Every finding on record at Towner County Living CTR

Based on observation, review of facility policy, review of resident council minutes, review of the facility assessment, review of the dietary schedule, and staff interview, the facility failed to ensure sufficient staff for meal service in 1 of 1 dining room. Failure to serve resident meals in a timely manner did not enhance the dining experience for the facility's residents.Findings include:Review of facility policy titled Nutrition Services Staffing occurred on 01/14/26. This policy, revised 04/08/25, stated, . The department will be staffed adequately to meet the patient's nutritional needs with regular meals served to patient at 7:30am [morning], 11:45am and 5:30pm [evening]. The facility will provide sufficient support personnel to safely and effectively carry out the supportive functions of the Food and Nutrition Services. These functions include, but are not limited to: . Safe and timely meal preparation . Providing meals and/or supplements in accordance with residents' needs . Review of the resident council minutes occurred on all days of survey and showed the following:* August 2025, stated, . short staffed at this time. Residents continue to wait for food .* September 2025, stated, . Dietary: . The department continues to be short staffed at this time. Residents continue to wait for food longer than they would like.* October 2025, stated, . dietary is short staffed at times. the wait time for food it too long.* December 2025, stated, . wait time for food is too long .* January 2026, stated, . dietary is short staffed at times.Review of the facility assessment identified one full time dietary manager on the day shift, three dietary assistants for 8 hours on the day shift, and one dietary assistant for 2.5 hours on the day shift.Review of the dietary schedule from December 8, 2025, through January 18, 2026, identified 18 days of less than three dietary assistants during the noon meal. Review of the meal and snack times identified lunch served at noon. Observation of the noon meal on 01/12/26 at 12:33 p.m., showed the dietary manager (#6) and the cook (#7) prepared and served the meal. The residents in the dining room received their meal at 1:00 p.m., one hour past the posted serving time. During an interview on 01/14/26 at 4:00 p.m., the dietary manager (#6) stated she would expect three to four kitchen staff during both the day and evening shifts and meals to be served at the scheduled times.The facility failed to serve the residents meals in a timely manner.

Based on observation, review of resident council meeting minutes, review of facility policy, and resident and staff interviews, the facility failed to take actions aimed at performance improvement and, after implementing those actions, measure its success, and track performance to ensure that improvements are identified and sustained. Failure to perform Quality Assurance and Performance Improvement Program (QAPI) for continued resident concerns placed all residents at risk for not having their needs met. Findings includeReview of policy, Quality Assurance & Performance Improvement Program occurred on 01/14/26. This undated policy stated, . the scope of the QAPI program encompasses all segments of TLCL ([NAME] County Living Center) including resident . feedback . Our organization will conduct Performance Improvement Projects [PIP] that are designed to take systemic approach to revise and improve care or services in the areas that we identify as needing attention. We will conduct PIPs (performance improvement plans) that will lead to changes and guide corrective actions in our systems . and have impact on quality of life and quality of care for the residents living in our community. We will conduct PIPs that will improve care and services delivery .- Observation of the noon meal on 01/12/26 at 12:33 p.m. showed the residents in the dining room received their meal at 1:00 p.m., one hour past the posted serving time.- During an interview on 01/12/26 at 1:20 p.m., a confidential resident (Resident A) stated, My main concern is with meals, we sit and wait for a long time, at least half an hour until our food is served. Resident A continued, We [the residents] have complained about long wait times for meals at the resident meetings and nothing ever happens about it. - During an interview on 01/12/26 at 1:40 p.m. Resident #1 stated, I eat in my room for now and I'm hungry. I haven't had my lunch tray yet. Depending on the day they are late getting me my food. I had my light on and requested food earlier. - Observation on 01/12/26 at 1:47 p.m. showed a lunch tray delivered to Resident #1's room, almost two hours past the serving time.Review of resident council meeting minutes for the past five months, (August 2025 through December 2025) showed the following:* August 4th, 2025: .Dietary: . Concerns: Residents continue to wait for food .* September 15th, 2025 Dietary: . Concerns: Residents continue to wait for food longer than they would like. Comments shared verbally with dietary manager.* October 6th, 2025 . Dietary: . Concerns: . residents report that the wait time for food is too long. Concerns e-mailed to and verbally discussed with dietary manager.* December 1st, 2025 . Concerns . residents report that the wait time for food is too long . Concerns verbally discussed with dietary manager.- During an interview on 01/14/26 at 4:22 p.m. an administrative staff member (#4) stated, food service complaints from resident council meetings are sent directly to the dietary manager, and she had not been notified of any dietary concerns. The staff member stated PIPs are prioritized by resident and staff concerns and verified the facility has not conducted a PIP related to long wait times for meal service.- During an interview on 01/14/26 at 4:41 p.m. an administrative staff member (#3) stated, The dietary manager has talked to me a couple of times about the concerns with long wait times for meal service. The facility failed to address and conduct a PIP related to continued resident complaints with long wait times for meal service. See F802

Based on review of the facility reported incident (FRI) investigation, record review, review of facility policy, and staff and resident interviews, the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 of 1 sampled resident (Resident #4) investigated for a fall. Failure to ensure staff provided hands on assistance with ambulation resulted in a fall with injury to Resident #4 and has the potential for all residents who require hands on assistance with ambulation to experience falls and/or injury.Findings includeReview of the facility policy titled Fall Prevention Policy occurred on 01/14/26. This policy, dated 10/03/24, stated, . Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls.Review of the FRI investigation, received from the facility on 03/19/25, stated, . RN [registered nurse] [#9] verbally reported CNA [#8] called her into the room and when she came in found [Resident 4] on the floor with a quarter size open flap to right posterior head with active bleeding. RN [#9] reported she asked CNA [#8] twice if she lowered her to the ground. RN [#9] reported the CNA did not answer her. LBSW [licensed baccalaureate social worker] [#5] interviewed [Resident #4], about the fall she had. [Resident #4] stated she was walking to the bathroom and fell part way between the area by the sink and the toilet. [Resident #4] stated the CNA [#8] put a gait belt on her and opened the door for her. [Resident #4] stated she walked to the bathroom by herself and the CNA was in the bedroom. When asked where the CNA was at this time, [Resident #4] stated she was in the bedroom beside her recliner. [Resident #4] stated she tried to catch her balance but was unable to do so. She hit her head on the countertop. [Resident #4] stated, I really cracked it, I can still hear the sound. This writer asked if the other CNA's hold onto her when she walks to the bathroom. She said yes, they all hang onto me, even the men do. [Resident #4] stated the CNA [#8] put the belt on her but did not walk in with her. It is noted [Resident #4] visited with three different staff members, and each time she reported she walked into the bathroom alone, and the CNA [#8] was in the other room.Resident #4's nursing progress notes stated the following:* 03/16/25 at 12:00 p.m. CNA called me to the BR [bathroom]. Res sitting on her buttocks in front of the sink area. CNA [#8] states she was walking her to the toilet when her rt [right] ankle twisted and she began to fall. Hit her head on the countertop. Has quarter sized open flap to rt post [posterior] head with active bleeding. Alert, oriented to what happened . Admits to pain at open site only. Denies HA [headache].During an interview on 01/13/26 at 9:45 a.m., Resident #4 stated she has not had any recent falls, Since I cracked my head on the countertop. When asked about that fall and if CNA helped her walk to the bathroom, Resident #4 stated, No she put the belt on me but did not walk with me into the bathroom. She was in the other room by my recliner.During interview on 01/14/26 at 2:43 p.m., an administrative staff member (#2) stated she expected staff to ensure residents received adequate assistance and followed the residents care plan.

