7 pounds, of the resident's body weight, in the four months following his/her admission to the facility. On 5/1/19 at 4:14 PM, consultant staff F confirmed that he/she was the registered dietician for the facility. Staff F confirmed that he/she completed the initial nutrition assessment for the resident on 1/9/19. Staff F had not made any further recommendations for the resident, but stated that his/her expectation of facility staff would be that they would inform him/her of any residents that experienced significant weight loss, so that he/she could review them and make recommendations. Staff F stated that he/she was aware the resident had lost some weight. Review of the facility's policy, revised 09/2008, for Weight Assessment and Intervention, documented that the facility would prevent, monitor and intervene for undesirable weight loss for residents. The facility failed to ensure that this resident remained within acceptable parameters of nutritional status, when he/she experienced a significant weight loss of 10.8%, or 13.7 pounds, of his/her body weight, in the four months following his/her admission, and when the facility failed to implement nutritional interventions in response to the resident's significant loss of weight.

The facility reported a census of 27 residents with 3 reviewed for accidents. Based on observation, interview, and record review the facility failed to ensure the 3 residents reviewed (#1, 2 and 3) received adequate supervision and assistive devices to remain as free of accidents as possible. Resident #1 sustained a [MEDICAL CONDITION] when staff left the resident standing alone, to turn down bed covers, with the resident falling and sustaining a [MEDICAL CONDITION]. Residents #2 and 3 did not experience significant injuries. Findings included: - Resident #1's [DIAGNOSES REDACTED]. The quarterly MDS (minimum data set), dated 10/17/18, identified the resident cognitively intact and required extensive assistance for most ADLs (activities of daily living), including transfers and ambulation. The assessment evidenced the resident lacked falls since the prior assessment. The annual MDS, dated [DATE], identified the resident cognitively intact, required limited to extensive assistance for ADLs, and with a fall since the prior assessment. A CAA (care area assessment), dated 1/28/19, for falls, evidenced the resident experienced an actual fall with a fractured left hip and returned to the facility with physical and occupational therapy rehabilitation orders. The resident required assistance of 1 or 2 staff with transfers and required assistance with all ADLs. The staff provided stabilization with transfers and the resident used a wheelchair for mobility. Fall risk assessments, dated 10/15/18 and 12/19/18, identified the resident not at high risk for falls, scoring 7 and 8 respectively. On 1/11/19 the resident scored 12. A score of 10 or greater reflected high risks for falls. The care plan for the resident, dated 3/26/18, instructed staff to provide the following: 1) Ensure the resident wears appropriate footwear, brown leather shoes when ambulating or mobilizing in wheelchair. 2) Anticipate and meet the resident's needs. 3) Do not leave me in the bathroom unattended, added 12/20/18. 4) Follow facility protocol. 5) Ensure call light is within reach and encourage the resident to use the call light for assistance, as needed. Respond promptly to all requests for assistance, added 1/21/19. 6) Needed assistance with transfers by 2 staff to move between surfaces and as necessary, or use of a sit to stand lift, added 1/21/19. The facility self-reported a fall with the resident on 12/20/18. The facility's investigation identified a staff member assisted the resident from the bathroom to the bed. Upon reaching the bed, and leaving the resident standing alone, the staff member turned away from the resident to pull down the blankets on the bed. The resident became unsteady and fell to the floor, onto his/her left side. An assessment identified pain to the left hip area and the resident was sent to the ED (emergency department) for examination and subsequently found to have a [MEDICAL CONDITION]. The ED nursing admit report, dated 1/18/18, identified the resident rated pain at a 9 of 10, on the pain scale (with 10 being the worst pain ever experienced). The report identified the hospital transferred the resident to a larger hospital for surgical repair of the [MEDICAL CONDITION]. X-ray reports dated 12/18/18, identified a comminuted intertrochanteric [MEDICAL CONDITION] left femur (hip bone). The resident's clinical record evidenced a follow-up consult with the orthopedist, on 1/7/19, with the resident complaining of increasing pain. The physician ordered a follow-up visit in 2 weeks with X-ray and to call if symptoms worsened. Follow-up orders, dated 1/16/19, evidenced the resident reporting increased pain to the left hip. The physician increased the [MEDICATION NAME] to 7.5/325 milligrams, QID (four times daily), every 6 hours. Observation of the resident, on 1/29/19 at 9:15 AM, identified the resident seated in the wheelchair, with shoes on, a gait belt to the resident's waist and the physical therapist cueing the resident to stand, bear weight and then to take a few steps, holding onto the walker. The therapist pulled the wheelchair behind the resident, as the resident tired quickly, taking only a few steps before his/her knees/legs became weak and unsteady. At 9:55 AM on 1/29/19, the resident moved about his/her room in the wheelchair and attempted to shave with an electric razor. At 10:15 AM, the resident sat in his/her recliner with the foot rest elevated and appeared to sleep. At 11:20 AM on 1/29/19, direct care staff E and G transferred the