Every finding on record at Washington County Nursing Home

Based on observations, record review and interviews, the facility failed to ensure three (#13, #2 and #35) of six residents reviewed for accidents out of 26 sample residents received adequate supervision to prevent accidents. Resident #13 was admitted on [DATE] with a diagnosis of dementia. Resident #13 was identified as a high fall risk. On 8/23/26 at approximately 4:27 a.m. Resident #13 awakened and a motion sensor in her room alerted certified nurse aide (CNA) #5 of Resident #13's movement. CNA #5 recognized that Resident #13 was restless, but did not assist the resident to the restroom at the time, which was a care planned fall intervention for the resident. Resident #13's wheelchair was next to her bed when CNA #5 left the room and within one minute of CNA #5 leaving the room, the resident sustained an unwitnessed fall when she fell over the wheelchair while attempting to get up to use the restroom. The fall resulted in a facial hematoma (a collection of blood outside the blood vessels) and significant facial bruising. The resident was transferred to the hospital and diagnosed with forehead contusion and closed head injury. The resident returned to the facility on 8/23/26.On 8/26/26, the resident had difficulty walking to the dining room with staff and the facility transferred the resident back to the hospital where she was diagnosed with a concussion which resulted from the fall on 8/23/26.Additionally, Resident #2 experienced a fall in the facility when staff failed to consistently implement care planned fall interventions for the residents. Staff additionally failed to utilize a gait belt as a fall intervention for Resident #35, who was a fall risk.Specifically, the facility failed to:-Ensure person-centered fall interventions were implemented for Resident #13, who sustained a fall with injury;-Ensure person-centered fall interventions were implemented for Resident #2, who sustained a fall; and,-Ensure person-centered fall interventions, specifically a gait belt, were implemented for Resident #35. Findings include: I. Facility policy and procedure The Fall Prevention Program policy, revised November 2025, was provided by the nursing home administrator (NHA) on 8/31/26 at 11:07 a.m. It read in pertinent part, Each resident will be assessed for the risks of falling and will receive care and services in accordance with the level of risk to minimize the likelihood of falls. Low/moderate risk protocols, implement universal environmental interventions that decrease the risk of residents falling, including, but not limited to: -A clear pathway to the bathroom and bedroom doors; -The bed is locked and lowered to a level that allows the elder's feet to be flat on the floor when the elder is sitting on the edge of the bed; -Call light and frequently used items are within reach; -Adequate lighting; and, -Wheelchairs and assistive devices are in good repair. High risk protocols: implement interventions from low/moderate risk protocols, provide interventions that address unique risk factors measured by the risk assessment tool, medications psychological, cognitive status, or recent change in functional status. Provide additional interventions as directed by the resident's assessment, including but not limited to: assistive devices, increased frequency of rounds, medication regimen review, low bed, alternate call system access, scheduled ambulation or toileting assistance, family/caregiver or resident education and therapy services referral. Each resident's risk factors and environmental hazards will be evaluated when developing the resident's comprehensive plan of care. II. Resident #13 A. Resident status Resident #13, age greater than 65, was admitted on [DATE]. According to the August 2026 computerized physician orders (CPO), diagnoses included dementia, osteoarthritis and kidney disease. The 5/24/26 minimum data set (MDS) assessment identified Resident #13 had severe cognitive impairment with a brief interview for mental status (BIMS) score of one out of 15. The MDS assessment revealed the resident required set-up assistance from staff for transferring. The MDS assessment indicated the resident used a motion sensor alarm daily. B. Observations and staff interviews On 8/26/26 at 11:45 a.m. Resident #13 was sitting at the dining room table. Most of Resident #13's face had dark purple bruising, specifically under her right eye, across her forehead and extending completely down the left side of her face. The resident had a large bump