Based on observation, review of facility policies, and staff interview, the facility failed to ensure food is stored in accordance with professional standards for food service sanitation in 1 of 1 kitchen. Failure to ensure food is stored, prepared and served in a sanitary environment, and to ensure sanitary strips are not expired, may result in contamination of foods and foodborne illness. Findings include:Review of the facility policy titled Food Storage occurred on 01/14/26. This policy dated September 2010, stated, . The store room will be clean . Items stored under refrigeration that are ready to eat and potentially hazardous shall be marked with date prepared. Potentially hazardous [foods] like meats, spreads and salads will be kept for three days after date prepared . Other less hazardous foods like gelatin and canned fruit will be kept five days after date opened. Food must be stored sufficiently above floor level . 6-12 off the floor . Lighting, ventilation and humidity should be controlled to meet requirements and prevent both condensation and the growth of microorganisms. All food products opened or placed in another container must be labeled, dated and covered.Review of the facility policy titled Sanitation and Infection Control occurred on 01/14/26. This policy, dated March 2007, stated, .The general responsibilities of the director of dietary and dietitians are: . To supervise sanitation and cleaning procedures in the Dietary Department. Dietary employees will be given a daily cleaning checklist that they must check off through their shift until completed and initialed. All floor surfaces must be wet-mopped daily and as needed. Food service equipment will be cleaned according to cleaning schedule.The initial observation of the kitchen occurred on 01/12/26 at 11:35 a.m. and showed the following:Walk-in cooler: * One container of meatballs and gravy not labeled or dated. * One container of an unknown food item not labeled or dated. * One container of tomato sauce dated 12/22.* Opened and undated containers of dressings (Mayo, Catalina, Frank's Red Hot, Italian Salad Dressing and coleslaw dressing). * One container of an unknown meat product dated 12/21. Walk-in freezer: * French fries and other food debris on the floor.* One box of English muffins stored on the floor. Stand up freezer #3:* One undated, unlabeled and unsealed bag of pastries. Dry storage: * Two unlabeled and undated containers of dry cereal not in original packaging. * Individual jelly packets and debris on the floor under the shelving.Observation of the kitchen on 01/14/26 at 9:50 a.m. showed the following:* Two large plastic containers of flour. One container not labeled or dated and a measuring cup in the second container.* One plastic container of sugar not labeled or dated.* Microwave dirty with food particles. * The inside of a deep fryer lined with old food debris.* Quaternary Ammonia Sanitizer test strips, used by staff to test the concentration sanitizer solution, with an expiration date of December 2025.Walk-in cooler: * The same open and undated dressings listed in initial walk through.* One large plastic container of unlabeled and undated mixed lettuce. * Deli meat dated 12/21. * Debris on the floor. Walk-in freezer: * One large plastic tote with individual unlabeled or undated foods stored in Ziplock baggies. * Ice buildup on the light above the fan. Stand up freezer #3:* Red liquid spillage frozen under the bottom drawer.Dry storage:* Debris on the floor under the canned good storage shelving.* One large bag of croissants dated 12/08/25. * Two clear plastic containers of chocolate glaze dated 11/11, not in original packaging. Small fridge #5: * One open and undated container of thickened cranberry juice.During an interview on 01/14/26 at 11:45 a.m., the dietary manager (#6) stated she expected prepared foods to be covered and labeled including the date and opened food containers to be labeled and dated. She confirmed the sanitizer test strips were outdated and new strips had been ordered. She expected staff to clean daily, and confirmed no daily cleaning checklist for staff to initial.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to follow standards of infection control and prevention for 1 of 1 sampled resident (Resident #3) observed during cares. Failure to apply appropriate personal protective equipment (PPE) when providing care to residents in enhanced barrier precautions (EBP) has the potential to spread infection to residents, staff and visitors. Findings include: Review of the facility policy titled, Infection Control-Enhanced Based Precautions occurred on 01/14/25. This policy, revised September 2025, stated, . Enhanced Barrier Precautions require the use of gowns and gloves . For residents for whom enhanced Barrier Precautions are indicated, Enhanced barrier Precautions is employed the preforming resident care activities: . Transferring. Changing briefs or assisting with toileting . Review of Resident #3's medical record occurred on all days of survey. A physician's order dated, 06/26/24, stated Enhanced Barrier Precautions due to indwelling catheter - G-Tube [feeding tube] Observation on 01/12/26 at 2:24 p.m. identified an EBP signage and PPE supplies outside Resident #3's door. A certified nurse aid (CNA) (#1) entered Resident #3's room, applied gloves, transferred the resident from wheelchair to the toilet, provided toileting hygiene, and transferred the resident back to the wheelchair. The CNA (#1) failed to apply a gown prior to providing cares. During an interview the afternoon of 01/14/26, an administrative nurse (#2) confirmed she expected staff to wear a gown when transferring and toileting residents in EBPs.