resident, using a gait belt and 2 staff extensive assistance from the recliner into the wheelchair. The resident requested to use the toilet; staff G then propelled the resident into the wheelchair to the shower room to toilet, again using the gait belt with the resident assisting by using the grab bars to pull him/her self up from the chair to sit onto the commode. Staff G offered the resident the call light and indicated for the resident to call when he/she completed toileting. The resident indicated he/she preferred the staff member to remain with him/her in the toilet, which the staff did. When the resident indicated he/she completed his/her toileting, staff G pulled the call light for additional assistance. After returning the resident to the wheelchair the staff propelled the resident in the wheelchair to the dining room, for lunch. Observation, at 12:30 PM on 1/29/19, identified the resident seated in his/her wheelchair in the resident's room. The residents call light remained attached to the recliner in his/her room, within reach of the resident. At 12:45 PM, observation identified the resident resting in the recliner, with his/her eyes closed, with the call light in reach. The resident remained in the chair until 4:30 PM, when direct care staff F and I assisted the resident with transferring from the recliner to the wheelchair. Staff utilized a gait belt and walker to provide the transfer, then assisted the resident to pivot and sit down into the wheelchair. Interview, on 1/29/19 at 1:44 PM, with direct care staff G reported the resident required 2 staff members to provide transfers prior to the resident's [MEDICAL CONDITION]. Some days, the staff indicated, on good days, 1 person could provide the transfer, but usually it was safer with 2 staff. The resident was able to assist with grabbing his/her toilet room grab bars to assist in transferring onto the commode and he/she did not ambulate then or now, only taking a few steps to complete the transfers. The resident was not safe to leave standing independently with the walker, being unsteady on his/her feet. Since the fall the resident always needed 2 persons out of bed into the recliner or the wheelchair. The staff reported the resident seemed to have more confusion since the fall and surgery. When asked what fall interventions were in place the staff reported the resident was usually transferred into the recliner shortly after meals and to ensure the resident's call light was within reach. The staff failed to identify the intervention of not leaving the resident alone in the bathroom, as he/she attempted to do, during the 11:20 AM toileting. On 1/29/19 at 4:30 PM administrative nursing staff A reported the resident experienced a fall with a [MEDICAL CONDITION], because of a staff member who did not provide appropriate care. Staff A reported the employee no longer worked at the facility. The staff further directed that care plans were current in the computer and the resident additionally had a working care plan in a book in the nursing area. Direct care staff E reported, on 1/29/19 at 2:13 PM, the resident required 2-person assistance for transferring and staff used a gait belt for all transfers. Since the fall, staff check on the resident more frequently and attempt to anticipate the resident needs. The staff further reported the staff toilet the resident in the bigger shower room due to pivoting/space issues. The staff lacked knowledge of the intervention of not leaving the resident alone on the toilet. On 1/29/19 at 3: 24 PM, licensed nursing staff C reported the resident experienced a fall with a [MEDICAL CONDITION] and required assistance with ADLs but lacked awareness of the latest interventions. On 1/29/19 at 3:34 PM, direct care staff J reported the resident required extensive assistance of 2 staff for cares, especially with transfers. The resident often sat up in the recliner in the evening before going to bed at 9 or 9:30 PM. Staff lacked awareness of other safety interventions. The facility policy, dated 4/14, labeled Fall Program, instructed staff to implement staff/patient/family education of precautions needed and to provide reinforcement of these precautions. The facility failed to ensure staff remained with the resident, when staff turned away from the resident to pull down the bed covers, leaving the resident standing alone. The resident lost his/her balance, fell and sustained a [MEDICAL CONDITION]. - Resident #2's [DIAGNOSES REDACTED]. The admission MDS (minimum data set), dated 1/9/19, included a BIMS of 1, which indicated severely impaired cognition, with the resident exhibiting inattention and disorganized thinking. The assessment further identified the resident needed extensive assistance of 2 staff for most ADLs (activities of daily living). The assessment evidenced the resident admitted with a fall history, with a fracture. The resident experienced one fall, without an injury, since admission to the facility. The CAA (care area assessment), dated 1/17/19, for falls evidenced the resident experienced an actual fall at home and in the facility. The staff transferred the resident with assistance of 1 or 2 staff and required 1 or 2 assistance with toileting. The assessment identified the resident at risk for falls due to cognitive impairment, hypnotic use, lack of ROM (range of motion), and a lack of safety awareness. The resident's Fall Risk Assessments on 1/3/19, 1/13/19, and 1/22/19 scored the resident at 18, 15, and 22 respectively. A score of 10 or greater indicated high risk for falling, per the assessment guidelines. The resident's care plan, dated 1/8/19, instructed staff in fall interventions of: 1) 1-2 assist with transfers, added 1/8/19. 2) Total dependence of 1 staff for locomotion using wheelchair, added 1/8/19. 