protruding from her left forehead (hematoma). On 8/26/26 at 5:50 p.m. Resident #13 was sitting in a recliner chair. The director of nursing (DON) and other nursing staff members were checking her blood pressure and talking to the resident. The NHA was present and said the nursing staff had had difficulty waking Resident #13 for dinner. The NHA said the resident did wake; however, the facility elected to send Resident #13 to the hospital for reevaluation due to her recent fall with a hematoma. On 8/27/26 at 3:30 p.m. Resident #13 was sleeping in a recliner chair in the lounge with CNA #2 standing next to her. Resident #13's facial bruising was dark purple in color. The hematoma was still present on her forehead. CNA #2 said she thought Resident #13's fall could have been prevented because fall interventions were not followed. CNA #2 walked to Resident #13's room and demonstrated where Resident #13's wheelchair should have been placed (approximately eight feet from the bed against a wall). She said the wheelchair was found in front of the resident's bed, obstructing the resident's path and the motion sensor. CNA #2 said when items were not in front of the bed the soft touch (motion sensor) alarm bell would be activated with Resident #13's movement so staff could respond immediately. CNA #2 said staff monitored Resident #13 for restlessness and frequent fidgeting when she needed to urinate. CNA #2 said after Resident #13's fall with injury, all of the CNAs were trained again to monitor the resident and were reminded to keep Resident #13's wheelchair away from the bed. CNA #2 said a bedside table had been moved away from the bed and a fall mat was placed on the floor. C. Resident representative interview Resident #13's representative was interviewed on 8/31/26 at 2:09 p.m. The representative said the facility used a motion sensor in Resident #13's room to alert the staff when the resident moved around. The representative said Resident #13 had a lot of facial bruising and a big knot on her forehead after her fall (on 8/23/26). The representative said on 8/26/26, the facility transferred Resident #13 back to the hospital because she was acting differently and the staff had more difficulty waking her up. She said the hospital physician told the representative that Resident #13 had a concussion. The representative said when Resident #13 felt the urge to urinate, she often was impulsive and got up quickly. The representative said Resident #13 did complain about pain after her fall, but it resolved quickly. The representative said the hospital physician told her it would take two to three weeks for the hematoma on the resident's forehead to resolve. D. Record review The fall care plan, revised 8/27/26 (during the survey), identified Resident #13 was at risk for falls related to confusion. Interventions prior to her fall on 8/23/26 included anticipating her needs, leaving the bathroom light on during the night, ensuring her call light was within reach, promptly responding to her call light, placing a motion sensor in the resident's room to help reduce falls, offering the restroom when Resident #13 became restless in the night and providing the resident with a soft touch call light. Interventions after her fall on 8/23/26 included a fall mat at the bedside when Resident #13 was in bed, moving the night table away from the resident's bed and placing the resident's wheelchair away from the bed to the side of the room when not in use. The unwitnessed fall incident report, dated 8/23/26, was provided by the NHA on 8/31/26 at 11:07 a.m. The incident report documented Resident #13's fall occurred on 8/23/26 at 4:27 a.m. The nursing description documented registered nurse (RN) #3 revealed RN #3 was called to Resident #13's room by CNA #5. It documented that Resident #13 was found on the floor with a large swollen area to her left forehead and the resident was unable to provide a description of what had happened. The report documented Resident #13 had facial grimacing and had occasional moaning. A nursing progress note, dated 8/23/26 at 6:04 a.m., documented the nurse was called to Resident #13's room and found the resident on the floor between the bed and the bathroom with a large goose egg above her left eye. The note documented Resident #13 was assessed on 8/23/26 at 4:30 a.m. and the primary care physician was notified. The note documented that emergency medical services (EMS) was notified at 4:34 a.m. and Resident #13 was transferred to the hospital at 5:00 a.m. The hospital record, dated 8/23/26 at 