Based on observation, review of facility policy, and resident and staff interviews, the facility failed to serve beverages at palatable temperatures in 1 of 2 meals observed. Failure to serve foods at palatable temperatures to residents may result in decreased intake, weight loss, and inadequate nutrition. Findings include: Review of the facility policy titled Food Storage occurred on 09/24/24. This undated policy, stated, .Purpose: to store food under sanitary conditions to protect it from contamination and outdating . 11. dairy products . must be stored at temperatures between 33-40 degrees Fahrenheit . During an interview on 09/23/24 at 2:15 p.m., Resident A stated, The cold drinks are warm. Observation of the breakfast meal occurred on 09/24/24 at 8:38 a.m. showed staff served residents their milk from three half gallon cartons sitting in a pan of water. Temperatures obtained showed the following: * Whole milk at 50 degrees Fahrenheit * 2% milk at 49 degrees Fahrenheit * Chocolate milk at 60 degrees Fahrenheit During an interview on 09/24/24 at 08:56 a.m., a dietary staff (#3) confirmed she expected staff to serve food at an acceptable temperature.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to ensure accurate labeling of medications for 1 of 2 sampled residents (Resident #22) with a gastrostomy tube (G-tube)observed during medication pass. Failure to ensure appropriate labeling of medications placed residents at risk for medication errors and/or injury. Findings include: Review of the facility policy titled Labeling of Medications occurred on 09/24/24. This policy, dated July 2024, stated, . 1. All medications will be labeled in accordance with applicable federal and state requirements and current accepted pharmaceutical principals and practices . 2. Labels for individual drug containers must include: . i. The route of administration . 10. The pharmacy must be informed of any order changes or changes in directions for the use of the medications . - Review of Resident #22's medical record occurred on all days of survey and included a physician's order to administer medications via G-tube. - Observation during medication pass on 09/24/24 at 2:49 p.m. showed a staff nurse (#2) administered five medications to Resident #22, via G-tube. Review of the instruction on the medication cartridge for Resident #22, . give by MOUTH, crushed, in pudding . During an interview on 09/24/24 at 2:06 p.m., an administrative nurse (#1) confirmed medications need to be labeled according to physician's orders.

Based on record review, review of facility policy, and staff interview, the facility failed to ensure the consultant pharmacist completed and reported the drug regimen reviews at least monthly for 5 of 5 sampled residents (Resident #2, #5, #6, #7, and #16) selected for unnecessary medication review. Failure to complete and report drug regimen reviews may result in residents receiving unnecessary medications and experiencing adverse consequences related to the medications. Findings include: Review of the facility policy titled Pharmacy Monthly Medication Review of LTC [Long Term Care] Residents occurred on 09/07/23. This undated policy, stated, . Review new orders since the last month's review. Scan medication profile/Physician Order Sheet for compliance with the DRUG REGIMEN REVIEW GUIDELINES (DRR). Review of Residents #2, #5, #6, #7, and #16's medical records occurred on all days of survey. The record identified the most recent drug regimen reviews dated as follows: * Resident #2 - 05/31/23 * Resident #5 - 03/31/23 * Resident #6 - 04/30/23 * Resident #7 - 03/31/23 * Resident #16 - 05/31/23 During an interview on 09/07/23 at 9:42 a.m., an administrative nurse (#7) confirmed the consultant pharmacist (#6) failed to complete the required monthly drug regimen reviews. 40488 46963

Based on record review, review of the North Dakota Provider Manual for Preadmission Screening and Resident Review (PASRR) and Level of Care Screening Procedures for Long Term Care Services, and staff interview, the facility failed to complete a status change assessment for 1 of 1 sampled resident (Resident #7) reviewed for PASRR. Failure to complete a change in status assessment with a newly diagnosed mental illness and/or change in treatment may result in the delivery of care and services that are inconsistent with residents' needs. Findings include: The North Dakota PASRR Provider Manual, revised December 2020, page 13, states, . Change in Status Process: Whenever the following events occur, nursing facility staff must contact [the contracted agency] to update the Level I screen for determination of whether a first time or updated Level II evaluation must be performed. These situations suggest that a significant change in status has occurred: . If an individual with MI, ID, and/or RC [mental illness, intellectual disability, and conditions related to intellectual disability (referred to in regulatory language as related conditions or RC)] was not identified at the Level I screen process, and that condition later emerged or was discovered. Review of Resident #7's medical record occurred on all days of survey. A PASRR Level I screen outcome, dated 01/13/22, stated, Facility knows very little about the resident's history. He denies any hx [history] of psych [psychiatric] treatment . however we have not been able to verify this. A PASRR Level II evaluation is not required at this time . The Level 1 form included mental health diagnoses of major depression and dementia. Psychiatry Provider Notes showed the following: * On 08/02/22, the psychiatry provider added a diagnosis of psychotic disorder with delusions due to known physiological condition and increased the resident's Aripiprazole to 15 mg. * On 11/09/22, the resident's Aripiprazole increased to 20 mg related to major depressive disorder and psychotic disorder with delusions due to known physiological condition. The medical record lacked evidence of an updated Level I PASRR screen with the new antipsychotic medication and diagnosis of psychotic disorder with delusions due to known physiological condition. During an interview on 09/07/23 at 11:21 a.m., an administrative staff member (#2) confirmed the facility failed to complete a change in status Level I screen for Resident #7 and agreed a newly diagnosed psychotic disorder required submission of an updated Level I PASRR screen.

Based on record review, review of facility policy, and staff interview, the facility failed to review and revise the comprehensive care plan to reflect the current status for 1 of 12 sampled residents (Resident #4). Failure to review and revise the care plan limited staffs' ability to communicate needs and ensure continuity of care. Findings include: Review of the facility policy titled Resident Care Plan occurred on 09/07/23. This policy, dated 08/16/18, stated, . the care plan will include measurable objectives and timetables to meet a resident's medical, nursing, and psychological needs as identified by the comprehensive assessment. The comprehensive care plan will be reviewed and revised by the Interdisciplinary Team on a quarterly basis at minimum and on an ongoing basis to reflect changes in resident status. Review of Resident #4's medical record occurred on all days of survey. The record identified a diagnosis, dated 07/20/22, of nicotine dependence with withdrawal. An annual Minimum Data Set (MDS), dated [DATE], indicated the resident cognitively intact and independent with mobility and transfers. Review of Resident #4's progress notes showed the following: * 07/16/23 at 7:34 p.m., He [resident] stated he is having a lot of anxiety lately. hands were shaking . Resident stated a cigarette would relaxme [sic] now. 1505 [3:05 p.m.] notified Provider on call. Order received for Ativan [treats anxiety] . While talking on the phone with HCP [health care provider], noticed resident walking towards front door 1515 [3:15 p.m.] Attempted to find resident . and he was unable to be located in the facility. 1610 [4:10 p.m.] Resident arrived back into the facility with walker . stated that he went to a 'friends house to drink a beer and smoke a cigarette.' . * 07/17/23 at 9:44 a.m., . States that the medication is not working anddoes [sic] not do anything but he knows a cigarette would help. Resident #4's care plan failed to identify nicotine dependence/withdrawal and interventions to address the problem. During an interview on 09/07/23 at 10:23 a.m., two administrative staff members (#1 and #2) agreed Resident #4's care plan failed to address nicotine dependence/withdrawal and interventions tried and/or refused by the resident to address this diagnosis.