3) Make sure call light is within reach, added 1/8/19. 4) Continue interventions on the at-risk plan, added 1/8/19. 5) Working with PT/OT (physical and occupational therapy) on weakness and ROM (range of motion) to arm to prevent further complications, added 1/8/19. 6) Wear a sling on left arm to hold arm up, added 1/17/19. 7) Staff educated to offer toileting to the resident before going to the recliner or bed, added 1/17/19. 8) Toilet or check and change, prn (as needed), added 1/17/19. 9) 30-minute checks added 1/23/19. The facility failed to add the intervention of adding a bed alarm to the care plan after a fall on 1/20/19. Furthermore, the facility failed to communicate to the direct care staff and off-duty nurse's the interventions implemented following a fall, to ensure these interventions were properly implemented. Review of the 1/12/19 at 9:05 PM, nursing notes evidenced the nurse received notification of the resident being found on the floor in the commons area. The staff nurse completed an assessment of the resident and the resident indicated wanting up off the floor. The staff assisted the resident up off the floor and to go to bed. Staff assisted the resident off the floor and into the nearby wheelchair. The nurse documented the plan to offer the resident the bathroom before transferring the resident into the recliner or going to bed. Nursing documentation on 1/22/19 at 2:09 AM, reflected a fall on 1/29/19. The nurse noted that the staff notified the nurse after finding the resident on the floor in his/her room. The resident lacked any injury and staff documented the plan to consider use of alarms being placed on the bed and/or wheelchair. However, observation of the resident's bed/wheelchair lacked evidence of an alarm, and the resident's care plan did not reflect the use of alarms. Observation of the resident on 1/29/19 at 9:45 AM, identified 2 staff members transferred the resident from the wheelchair into a recliner in the lobby area. Staff used a gait belt and the resident wore gripper socks to both feet. After seating the resident into the recliner, staff elevated the foot rest of the recliner and soon thereafter, the resident appeared to sleep with eyes closed. The resident remained in the recliner, asleep most of the observations, until 11:50 AM. At that time, direct care staff F and G transferred the resident from the recliner into the wheelchair with the use of a gait belt. Staff offered toileting, however, the resident snapped at the staff that he/she did not want anything. Staff then propelled the resident into the dining room, in the wheelchair. At 12:40 PM on 1/29/19, direct care staff G and H provided toileting assistance to the resident before assisting the resident into the recliner in the lobby area. Interview, on 1/29/19 at 1:48 PM, with direct care staff G reported the resident required 2 staff assistance for all cares. Staff G noted the resident admitted wearing a sling to prevent movement of the left arm, however, the resident refused to keep it in place and he/she did not seem to have any pain with movement of the arm. The staff noted the resident required 2 assistance with transfers, awakens naturally in the mornings, therefore the staff monitored him/her closely while in bed to ensure the resident did not attempt to arise without assistance. The staff further noted the resident during daytime hours spent a good deal of time in the front lobby, where staff frequently monitored the resident for restlessness. The staff lacked awareness of any other safety interventions. Direct care staff E reported on 1/29/19 at 2:12 PM, the resident required 2 staff's assistance with all transfers. The staff reported a lack of awareness of other safety interventions, adding, the staff rarely provided care for the resident. On 1/29/19 at 3:20 PM, licensed nursing staff C reported the off-going shift, provided a shift change report, which included any falls with interventions implemented during the report. The staff noted this resident needed 2 staff assistance with transferring and required frequent visual checks related to the resident not remembering to call for assistance with transferring. The staff noted the resident wears slipper (non-skid) socks to bed at night and should be offered a toileting opportunity every 2 hours. In the event the resident refused toileting then staff should wait a short while and then return and offer again. The nurse reported being unaware of any other safety interventions, without looking at the resident's care plan. Direct care staff J reported, on 1/29/19 at 3:38 PM, the resident required assistance of 2 staff members for transferring. The staff reported the resident required toileting before going to supper, then an hour or so after supper and before going to bed. The staff reported the resident did not use a chair alarm but believed the resident had a bed alarm and a low bed. The staff reported being unaware of other safety interventions to prevent falls for this resident. At 4:00 PM on 1/29/19 the resident's adult child visited and reported being pleased with his/her parents care, with the exception that frequently the staff transferred the resident without a gait belt. The resident's adult child expressed fear of injury to the resident's broken arm when staff grabbed his/her arm to transfer the resident. Interview, on 1/31/19 at 11:45 AM, with administrative nursing staff B verified the facility IDT (interdisciplinary team) determined to not implement the use of alarms at the time of the fall and therefore this was not added into the plan of care and instead the staff implemented frequent checks. The facility policy, dated 4/14, labeled Fall Program, instructed staff to implement staff/patient/family education of precautions needed and to provide reinforcement of these precautions. Additionally, the facility policy, instructed in interventions for residents with a mild risk for falling included: 1) Implementation of education for staff, resident and family. 