6:17 a.m., documented Resident #13 had diagnoses of a forehead contusion, a closed head injury and musculoskeletal contusions from her fall at the facility. A nursing progress noted, dated 8/23/26 at 11:30 a.m., documented Resident #13 returned from the hospital. It documented Resident #13 had received ibuprofen 600 milligrams (mg) and Tylenol 1000 mg at the hospital. The note documented the hospital had determined Resident #13 had no fractures; however, it documented the resident had a large hematoma above her left eye. A nursing progress note, dated 8/26/26 at 5:09 p.m., documented the CNAs had requested the nurse to assess Resident #13 as the nursing staff was having difficulty waking the resident. The note documented Resident #13 had had a recent fall with monitoring. The note documented the nurse was able to wake the resident; however, Resident #13 was lethargic and wanted to go back to sleep. The note documented Resident #13 became nauseous and the physician was notified. The note documented Resident #13 was transferred to the hospital at 5:45 p.m. The hospital record, dated 8/26/26 at 9:07 p.m., documented Resident #13 had new diagnoses of altered mental status and cerebral concussion following her fall on 8/23/26. The hospital physician documented the resident had no evidence of intracerebral (brain) bleeding, however, the physician documented suspicion that the resident's concussion and dementia contributed to her altered mental state. An interdisciplinary team (IDT) progress note, dated 8/27/26 at 9:25 a.m., revealed Resident #13 had a fall in her room while trying to self-ambulate (on 8/23/26). The investigation identified the resident tripped on her wheelchair that was near the bed and fell, hitting her head on a bedside table. The note revealed the bedside table was moved and a fall mat would be placed when the resident was in bed. The note revealed the resident's wheelchair would be placed away from the bed. The note revealed Resident #13 had a hematoma on her forehead with significant bruising across both eyes and down her cheek. Resident #13 was evaluated at the hospital and returned to the facility the same day. -However, Resident #13 was sent back to the hospital on 8/26/26 for altered mental status (see 8/26/26 hospital note above). E. Staff interviews CNA #3 was interviewed on 8/27/26 at 2:18 p.m. CNA #3 said Resident #13's fall (on 8/26/26) could have been prevented. CNA #3 said another CNA had left Resident #13's wheelchair in front of her bed and the resident tripped over it. CNA #3 said after the fall, the CNAs were instructed to ensure Resident #13's wheelchair was not placed next to her bed. CNA #5 was interviewed on 9/1/26 at 8:40 a.m. CNA #5 said he was Resident #13's CNA during the night of her fall on 8/23/26. CNA #5 said the resident's motion sensor alerted him that Resident #13 was moving. CNA #5 said he entered the resident's room and Resident #13 was trying to get up out of bed and was confused. He said he asked Resident #13 if she wanted to go to the bathroom. He said the resident did not know where she was at the time and he reassured her and reminded her where she was. CNA #5 said he calmed the resident and helped her back into bed. CNA #5 said about 30 seconds later, Resident #13's motion sensor went off again. He said he heard Resident #13's fall and he ran into her room. CNA #5 said after the event, he realized that Resident #13 was probably trying to go to the bathroom. CNA #5 said he should have taken her to the bathroom to see if she needed to urinate. CNA #5 said whoever tucked the resident into bed that night had left the wheelchair next to the bed and it looked like Resident #13 might have tripped over the wheelchair. CNA #5 said he wished he had taken Resident #13 to the bathroom even though she did not acknowledge that she had to go. CNA #5 said Resident #13 was a fall risk and was impulsive and it was important for staff to go to her room right away if the motion sensor alerted staff that she was moving. CNA #5 said after Resident #13's fall, the facility implemented a fall mat in front of the resident's bed and moved a little table away from the bed. The DON and the NHA were interviewed together on 9/1/26 at 11:20 a.m. The DON said the facility's investigation of the fall on 8/23/26 revealed Resident #13 had been taken to the restroom by CNA #5 and the CNA accidentally left the wheelchair next to the resident's bedside. -However, CNA #5 said he did not take Resident #13 to the restroom (see interview above). The DON said Resident #13's