Based on observation, record review, and staff interview, the facility failed to provide food in a form to meet individual needs for 1 of 1 sampled resident with an order for ground meat (Resident #76). Failure to provide ground meat as ordered may result in reduced intakes and chewing/swallowing difficulties. Findings include: Review of Resident #76's medical record occurred on all days of survey. A physician's order, dated 08/29/23, stated, Regular diet, Regular texture, Thin consistency, Ground Meat. The resident's care plan also identified a regular diet with ground meat. Observation on 09/05/23 at 5:55 p.m. showed Resident #76 eating dinner in the dining room. Staff served the resident whole sausage links which were not chopped/ground. Observation on 09/06/23 at 5:47 p.m. showed Resident #76 eating dinner in the dining room. Staff served the resident a hamburger on a bun which was not chopped/ground. During an interview on the afternoon of 09/07/23, an administrative nurse (#1) identified Resident #76 is to have ground meats related to poor dentition.

Based on observation, facility policy, and staff interview, the facility failed to serve, prepare, and store food in a safe and sanitary manner for 1 of 1 kitchen. Failure to label and date food with the expiration date, discard expired food, and ensure dishware and food is free from dust/debris increased the risk for contamination and has the potential to result in foodborne illness to residents, staff, and visitors. Findings include: Review of the facility policy titled Dietary Services occurred on [DATE]. This undated policy stated, . food/leftovers must be dated, labeled, covered . toxic cleaning materials must be stored and used in such a manner as not to contaminate food . stored in a separate room . Observationsof the kitchen occurred on [DATE] at 1:54 p.m. and showed the following: - One package of turkey and ham with an expiration date of [DATE]. - One undated package of cooked chicken. - One undated, unlabeled, and uncovered container of a custard dessert. - One undated and uncovered container of pudding. - One undated container of cooked carrots. - One undated open package of pancake mix. - One bin of flour dated [DATE]. - One bin container of sugar dated [DATE]. - One container of Quat Oasis [a disinfecting cleaner] with expiration date [DATE]. - A box fan visibly soiled with dust blowing in the direction of the food preparation area. During an interview on [DATE] at 9:11 a.m., a dietary manager (#5) confirmed food is to be dated and labeled, expired chemicals must be discarded and fans should be cleaned.

Based on observation and review of facility policy, the facility failed to follow standards of infection control for 2 of 7 sampled residents (Resident #6 and #14) observed while receiving toileting assistance. Failure to follow infection control practices regarding hand hygiene during cares has the potential for transmission of communicable diseases and infections to residents, staff, and visitors. Findings include: Review of the facility policy titled Infection Control - Hand Hygiene occurred on 09/07/23. This policy, dated July 2023, stated, . The Centers for Medicare and Medicaid State Operations Manual indicates that hand hygiene should be performed . Before and after assisting a resident with personal cares . before and after assisting a resident with toileting . after removing gloves . The use of gloves does not replace handwashing/hand hygiene. - Observation on 09/05/23 at 3:37 p.m. showed a certified nurse aide (CNA) (#3) assist Resident #14 with toileting. Resident #14 placed her left hand on the toilet riser to lower herself onto and off the toilet. The CNA (#3) provided perineal cares, pulled up the resident's underwear, removed her gloves, and assisted the resident to ambulate to her recliner. Without performing hand hygiene, the CNA (#3) opened the resident's blinds and positioned the resident's snacks, coffee mug, and other personal items located on the overbed table within the resident's reach. The Resident (#14) then opened a bag of chips and began eating them. The CNA (#3) failed to perform hand hygiene after providing Resident #14 perineal cares and removing her gloves and failed to offer/provide Resident #14 hand hygiene after toileting. - Observation on 09/05/23 at 4:20 p.m. showed two CNA's (#3 and #4) provide care to Resident (#6) while in bed. Both CNAs removed the resident's soiled pants, brief, and bed protector pad. The CNA (#3) cleansed the perineal area, removed her gloves, and without performing hand hygiene, put a new pair of gloves on. Both CNAs placed a new brief and pants on the resident and utilized a full body mechanical lift to transfer the resident to her wheelchair. The CNA (#3) removed her gloves, and without performing hand hygiene, placed palm protectors in both resident's hands, placed glasses on the resident's face, and then performed hand hygiene. The CNA (#4) failed to remove gloves/perform hand hygiene throughout the observation and failed to perform hand hygiene prior to exiting the resident's room.

THIS IS A REPEAT DEFICIENCY FROM THE STANDARD SURVEY COMPLETED 04/22/21. Based on observation, review of facility policy, and staff interview, the facility failed to prepare, store, and serve food under sanitary conditions in 1 of 1 kitchen. Failure to monitor fridge and freezer temperatures, monitor the quaternary (quat) sanitizer concentration, serve food in a sanitary manner, and maintain a clean kitchen may result in unsafe food storage/preparation and foodborne illness. Findings include: Review of the facility policy titled Infection Prevention and Control - Dietary Service occurred on 06/29/22. This policy, revised February 2016, stated, . Director of Food Service Responsibilities: . Provide for the proper receipt and storage of all food supplies. Food Storage: . Food must be stored sufficiently above floor level and away from walls. All staple food should be stored in a clean dry place 8 inches to 12 inches off the floor on food dollies or shelves. Proper Food Handling: Foods are prepared and served with clean tongs, scoops, spatulas, or other suitable implements so as to avoid manual contact of prepared foods. Dietary Housekeeping: . Ranges and grills should be cleaned daily. All work surfaces, utensils, and equipment should be cleaned and sanitized after each use. Review of the facility policy titled Testing Sanitizer Concentration occurred on 06/29/22. This policy dated March 2016, stated, . Sanitizing solution is dispensed with a metered dispenser located above the 3 compartment sink. Staff will test sanitizer concentration of sanitizing solution with quaternary test strips. Staff will record the concentration on the record provided . indicating the location of the solution being tested , i.e. sink, squirt bottle, bucket for cloths. If test number is within acceptable range product may be used as intended. If acceptable concentrations are not met, they will be re-checked. The dietary director or maintenance will be notified if solution does not meet acceptable ranges. Observation of the kitchen occurred on 06/27/22 at 12:30 p.m. with a dietary aide (#7), and showed the following: * The top of the dishwasher showed a large amount of water mineralization. * The toaster oven showed a excessive amount of crumbs in the oven and on the floor. * A large mixer stand with a large amount of debris on the stand. * A window air conditioner unit by the dishwasher and clean dishes showed a large amount of dust and lint blowing onto the clean dishes. * The dry storage area contained multiple boxes of chips, Prosource and supplements on the floor. * The walk in cooler contained multiple boxes of muffins and mighty shakes on the floor * The stove top was soiled with food and grease. Review of the facility kitchen logs for June 2022 identified the following: * The Sanitizer Concentration not recorded 24 of 27 days * The daily cleaning checklist for the week of June 19-25 not documented 6 of 7 days, and no documentation the week of June 26-July 2nd. * The dishwasher Temperature Record not recorded 20 of 27 days with incomplete readings for each use (Breakfast / Lunch / Dinner) * The Food Temperature Record not recorded 17 of 27 days for breakfast and lunch, and 26 of 27 days for the dinner meal. During an interview on 06/27/22 at 12:30 p.m., a dietary aide (# 7) stated the facility shares a dietary manager with the hospital, but the manager is not currently coming to the facility. Observations of the kitchen and meal service on 06/29/22 at 8:15 a.m. identified the stove top remained dirty with food and grease, the window air conditioner unit in the dishwasher area remained dirty with dust and lint, and the mixer stand remained dirty with debris. The dietary aide (#8) was unable to test the mixed quat in the bucket related to no availability of test strips. Observation of the meal service on 06/29/22 at 8:41 a.m. showed a dietary aide (#8) touching multiple services with gloved hands (microwave, milk cartons, fridge handle), then picking up toast with the same gloves and placing it on multiple residents plates. During an interview on 06/29/22 at 10:36 a.m., an administrative nurse (#7) confirmed the facility hired a new dietary manager that is at the hospital is not currently coming to the facility.