2) Placing the resident on a toileting schedule, if needed. 3) Call light within reach. 4) Side rails up while in bed. 5) Non-skid footwear, socks. 6) Consider use of a body alarm while in chair. 7) Remove clutter in room, if possible. 8) Assess for need of pain medication. Residents at moderate risk for falling included: 1) As above plus adding a body alarm with the family consent. 2) Anti-skid strips next to the bed if falls occur while trying to get out of bed. Residents at high risk included, as above plus: 1) Evaluate for the use of a low bed, consulting with family. The facility failed to implement individualized interventions appropriate to the resident's needs, following falls on 1/12/19 and 1/20/19. - Resident # 3's admission MDS (minimum data set), dated 10/16/18, included a BIMS (brief interview of mental status) of 12/15, which indicated the resident as moderately cognitively impaired. The assessment further noted the resident required supervised to limited assistance for ADLs (activities of daily living), including transfers. Additionally, the assessment reflected the resident with a history of falls and identified the resident experienced one non-injury fall since admit. The quarterly MDS, dated [DATE], identified the resident scored 9/15 on the BIMS assessment which indicated moderately impaired cognition. The assessment identified the resident required extensive assistance for most ADLs, and experienced one non-major injury fall since the prior assessment. The CAA (care area assessment) for Falls, dated 10/21/18, included the resident experienced severe back pain and an unsteady gait, making the resident a fall risk. The resident's family reported the resident fell at home prior to admission. The Fall Risk Assessments, upon admission identified the resident at mild risk for falling and steadily increased the resident risk for falling since admission, as follows: 10/11/18 a score of 9. 11/21/18 a score of 15. 1/4/19 a score of 17. 1/24/19 a score of 19. The risk assessment identified scores of 10 or greater indicating high risk for falling. The care plan, dated 1/16/19, included the following fall interventions: 1) Anticipate and meet my needs. 2) Ensure wearing of appropriate footwear. 3) Follow facility fall protocol. 4) The resident chooses to ambulate independently without calling for staff to help. 5) Needed reminding to use call light for assistance. 6) Staff to stay with me while I am in the bathroom. 7) Transfers with assist of 1 staff. 8) Cue, reorient and supervise as needed. 9) Non-skid strips in front of recliner and ensure wearing gripper socks. 10) Ensure wheelchair within reach. 11) Encourage me to use the call light and wait for assistance, added 1/16/19. The care plan failed to identify the resident's toileting needs, based on the assessment completed. Furthermore, the facility failed to implement a fall intervention appropriate to the residents fall on 1/14/19 and ensure a method of transmitting this information to the staff to provide an individualized plan of care for the resident. Review of the resident's electronic clinical record nursing notes, included on 11/21/18 at 10:53 AM, that at 7:17 AM the staff found the resident on the floor of the bathroom. The resident indicated he/she lost his/her balance when becoming weakened. The resident lacked any injury and the staff determined an appropriate intervention of the staff to remain with the resident when toileting. On 12/3/18 at 11:45 PM, the staff documented the resident at approximately 9:45 PM, yelled from his/her room and staff found the resident on the floor in front of his/her recliner. The staff reported checking the resident 5 minutes prior and the resident slept peacefully in his/her recliner and staff did not awaken the resident. Staff toileted the resident, found the resident was incontinent of urine and then per the resident's request returned to the recliner. On 1/14/19 at 1:55 AM, staff documented the resident called out for help and staff responded to the call. The staff found the resident on the floor and indicated he/she planned on going to the bathroom, when he/she lost his/her balance. The staff failed to implement an appropriate intervention after this fall. On 1/24/19 at 4:30 AM, the staff again found the resident on the floor, because of attempting to self-toilet. The staff found the resident's slippers lacked any gripper to the soles and changed the resident's slippers to non-skid slipper socks, however, the facility continued to fail to address the resident's toileting needs. Observation on 1/29/19 at 9:47 AM, identified the resident's room with gripper strips in front of the recliner, the call light attached to the resident's recliner and the resident seated in a wheelchair in the hallway, with anti-roll back brakes in place and non-skid socks to the resident's feet bilaterally. At 10:17 AM on 1/29/19, observation identified direct care staff G and H transferred the resident from the wheelchair to the beauty shop chair, utilizing a gait belt for safety. Observation on 1/29/19 at 1:11 PM, identified the resident seated on the toilet without any staff member in attendance. A minute or two later direct care staff E entered the resident's room to complete toileting care for the resident. Upon completion of the toileting care the staff assisted the resident back into the wheelchair and the resident began to self-propel about the hall. On 1/29/19 at 1:56 PM, direct care staff