call light was not properly placed to alert staff if she moved. She said the investigation revealed the resident had gotten out of bed, tripped over her wheelchair and fell on the bedside table. The DON said staff did not usually leave Resident #13's wheelchair next to her bed and it should not have been placed next to the bed. She said the wheelchair was kept out of the way in order for the motion sensor to detect her movement. The NHA and the DON both said Resident #13's fall on 8/23/26 could have been prevented. The DON said staff recognized Resident #13's change in condition after the fall and sent her to the hospital. III. Resident #2 A. Resident status Resident #2, age greater than 65 was admitted on [DATE]. According to the August 2026 CPO, diagnoses included unspecified dementia, hemiplegia (paralysis) and hemiparesis (weakness) following cerebral infarction (stroke) affecting the right side, and generalized muscle weakness. The 6/10/26 MDS assessment documented Resident #2 had severe cognitive impairment with a BIMS score of five out of 15. The assessment documented Resident #2 was dependent on staff for transferring from surface to surface, required substantial to maximum assistance to sit from a lying position on the side of the bed, and required substantial to maximal assistance to hold himself up without back support. B. Record review Resident #2's fall risk care plan, revised 6/8/23, documented Resident #2 was assessed as a moderate risk for falls related to confusion, cognitive impairment, balance problems and incontinence. Pertinent interventions included ensuring a call light within reach and to encourage its use, anticipating Resident #2's needs and following the facility fall protocol, including monitoring for changes in Resident #2's cognition, gait, ability to rise, sit and balance himself. -However, Resident #2 sustained a fall after CNA #5 stepped away from his side for approximately 10 seconds while the resident was seated on a shower bench equipped with only one arm rest to the right side (see record review and staff interview below). Resident #2's activities of daily living (ADL) care plan, revised on 6/8/23, revealed the resident had a self-care performance deficit related to dementia and limited range of motion. Resident #2 required extensive assistance of two people to move between surfaces and required a sit-to-stand mechanical lift for transfers. The incident note, dated 6/15/26, documented that on 6/15/26 at 9:30 p.m., Resident #2 leaned over and slipped out of the shower chair. The resident said he hit his head on the wall and he had a visible scratch to the top right side of his head measuring 2.5 centimeters (cm) long by 0.25 cm wide. He was able to move all extremities as per usual, and neurological checks were performed and were within normal limits. Resident #2 was assisted back into his wheelchair and no other injuries were noted. A fall intervention document, dated 6/15/26, noted corrective actions put in place after the incident were to ensure proper placement of Resident #2 on the shower bench. -However, the document failed to acknowledge that the bench had only one armrest or that its use should be discontinued (see staff interviews below). The IDT post-fall assessment, dated 6/17/26 at 10:18 a.m., documented that on 6/15/26 at 9:30 p.m. Resident #2 leaned over and slipped out of the shower chair. Resident #2 stated he hit his head on the wall and a scratch was noted to the top right side of his head measuring 2.5 cm long by 0.25 cm wide. He was able to move all of his extremities as per usual, with no reports of increased pain except for where he hit his head. Vital signs and neurological checks were initiated and the physician and the DON were notified. The post-fall assessment documented no further treatment was needed and staff were educated to be sure Resident #2 was seated properly on his shower chair prior to unhooking him from the sit-to-stand mechanical lift. -However, the document failed to acknowledge that Resident #2 was left unsupervised on a shower bench that was equipped with only one armrest on the right side (see staff interviews below). The fall committee binder, provided by the NHA on 8/31/26 at 2:30 p.m., documented the post-fall intervention for Resident #2's fall on 6/15/26 included the staff were educated to use a shower chair with arms on both sides. C. Staff interviews CNA #4 was interviewed on 8/31/26 at 2:55 p.m. CNA #4 said she was outside of the bathroom pulling the sit-to-stand mechanical lift out at the time of