THIS IS A REPEAT DEFICIENCY FROM THE PREVIOUS STANDARD SURVEY COMPLETED 04/22/21 Based on observation, record review, review of facility policy, review of professional reference, and staff interview, the facility failed to follow infection control practices for 7 of 12 sampled residents (Resident #1, #5, #6, #9, #20, #21, and #22) observed during cares and meals. Failure to follow infection control practices related to hand hygiene, catheter care, dressing changes, and use of personal protective equipment (PPE), has the potential for transmission of communicable diseases and infections to residents and staff. Findings include: PERSONAL PROTECTIVE EQUIPMENT (PPE) Review of the facility policy titled COVID-19 Plan occurred on 06/29/22. This policy, revised June 2022, stated, . Employees will be provided with facemasks or a higher level of respiratory protection by the employer. Facemasks must be worn by employees over the nose and mouth when providing direct patient care or when in direct contact (within 6 feet) of patients. Review of the facility policy titled Pandemic Plan - Respiratory Illness occurred on 06/29/22. This policy, revised April 2022, stated, . Healthcare personnel should wear well-fitting source control at all times while they are in the facility. The only exception should be: Source control may be removed in the breakrooms only while eating . Source control may be removed by staff in their office, as long as they are not within 6 feet of others. During the entrance conference on 06/27/22, two administrative staff (#1 and #2) stated they expected all staff to wear an N95 (type of particulate-filtering respirator) mask when in resident care areas and when providing resident cares. Observations showed the following: * 06/28/22 at 8:46 a.m., a certified nurse aid (CNA) (#3) provided cares for Resident #1 with an N95 mask under his nose. The CNA frequently pulled the mask down from his nose and mouth while communicating with the resident. * 06/28/22 at 9:01 a.m., a CNA (#3) wore his N95 mask under his nose while assisting Resident #5 into a wheelchair and pulled the mask down from his nose and mouth while speaking to other residents and staff in the hallway. * 06/28/22 at 9:09 a.m., a dietary aide (#7) served breakfast with no mask in place and handed plated food to staff located on the other side of the serving window less than 6 feet away. * 06/28/22 at 11:24 am., a CNA (#3) assisted a staff nurse (#6) in Resident #21's room. The CNA wore an N95 mask under his nose. * 06/29/22 at 08:32 a.m., a CNA (#3) performed cares on Resident #6 with no mask in place, exited the room, put an N95 mask on his face below the nose, and walked down the hallway. During an interview on 06/28/22 at 9:23 a.m., an infection control nurse (#1) confirmed the facility expected kitchen staff to wear a surgical mask when serving food. During an interview on 06/29/22 at 5:10 p.m., an administrative staff member (#2) verified she expected the N95 mask to cover a staff's nose and mouth. HAND HYGIENE Review of the facility policy titled Hand Hygiene occurred on 06/29/22. This policy, revised June 2017, stated, . Hand hygiene is generally considered the most important single procedure for preventing health care-associated infections . Antiseptics can reduce the microbial contamination . all employees will utilize good handwashing technique between each patient contact . handwashing is the most important factor in infection control . hands must be washed routinely at the following times: before patient contact . after body fluid exposure . after touching a patient . after touching patient surroundings . before leaving the patient room . Review of the facility policy titled Gloving occurred on 06/29/22. This undated policy stated, . Wash hands after removing gloves. Gloves do not replace hand hygiene. Observations showed the following: * 06/27/22 at 3:27 p.m., a CNA (#4) performed perineal cares on Resident #1. Without removing his gloves, the CNA grabbed both handles of the resident's walker and placed the walker in front of the resident. The resident grabbed the handles of the walker while transferring from the toilet to the wheelchair. The CNA (#4) failed to remove his gloves and perform hand hygiene prior to touching walker handles. The CNA (#4) removed his gloves but failed to perform hand hygiene prior to exiting Resident #1's room. * 06/27/22 at 4:48 p.m., a CNA (#9) entered Resident #20's room and assisted with toileting. After cares, the CNA (#9) removed his gloves and failed to perform hand hygiene prior to exiting the resident's room. * 06/28/22 at 3:57 p.m., a CNA (#4) removed his gloves after draining urine from Resident # 22's catheter bag, removed his gloves, and failed to perform hand hygiene prior to exiting the resident's room and assisting other residents. During an interview on 06/29/22 at 5:10 p.m., an administrative staff member (#2) stated she expected staff to perform hand hygiene before/after removing gloves and between clean/dirty tasks. The staff member (#2) also agreed the CNA (#4) should have followed hand hygiene/glove use protocol after performing Resident #1's perineal cares. DRESSING CHANGE The facility failed to provide a policy on dressing changes. Review of professional reference found at https://courses.cdc.train.org/Module10C_WoundCare_LTC/module_10c_wound_care_lesson_2_24_hand_hygiene_and_ppe_use_during_wound_care.html indicated, . Hand hygiene should be performed before and after wound care, even if gloves will be worn. Hand hygiene should also be performed after removal of PPE, including if gloves are changed during the procedure. Environmental surfaces . can also serve as sources of pathogen transmission if they are not properly cleaned and disinfected . any surface . that could have been contaminated . should be immediately cleaned and disinfected after the procedure. Review of Resident #9's medical record occurred on all days of survey and identified a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's order stated, Gelling Fiber +AG [silver] dressing [designed to help create the optimal healing environment] to bottom of left foot - change every 2 days - Cover with Silicone foam [an absorbent self-adherent dressing] every day shift every other day . Observation on 06/29/22 at 11:25 a.m. showed a staff nurse (#5) performed a dressing change to Resident #9's left foot. The nurse failed to follow standard infection control practices related to glove use, hand hygiene, supply use, moving between clean/dirty tasks, and environmental surfaces during the dressing change. During an interview on 06/29/22 at 5:10 p.m., an administrative staff member (#2) confirmed the staff nurse (#5) failed to follow proper infection control practice during Resident #9's dressing change. EMPTYING CATHETER BAGS - Observation on 06/28/22 at 2:20 p.m. showed a CNA (#3) placed a graduate (measuring container) on Resident #22's floor, drained urine from the resident's catheter bag into the graduate, and placed it on top of the resident's dresser to obtain a measurement. The CNA carried the graduate to the bathroom, dumped the urine into the toilet, obtained water directly from the sink faucet to rinse the graduate, and emptied the rinse water into the toilet. The CNA (#3) failed to disinfect Resident #22's dresser surface after removing the urine filled graduate, and failed to use a clean container in the resident's bathroom sink to obtain rinse water for the graduate. - Observation on 06/28/22 at 2:28 p.m. showed a CNA (#3) placed a graduate container on the footrest of Resident #21's recliner, drained urine from the resident's catheter bag into the graduate, removed the graduate from the footrest, and placed it on the resident's end table adjacent to the recliner. The CNA carried the graduate to the bathroom, dumped the urine into the toilet, obtained water directly from the sink faucet to rinse the graduate, and emptied the rinse water into the toilet. The CNA (#3) failed to disinfect Resident #21's end table surface after removing the urine filled graduate and failed to use a clean container in the resident's bathroom sink to obtain rinse water for the graduate. During an interview on 06/29/22 at 5:10 p.m., an administrative staff member (#2) confirmed she expected staff to use a clean container to obtain water from resident bathroom sinks to rinse graduates contaminated with urine and sanitize contaminated surfaces.