G reported the resident needed 1 staff members assistance for most tasks, with the resident self-propelling in the hallway independently. The staff indicated the resident required extensive care for toileting. The staff indicated the only safety intervention for the resident assisting the resident into the recliner when in his/her room. The staff reported the resident's toileting schedule included toileting every 2 hours and as requested. The staff reported new interventions implemented during off shift days are also provided during the shift to shift report. On 1/29/19 at 2:04 PM, direct care staff E reported the resident required assistance with transfers with use of a gait belt. If the resident were lethargic he/she might require 2 persons to assist. Staff indicated the resident was usually incontinent of urine. When inquiring about the intervention of staying with the resident when toileting, the staff indicated that he/she did not believe that intervention was still on the care plan and that the resident usually called when he/she completed toileting. The staff further noted, when leaving the resident, he/she did not go very far away. When asked if any residents cannot be left alone on the toilet the staff responded with only 1 resident's name. Staff E reported the resident's toileting schedule included upon awakening, before lunch, and before assisting into the recliner. Licensed nursing staff C reported, on 1/29/19 at 3:05 PM, the resident, when first admitted experienced a lot of back pain and spasms. The staff reported the resident seemed more comfortable now and falls decreased. The staff reported the resident does wear non-skid socks at night and used a soft touch call light, which he/she used to call for assistance when needing assistance. The staff reported the resident rang for staff assistance when toileting needs arose and then the staff only provided stand by assistance. On 1/29/19 at 3:40 PM, direct care staff J reported the resident required 1 to 2 assistance for toileting and transfers and did not recall the resident required a staff member to remain with him/her when toileting. Interview on 1/29/19 at 3:50 PM, with administrative nursing staff D verified the resident's who have falls have interventions implemented by the charge nurse, immediately after the fall. The staff further noted, that the IDT (interdisciplinary team) do evaluate the effectiveness of the intervention during the review of the incident and at times change or add additional interventions. In this case of the resident needing staff to remain with him/her when toileting the direct care staff never indicated the resident's care plan needed changed and to the staff's knowledge the staff continued to require staff stay in attendance during toileting, to prevent falls. The facility policy, dated 4/14, labeled Fall Program, instructed staff to implement staff/patient/family education of precautions needed and to provide reinforcement of these precautions. Additionally, the facility policy, instructed in interventions for residents with a mild risk for falling included: 1) Implementation of education for staff, resident and family. 2) Placing the resident on a toileting schedule, if needed. 3) Call light within reach. 4) Side rails up while in bed. 5) Non-skid footwear, socks. 6) Consider use of a body alarm while in chair. 7) Remove clutter in room, if possible. 8) Assess for need of pain medication. Residents at moderate risk for falling included: 1) As above plus adding a body alarm with the family consent. 2) Anti-skid strips next to the bed if falls occur while trying to get out of bed. Residents at high risk included, as above plus: 1) Evaluate for the use of a low bed, consulting with family. The facility failed to provide care, supervision and assistive devices including: 1)the failure to remain with the resident during toileting, 2) developing appropriate interventions following falls, and 3) address an individualized toileting plan to prevent repeated falls when the resident attempted to self-toilet

The facility had a census of 28 residents. The sample included 4 residents. Based on observation, interview and record review the facility failed to thoroughly investigate falls, and initiate appropriate interventions to identify and prevent future falls for 3 of 3 residents reviewed. (#1, #2, #3) The facility further failed to provide an environment free of accident hazards by providing side rails which measured beyond the requirement creating an accident hazard and possible entrapment for 2 of 3 residents reviewed for side rails. (#3, #4) Findings included: - Resident #1's quarterly (MDS) Minimum Data Set assessment, dated 9/24/14, identified the resident with moderately impaired cognition, had no recall ability, required limited assistance of 1 staff for bed mobility, transfer, walking in room, dressing, toileting, and hygiene. The resident needed physical assistance to stabilize his/her balance, had lower extremity impairment on 1 side, had no history of falls, not on a toileting program and occasionally incontinent of urine. The admission MDS, dated [DATE] stated the same except the resident had severely impaired cognition, and did not have any falls. The (CAA) Care Area Assessments, dated 7/2/14, did not trigger for falls. The 9/23/14 Fall Risk Assessment revealed a score of 16, a moderate risk for falling. The 9/30/14 care plan stated the resident required assistance with (ADLs) Activities of Daily Living, was a risk for falls, instructed the staff to provide assistance with ADL's, keep the call light in reach, and instruct the resident on the use of the call light. The care plan stated the resident was to request assistance with walking until he/she was stable although