Based on observation, record review, and review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.17.1), the facility failed to complete a Minimum Data Set (MDS) that accurately reflected the resident's status for 1 of 1 sampled resident (Resident #1) with a feeding tube. Failure to accurately code the MDS may negatively affect the development of a comprehensive care plan and the care provided to the residents. Findings include: SECTION K: SWALLOWING/NUTRITIONAL STATUS The Long-Term Care Facility RAI Manual, revised October 2019, page K-13, stated, . [K0710]A. Proportion of total calories the resident received through [MEDICATION(S)] [taken into the body in a manner other than through the digestive canal] or tube feeding [tube inserted into the digestive canal]. 1. 25% or less. 2. 26-50%. 3. 51% or more. [K0710]B. Average fluid intake per day by IV [intravenously - into a person's veins] or tube feeding. 1. 500 cc [cubic centimeter - one cc is equal to one milliliter]/day or less. 2. 501 cc/day or more. Review of Resident #1's medical record occurred on all days of survey. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . and the resident's care plan indicated, . I am currently getting my nutrition and fluids through my G-tube r/t [related to] Dysphagia. A nutritional progress note, dated 04/26/22 at 11:04 a.m., stated, . continues with tube feedings -[MEDICATION(S)] . [oral] intake at meals remains poor, mostly 0-25%. The facility failed to code section K0710A (percentage of caloric intake via tube feeding) and K0710B (average fluid intake per day via tube feeding) on Resident #1's quarterly MDS dated [DATE].

Based on observation, record review, review of facility policy, and staff and resident interview, the facility failed to follow professional standards of practice for 1 of 3 sampled residents (Resident #22) reviewed for pain management. Failure to regularly monitor and assess pain per the facility policy may result in ineffective management and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Findings include: Review of the facility policy titled Pain Management Policy occurred on 06/29/22. This policy, dated November 2006, stated, Residents experiencing pain will have that pain managed to their acceptable level thereby allowing them to reach their highest practicable level of functioning and well-being. Pain assessments will be completed on all residents on a quarterly arid [sic] PRN [as needed] basis. Residents will be re-assessed by the nursing staff weekly for four weeks after each pain medication change or until pain is managed satisfactorily. Pain assessments will be done q [every] week on residents with scheduled pain medication and charted on the Pain Assessment Sheet. Observation and Interviews showed the following: * 06/27/22 at 12:26 p.m., Resident #22 stated, My neck is bad. I have a headache. He motioned with his hand over the left side/rear part of his head, explained he had a fall in the past, indicated he still has a raised area on his head from the fall, and stated, This is where it always hurts. * 06/29/22 at 3:27 p.m., Resident #22 grimaced and verbalized oh, oh, oh while getting himself up and out of the recliner. When asked what was wrong, he stated he had pain to both legs. Review of Resident #22's medical record occurred on all days of survey identified diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The record identified the resident received scheduled pain medications and had four pain medication changes since admission on 12/21/21. The record lacked evidence of completed weekly pain assessments for the scheduled pain medications and for the added/changed pain medication orders (26 missed weekly assessments). During an interview on 06/29/22 at 5:10 p.m., an administrative staff member (#2) confirmed the facility failed to follow its policy on pain assessments for Resident #22.

Based on observation, review of facility policy and procedure, and staff interview, the facility failed to provide adequate supervision and assistive devices necessary to prevent accidents for 2 of 7 sampled residents (Resident #6 and #21) observed during a gait belt transfer. Failure to utilize the gait belt during transfers placed Residents at risk of accidents and/or injury. Finding include: Review of the facility policy titled . GAIT BELT. FALL PREVENTION PROTOCOL POLICY AND PROCEDURE. This policy, revised August 2013, stated, . to assure the safety of the residents and staff when assisting with a transfer or ambulation a gait belt will be used . all residents who require assist with transfers and do not require an electric lift will utilize a gait belt with all transfers . with MD/NP (Medical Doctor/Nurse Practitioner) order . -Review of Resident #6's medical record occurred on all days of survey and identified diagnoses of chronic low back pain and dementia. The current care plan stated, . I have limited physical mobility r/t [related to] weakness, fatigue, and impaired balance . I am at risk for falls r/t psychoactive drug use, confusion, gait/balance . I require assist of 1 with 4 WW [four wheeled walker] with gait belt with transferring . The current physician orders stated, . use gait belt for all transfers . Observations showed the following: * 06/27/22 at 3:52 p.m., a certified nursing assistant (CNA) (#4) transferred Resident #6 from the wheelchair without a gait belt and instead grabbed the residents pants. * 06/29/22 at 8:32 a.m., a CNA (#3) transferred Resident #6 to/from the wheelchair and toilet without a gait belt and instead grabbed the resident's pants. During an interview on 06/29/22 at 4:26 p.m., an administrative staff member (#2) stated staff should transfer Resident #6 using a gait belt as care planned and per physician's order. - Review of Resident #21's medical record occurred on all days of survey and identified a diagnosis of [CONDITION(S)] disease. The current care plan stated, . I have limited physical mobility r/t Weakness . Transfer with FWW [front-wheeled walker] with gait belt and minimal assist of 1[assistance of at least one staff]. Observation on 06/28/22 at 11:36 a.m. showed a CNA (#3) assisted Resident #21 from a sitting to standing position without using a gait belt, and instead, grabbed onto both resident's hands. During an interview on 06/29/22 at 5:10 p.m., an administrative staff member (#2) confirmed staff should transfer Resident #21 using a gait belt as care planned.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to provide the care and services to prevent potential complications for 1 of 1 sampled resident (Resident #1) receiving nutrition by a gastrostomy tube (an artificial external opening into the stomach for nutritional support). Failure to verify placement of the gastrostomy tube prior to administering nutrition and change/replace the feeding syringe every 24 hours has the potential to result in adverse events such as aspiration pneumonia and infection. Findings include: Review of the facility policy titled TUBE FEEDINGS occurred on 06/29/22. This policy, revised July 2022, stated, . gastric (G) . tubes are used to supply nutrition and hydration . Change . feeding set (tubing and appropriate syringe) every 24 hours. Insert 30 cc [cubic centimeter - one cc is equal to one milliliter] of air into the feeding tube while holding the stethoscope over the epigastrium [upper abdomen immediately over the stomach] to listen for gurgling sound. (If none is heard, do not start feeding and report to supervisor or charge nurse.) . Review of Resident #1's medical record occurred on all days of survey and identified diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The current care plan indicated, . I am currently getting my nutrition and fluids through my G-tube r/t [related to] Dysphagia. Check for tube placement and gastric contents/residual volume per facility protocol . Resident #1's physician's orders stated the following: * 12/10/21, NI [nursing instruction]: check placement of G-Tube Per TCLC [[NAME] County Living Center] tube feeding policy four times a day for placement. * 06/16/21, Replace 60cc syringe daily . * 05/02/22, [MEDICATION(S)] 1.5 Cal [calorie]/Fiber Liquid (Nutritional Supplement) Give 10 ounce via G-Tube four times a day for Health Maintenance. Observations showed the following: * 06/27/22 at 4:20 p.m., a staff nurse (#5) utilized a syringe dated 06/24/22 to administer a water bolus and [MEDICATION(S)] feeding per Resident #1's gastrostomy tube. The nurse failed to check placement of the tube prior to administering the water/[MEDICATION(S)], and failed to replace the syringe. * 06/28/22 at 8:50 a.m., a staff nurse (#6) utilized a syringe dated 06/24/22 to administer Resident #1's water bolus and [MEDICATION(S)] feeding. The nurse failed to replace the syringe. During an interview on 06/29/22 at 5:10 p.m., an administrative staff member (#2) stated she expected staff to replace Resident #1's feeding syringe every 24 hours.

Based on observation, review of facility policy, and staff interview, the facility failed to store medications at the correct temperature in 1 of 1 medication refrigerator. Failure to maintain the medication refrigerator temperature within an acceptable range increases the risk of residents receiving improperly stored medications with reduced efficacy. Findings include: Review of the facility policy titled Storage of Drugs occurred on 06/28/22. This undated policy stated, . Twice daily temperature checks are taken on the medication room refrigerator. The monthly report is stored on the refrigerator. Temperature shall be maintained at 35-45 degrees. A thermometer shall be in the refrigerator at all times to properly monitor the temperature. Observation of the medication room occurred on 06/28/22 at 2:45 p.m. with a licensed nurse (#1) and showed a locked medication refrigerator containing multiple boxes of insulin pens, Dulcolax and Tylenol suppositories, and [MEDICATION(S)] (antianxiety) injectables. The thermometer identified a temperature of 23 degrees Fahrenheit (F). The Temperature Recording Chart for the medication refrigerator stated, Temperature Range: 35-46 degrees F (ideal temp [temperature] 40-44). If the temperature is out of range, adjust fridge or call maintenance. Review of the refrigerator temperature log for the month of June 2022 identified five days the temperature was below 35 degrees F. The facility failed to take corrective action for the low temperature readings. During an interview on 06/28/22 at 3:05 p.m., an administrative nurse (#2) confirmed facility staff should adjust the refrigerator temperature or notify maintenance when the temperature is out of the recommended range.