the 9/24/14 MDS stated the resident had moderately impaired cognition and no recall. The 10/3/14 (untimed) nurse's note stated the staff found the resident on the floor beside the bed at 12:35 PM, with his/her legs extended out. The resident stated he/she moved from the chair to the bed and missed the bed. Interventions in place included gripper socks and the call light within reach and to instruct the resident to call for help. The staff made no change to the care plan to minimize the risk of further falls. Although a request was made to the facility for the investigation of causal factors for the 10/3/14 fall, the information was not provided. The 10/4/14 at 4:00 PM, nurse's note stated the resident had an unsteady gait when assisted to the bathroom and became dizzy. The 10/10/14, nurse's note stated the resident returned from the hospital with a [DIAGNOSES REDACTED]. The 10/11/14 (untimed), nurse ' s note stated the resident was alert to person only, had increased confusion, did not use the call light, was up to the bathroom several times, and staff found the resident seated on the roommate's bed. The 10/12/14, 2-10 shift, nurse's note stated the resident did not use the call light for assistance. The 10/13/14, 6-2 shift, nurse's note stated the resident did not use the call light and the staff found the resident in the bathroom 2 times, and assisted him/her back to the recliner. The staff re-educated the resident to use the call light for assistance. Review of the medical record revealed the staff identified the resident's increased confusion, lack of using the call light, and finding the resident in the bathroom two times. The medical record revealed no new interventions implemented by the staff to decrease the risk of the resident ambulating unassisted and potential further falls for the resident. The 10/14/14 at 4:50 AM nurse's note stated the staff found the resident on the floor in the bathroom. He/she had a skin abrasion to his/her left forehead, a skin tear to the left 3rd knuckle, and 2 small areas to the left knee with the skin slid to one side, but not open. A care plan update after the staff found the resident on the floor on 10/14/14, stated the resident fell at 4:50 AM, taking him/herself to the bathroom unassisted. He/she had abrasions and bruises, was weaker, and recommended a toilet schedule if the resident could not call for assistance. The update stated staff would assess the resident's ability to use the call light. Upon request for the assessment, Nurse E verified the staff had not completed an assessment on the resident's ability to use the call light. The 10/14/14 (untimed), nurse's note stated the staff noted the resident's confusion when he/she, used his/her walker backward when going to the recliner with his/her pants halfway down. The nurse informed the resident he/she would obtain an order for [REDACTED]. The 10/14/14 investigation stated the staff found the resident at 4:50 AM on the floor in the bathroom. The staff instructed the resident on the use of the call light, then the resident did not use the call light. The resident reported he/she stood from the toilet and " went over ", and he/she complained of knee pain. The 10/15/14 (untimed), nurse's note stated the resident had increased swelling and pain to his/her left knee. An X-Ray revealed a fracture to the patella (knee cap). The physician ordered a brace to the resident's left knee. On 11/12/14 at 1:26 PM, observation revealed the resident transferred from the wheelchair to the bed with assistance from Staff D and Staff F. Observation revealed the resident shoulde'rs slumped, his/her torso leaning forward, dependent on weight bearing support from the staff, and took short steps in non-skid slipper socks with hesitation. On 11/12/14 at 1:10 PM, Resident #1 stated his/her knee hurt because he/she attempted to walk to the bathroom, fell , and broke his/her knee. On 11/12/14 at 1:34 PM, Nurse Aide F stated the resident transferred with the assistance of 1 staff prior to his/her fall with injury. The resident got up on his/her own to go to the bathroom and staff found the resident on the floor. On 11/12/14 at 5:20 PM, Nurse G stated the resident was alert, but very forgetful, with increased confusion. The resident walked on his/her own before the fall, but would forget to call for help. He/she stated staff observed increased confusion since the resident's hospitalization for a GI bleed. Nurse G stated the staff re-educated the resident several times on using the call light, but was not successful. Nurse G explained the staff added an alarm as a fall intervention after the resident fell and sustained a fracture. On 11/12/14 at 4:57 PM Nurse E acknowledged the resident returned from the hospital weaker and more debilitated and stated following the 10/10/14 care plan note, a specific toileting schedule was not developed, but the 10-6 staff were to assist the resident to the bathroom during rounds. Nurse E acknowledged the resident was confused and made poor decisions prior to and after the falls and was a risk for falling. On 11/13/14 at 11:50 AM, Nurse A acknowledged an investigation was not completed following the 10/3/14 fall, and verified staff added the intervention of the alarm to the care plan following the fall with injury. Nurse A verified the resident's health declined with an acute illness, he/she had more confusion and was a fall risk. He/she stated the staff educated the resident several times on the use of the call light, but the resident was unable to remember to use the call light and staff did not add any new interventions to the care plan for fall prevention prior to the 10/14/14 fall. The facility's April 2014 Fall Program Policy and Procedure stated a resident scoring 10 or above on the fall risk assessment tool will have fall prevention interventions planned. Under evaluation/Intervention a resident with a score of 10-14, mild risk, would have the following interventions: *Education for staff, resident, and family, *Place on a toileting schedule as needed, *Call light within reach, *Non-skid footwear, socks, *Consider use of a body alarm while in the chair, *Assess for the need for pain medication A score of 15-18, a moderate risk, would include the above interventions and use of a body alarm with the family consent. The facility failed to provide Resident #1 with adequate supervision to prevent falls when staff failed to assess for causative factors for 1 fall and then develop and implement appropriate interventions to prevent additional falls. The facility readmitted Resident #1 from the hospital and noted his/her increased confusion and lack of activating the call light for assistance and the resident fell and sustained a fracture of his/her patella. - Resident #2's significant change (MDS) Minimum Data Set assessment, dated 5/13/14, identified the resident with moderately impaired cognition, and supervision and set-up help needed with his/her (ADLs) Activities of Daily Living. The resident did not walk in the hallway. The quarterly MDS assessment, dated 8/6/14, identified the resident with moderately impaired cognition, supervision of 1 staff with his/her (ADLs) Activities of Daily Living, he/she could stabilize his/her balance with staff help, and had impaired (ROM) Range of Motion on 1 side of his/her upper extremities, and bilaterally on his/her lower extremities. He/she did not have a history of falls. The 5/13/14 (ADLs) Activities of Daily Living (CAA) Care Area Assessment stated he/she experienced pain, had weakness and poor coordination, walked and transferred on his/her own, and received assistance of 1 staff on his/her request. The Care Plan Review Log lacked a signature, verifying the staff completed a review of the care plan for the 8/6/14 MDS. The 5/14/14 care plan stated the resident had increased his/her participation in daily care, supervision was indicated with staff assistance for ADL ' s as needed for dressing, incontinence, and skin care. The care plan directed staff to instruct the resident on use of the call light. The 9/12/14, Fall Risk Assessment revealed a score of 13, a mild risk for falls. The 10/28/14, (ROM) range of motion assessment stated the resident had moderate ROM impairment to all joints. The 9/12/14 at 1:10 PM nurse's note stated the resident had a fall in his/her room, backing out of the closet, and had no injuries. The 10/21/14 at 10:05 AM nurse's note stated the staff found the resident on the floor beside the bed. The resident stated he/she had gotten down on one knee to get his/her shoe from under a table, his/her knees gave out, so the resident sat on his/her bottom. The 10/22/14 (2-10 shift) nurse's note stated the interdisciplinary team met to discuss further actions related to the above fall. The team determined no need for further follow-up. The medical record revealed, after the above noted falls, no documentation the staff completed a fall follow-up assessment as stated in the policy (morning, afternoon, and evening) at the following times: *9/13/14, 2-10 shift, the entry failed to document the needed assessment information *10/22/14, 6-2 shift, the entry failed to document the needed assessment information On 11/13/14 at 7:56 AM, observation revealed the resident as he/she exited the bathroom using a wheeled walker, and wearing non-skid socks. The resident walked with a slumped forward posture, slow gait, and short steps. On 11/12/14 at 3:52 PM, Nurse Aide H stated the resident moved independently, does his/her own ADLs, has some pain and takes pain medication. Nurse Aide H stated the resident had 1 fall when he/she knelt down, could not stay in that position, and staff found him/her on the floor. On 11/12/14 at 5:20 PM, Nurse G stated the resident was alert and forgetful at times, staff assisted him/her to get into bed, and otherwise he/she is independent with ADL's. He/she explained staff assisted the resident upon his/her request. On 11/18/14 at 1:05 PM, Nurse E stated the staff reviewed the care plan for the 8/6/14 MDS, but verified the signature that would have documented the review was absent. On 11/13/14 at 11:50 AM, Nurse A verified staff failed to completed follow-up fall documentation as stated in the policy. The facility's April 2014 Fall Program Policy and Procedure stated vital signs and assessments were to be completed for 72 hours after a fall 3 times a day: morning, afternoon, and evening. The assessment should include vital signs, range of motion, pain, any new redness or bruising, and ambulation and mobility. The facility failed to provide Resident #2 with adequate supervision to prevent falls and complete follow-up assessments after falls, as outlined in the facility policy. - Resident #3's annual (MDS) Minimum Data Set assessment, dated 8/27/14, indicated the resident had moderate cognitive impairment with a (BIMS) Brief Interview for Mental Status score of 10, and required limited assistance from 1 staff for bed mobility, transfers, dressing, toilet use, walk in room, and personal hygiene. The MDS further indicated the resident's balance was not steady but able to stabilize without assistance of the staff, had an upper and lower extremity impairment on 1 side, used a walker as an assistive device, had 1 non-injury fall, received antianxiety medications, and required oxygen therapy. The 9/2/14 care plan instructed the staff to remind the resident to use the call light at night when going to the toilet, move the oxygen concentrator behind him/her