Based on record review, review of facility policy and procedure, and staff interview, the facility failed to ensure the resident environment remained as free of accident hazards as possible regarding assessing and implementing fall prevention strategies and the use of side rails, and following physician's advice for bedrest after a pelvic fracture for 1 of 1 sampled resident (Resident #9) who experienced injuries (pelvic fracture and lacerations to the head) which required evaluation in the emergency room . Failure to follow physician's advice regarding bedrest for a week after a pelvic fracture, failure to accurately assess each fall and revise/implement prevention strategies and assess the use of bed side rails as a potential safety hazard, resulted in injury/pain and placed the resident at risk for further harm. Findings include: Review of the facility policy titled "Fall Prevention Protocol Policy and Procedure" occurred on 08/02/12. This undated policy stated, "Policy: All residents who are assessed as being at high risk for falls will be identified and individualized fall precautions will be developed for that resident. Preventative measures shall be taken to decrease the number of falls whenever possible. Objectives: 1. To consistently identify and evaluate residents who fall and treat or refer for treatment appropriately. 2. To achieve each resident's maximum of physical functioning. 3. To prevent/reduce injuries related to falls . . . Procedures: 1. A Fall Risk Assessment will be completed . . . 2. If the assessment finds the resident at high risk, implement appropriate interventions/precautions. . . . 3. Post Fall Assessment will be completed after each fall and any changes in interventions will be noted. . . on the resident's care plan, Nurse Aide team cards, if appropriate, and in the nurses' notes. . . ." Review of Resident #9's medical record occurred on August 1-2, 2012. Resident #9's medical [DIAGNOSES REDACTED]. Review of Resident #9's Minimum Data Set (MDS), dated [DATE], and the current MDS dated [DATE], identified severely impaired cognition and extensive assistance of two or more persons for transfers and bed mobility. Review of Resident #9's Progress Notes identified the following: 10/22/11 *7:25 a.m. Nurse's Note - CNA (certified nursing assistant) heard resident's alarm ringing and resident was on the floor. Resident was laying on her side with her head curled against the wall. Felt resident's head and there were no bumps or open areas. Resident could move arms and legs but screamed her back hurt. Called Dr. (name) and he okay to send resident by ambulance to (name of hospital) to be checked out. Called resident's daughter. . . " 10/26/11 *8:40 a.m. Physician's Progress Note - "Reviewed radiology report. They see a nondisplaced hairline fracture of the left pubic bone. I advised nursing home of this and that she should be kept on bedrest for the next week and then evaluated by PT (physical therapy) for progressive weightbearing as tolerated. . . ." 10/28/11 *11:43 a.m. Nurse's Note - "Quarterly Nurses Note: . . . continues to require extensive assist with all ADL's (activities of daily living) . . . transfers with assist of 2 but is unable to ambulate any longer due to lower ext (extremity) weakness and pain. . . . fell in (sic) the 22nd of October and went to the ER (emergency room ). She had an x-ray done that revealed a nondisplaced pelvic fracture. Received orders today for resident to be non-wt (weight) bearing for a week and then have PT (physical therapy) evaluate her. . . . has a fall risk score of 24 (high). She has a bed and chair alarm and a grab bar on her bed for repositioning. . . . " *1:44 p.m. Nurse's Note - ". . . The hoyer lift was used to transfer to bed after dinner - she yelled out "my bones" - will observe transfer later and eval (evaluate) if more pain with hoyer or transfer of 2." *7:19 p.m. Nurse's Note - ". . . yelled out "ow" and "don't do that to me" when the hoyer was used again. Message left for . . . PT re (regarding) order to have PT eval after being NWB (non-weight bearing) x 1 week." 10/30/11 *9:39 p.m. Nurse's Note - resident found on floor in her room. Trauma to head and excessive bleeding. Ambulance called to transfer to (name of hospital). Daughter called. . . ." *10:40 p.m. Physician's emergency room Note - ". . . brought from the nursing home earlier this evening after sustaining a fall from the edge of the bed with trauma laceration to her left eyebrow area. . . . The area was cleansed with Betadine and saline and Dermabond was used for suturing. Steri-Strips were applied . . . Patient will be returned to the nursing home with neuro checks every 2 hours. . . " 10/31/11 *1:00 a.m. Nurse's Note - " Resident returned to the nursing home . . ." *9:26 a.m. Nurse's Note - "Resident found on floor by staff and was bleeding around by here (sic) head. When talking with resident she had gotten up and out of bed by herself and did not put on call light and ask for assisstance (sic). Appeared to have a 2-3 inch laceration by Her (sic) Lt. (left) eye brow, however could not see or feel any other laceration at this time due to all the bleeding and clumping of her hair. Ambulance called for transport to hospital. . . . " *1:06 p.m. Nurse's Note - "Consent for Side Rail use signed by legal representative of resident. Side rail in place by maintenance." 11/01/11 *9:27 a.m. Nurse's Note - "Family Conference: A meeting with (name of resident's daughter) . . . was held with the DON (director of nursing) today in regards to (name of resident)'s fall. (Name of daughter) would like for (name of resident) to have a half rail for bed so that she does not fall out. (Name of daughter) would also like a mat on the floor for her mom so that if she does fall she does not hit the hard floor. A mat is being ordered, and the half rail has been placed on her bed. . . . " 11/02/11 *12:03 p.m. Physician's Progress Note - ". . . She had a recent pelvic fracture and fell again recently. . . . Had a CT scan which apparently showed no injury. . . ." 01/02/12 *12:07 a.m. Nurse's Note - "res (resident) alarm going off res trying to get up out of bed . . ." 01/07/12 *1:05 a.m. Nurse's Note - "res alarm going off, cna reported that res was sitting on the edge of bed . . ." 02/03/12 *8:04 a.m. Nurse's Note - "Quarterly nurses note: . . . continues to require extensive assist with all ADL's . . . has a high fall risk score of 21. She has a bed and chair alarm, a mat on the floor by her bed, and a high low bed. . . ." 02/12/12 *2:46 a.m. Nurse's Note - "res light going off, alarm, res yelling help as writer got to door, saw res with feet on the floor and belly on the bed, assessment done cna came with gait belt, res was assisted by two unto bed, res stated she fell . . . ." 03/27/12 *3:32 p.m. Nurse's Note - "At 1430 (2:30 p.m.), cna was charting - she heard (name of resident) call out 'isn't anyone going to get me up?,' alarm went off and as the cna entered her room, she saw (name of resident) roll out of bed unto her knees to the floor. . . ." Fall Risk Assessments, dated 10/23/11, 01/20/12, 02/13/12, 03/28/12, and 06/25/12, identify Resident #9 as "High Risk" for falls. Review of Resident #9's current care plan identifies the following regarding falls: "FOCUS: I am at Moderate risk for falls r/t (related to) my decreased mobility, dementia, Parkinson's DZ (disease), history of falls and medications I take. Date Initiated: 8/10/2011. GOALS: I will be free of falls through the next review date. I will have no injury from falls through the next review date. Date Initiated: 8/10/2011 Target Date: 10/11/2012 INTERVENTIONS: . . . *Follow facility fall protocol. Date Initiated: 8/10/2011. . . . *I use a chair and bed alarm. . . . Date Initiated 8/10/2011. *I need a safe environment with: . . . the bed in low position at night. . . . Date Initiated 8/10/2011. . . . *I need to be evaluated for, and supplied (a half rail for my bed). Re-evaluate (quarterly) and as needed for continued appropriateness and to ensure least restrictive device or restraint. Date Initiated: 11/1/2011. *I have a mat on the floor beside my bed when I am in it. Date Initiated: 2/3/2012. . . . " The facility failed to follow the physician's advice on 10/26/11 for the resident to be bedrest for a week resulted in the resident experiencing pain during transfers. The facility failed to update the current care plan to High Risk for falls, as identified by the Fall Risk Assessments (completed since 10/23/11) and failed to implement a fall mat as requested by the family until 02/03/12. The facility failed to complete a Post Fall Assessment after each of the falls to determine if any revisions or changes were needed in fall prevention strategies and failed to assess the side rails on the resident's bed as a potential safety hazard, even though the nurse's notes showed Resident #9 tried to get out of bed by herself. The facility failed to consider the bed height during the day (care plan identified bed in low position only at night), as a nurse's note identified the resident rolled off the bed in the afternoon. During interview the afternoon of 08/02/12, two administrative nursing staff members (#1 and #3) confirmed staff had not implemented interventions in a timely manner after the resident experienced three successive falls, and had not completed a side rail assessment.