when ambulating, to clear a path to the bathroom in case the resident got up independently, shorten the oxygen tubing, and remind the resident to wear shoes or non-skid socks. The care plan further instructed the staff to provide the resident with partial bed side rails, to provide independence with repositioning. The 10/30/14 care plan update instructed the staff to remind the resident to use the call light. The 11/5/14 care plan update instructed the staff to remind the resident to use his/her call light for assistance. The 11/9/14 instructed the staff to rearrange the resident's room. The 6/4/14 side rail assessment indicated the resident was safe to use the side rails and there was no gap in-between the side rail and the mattress. The 8/27/14 fall risk assessment indicated the resident was a high fall risk. The physician order [REDACTED]. The physician order [REDACTED]. The 10/30/14 at 3:20 AM, nurse's note indicated the staff found the resident sitting on the floor in his/her bathroom. The note indicated the resident had no injuries, and he/she slid off of the toilet when trying to toilet him/herself. The 11/5/14 at 11:24 PM, nurse's note indicated the staff found the resident sitting on the floor by his/her chair and bed. The note indicated the resident had no injuries, and the resident stated he/she missed a step and fell into the trash can when transferring to bed independently. The 11/9/14 at 11:10 PM, nurse's note indicated the staff found the resident on the floor by his/her closet. The note indicated the resident had no injuries, and the resident stated he/she lost his/her balance getting a snack from the closet. The medical record revealed, after the above noted falls, no documentation the staff completed a fall follow-up assessment on the night shift on the following days: - 10/30/14 - 11/7/14 - 11/8/14 - 11/11/14 - 11/12/14 Review of the medical record revealed no root cause analysis completed in regards to the resident's falls. On 11/13/14 at 7:50 AM, observation revealed the resident lying in bed, the side rails in the up position on both sides, non-skid socks on his/her feet, and oxygen applied by nasal cannula (nose piece). Continued observation revealed 1 staff assisted the resident to the bathroom with use of a gait belt, walker, and stand by assistance. At 8:30 AM, observation revealed the bed side rails had a gap, which measured 7 inches by 9 inches. On 11/13/14 at 8:08 AM, Nurse Aide B stated they remind the resident frequently to use his/her call light and have even placed a sign on his/her dresser to remind the resident to use the call light. Nurse Aide B further stated the resident's side rail had a large gap which could cause an entrapment, but the resident used the bed side rails for bed mobility and the bed side rails do not restrain him/her from getting out of bed independently. On 11/13/14 at 9:37 AM, Nurse C stated the staff reinforced to the resident the importance of using the call light when he/she needs assistance. Nurse C further verified the staff ensure the resident has on gripper socks in case he/she forgets to put on shoes, and the staff rearranged his/her room, to provide less congestion in case he/she were to get up independently. On 11/13/14 at 10:45 AM, Administrative Nurse A verified the facility had not conducted a root cause analysis on the resident's falls in order to prevent future falls, and verified a licensed nurse should have assessed the resident in the morning, afternoon,and evening for 72 hours after a fall. Administrative Nurse A further verified the resident's side rails could cause entrapment and were unsafe due to the large gap. The facility's 4/2014 Fall Program policy instructed the staff vital signs and assessments are to be completed 3 times a day for 72 hours following a fall, and the assessment should include vital signs, range of motion, pain, any new redness or bruising, and ambulation and mobility. Upon request the facility failed to provide a policy in regards to side rails. The facility failed to conduct a root cause analysis after Resident #3's falls to prevent future falls, and the resident continued to fall, the facility failed to provide follow up fall assessments as outlined in the facility policy. The facility failed to provide Resident #3 with side rails that were safe, with no potential for entrapment. - Resident #4's quarterly (MDS) Minimum Data Set assessment, dated 9/3/14, indicated the resident had severe cognitive impairment with a (BIMS) Brief Interview of Mental Status score of 0. The MDS further indicated the resident required total assistance of 2 staff for bed mobility, transfers, dressing, and personal hygiene, had upper and lower extremity impairments on both sides, and had no restraints. The 9/9/14 care plan instructed the staff to provide the resident with partial right and left bed side rails, while in bed, for security. The 3/20/14 Side Rail assessment indicated the resident was safe to use the side rails and the mattress fit properly with no gap between the bed rail and the mattress. The 10/7/14 physician order [REDACTED]. On 11/12/14 at 3:37 PM, observation revealed the resident lying in bed with his/her side rails in the up position. On 11/13/14 at 8:30, observation revealed the bed side rail gap measured 7 inches by 9 inches. On 11/13/14 at 9:37 AM, Nurse C verified the staff provided the resident with side rails so the resident felt safe and secure. On 11/13/14 at 10:45 AM, Administrative Nurse A verified the resident's side rails could cause entrapment and were unsafe due to the large gap. Upon request the facility failed to provide a policy in regards to side rails. The facility failed to provide Resident #4 with safe side rails, with no potential for entrapment.