Resident #2's fall. CNA #4 said CNA #5 was inside the bathroom assisting Resident #2. She said CNA #5 turned away from Resident #2 to help push the mechanical lift through the doorway of the bathroom. CNA #4 said while CNA #5's back was to Resident #2, Resident #2 slipped off of the shower bench. She said the bench in use had only a single armrest to the right side and lacked an armrest on the left side. CNA #4 said Resident #2 fell off the shower bench from the left side. CNA #4 said Resident #2 sustained a small scratch to the middle of his forehead with no other injury. She said staff no longer used that shower bench for Resident #2 and it was replaced with a shower chair with armrests to both sides. CNA #5 was interviewed by phone on 9/1/26 at 8:41 a.m. CNA #5 said after placing Resident #2 on to the shower bench (on 6/15/26), he stepped away from the resident for approximately 10 seconds to assist CNA #4 with pushing the mechanical lift out of the bathroom while CNA #4 was pulling it from the other side. CNA #5 said when he turned back around, he saw Resident #2 on the floor. CNA #5 said the shower bench had an armrest to one side only. He said the shower bench was taken out of service for Resident #2 after the resident's fall and was replaced with a shower chair with armrests on both sides. CNA #5 said he should have stayed alongside Resident #2 and should not have turned his attention away from the resident. The NHA and the DON were interviewed together on 9/1/26 at 9:40 a.m. The NHA and the DON said that CNA #5 should not have turned away and left Resident #2's side to assist CNA #4 with the mechanical lift. The DON and the NHA said Resident #2 should only use a shower chair equipped with armrests to both sides. IV. Resident #35 A. Resident status Resident #35, age greater than 65, was admitted on [DATE]. According to the August 2026 CPO, diagnoses included abnormalities of gait and mobility, osteoarthritis to both knees, weakness and chronic obstructive pulmonary disease with dependence on supplemental oxygen. The 6/17/26 MDS assessment documented Resident #35 was moderately cognitively impaired with a BIMS score of 12 out of 15. The assessment documented Resident #35 could walk 150 feet with supervision or touching assistance and was independent with surface to surface transfers and bed mobility. -However the physical therapy assistant recommended a contact guard assistance with gait belt for Resident #35 while ambulating (see record review and interview below). B. Observations On 8/26/26 at 12:00 p.m. Resident #35 was ambulating to her chair in her room without her walker. She was unsteady and visibly short of breath with the activity. On 8/31/26 at 11:55 a.m. activity assistant (AA) #1 brought Resident #35's walker to her room and then immediately left the room. Shortly after, Resident #35 exited her room, ambulating independently with her walker. -AA #1 did not provide supervision or touching assistance as the MDS assessment required. -Additionally, AA #1 failed to provide contact guard assistance with a gait belt per the physical therapy assistant's recommendations (see physical therapy assistant's interview below). C. Record review The fall risk care plan, revised 9/8/26, revealed Resident #35 was a moderate fall risk related to gait and balance problems. Interventions included ensuring the call light was within reach, ensuring the resident was wearing appropriate footwear when ambulating and following the facility fall protocol, including monitoring for changes in the resident's cognition, gait, ability to rise, sit and balance. Resident #35's ADL care plan, revised 4/28/26, revealed the resident had a self-care performance deficit related to activity intolerance and impaired balance.Interventions included the use of a forward wheeled walker to maximize independence with transferring at times with one-person assist and a gait belt. An incident note, dated 4/26/26 at 11:55 a.m., documented that Resident #35 was waving to a friend at the dining table when she fell backwards in front of the courtyard door and hit her head on the door. She then landed on the floor on her right side complaining of right hip pain and pain in the back of her head. Upon further inspection, it was determined she had a three cm lump to the back of her head. The resident was transported to the hospital for evaluation and returned the same day, at 5:00 p.m., with no additional injuries. The IDT post-fall assessment, dated 4/29/26 at 10:20 a.m., documented Resident #35 fell in the dining room while walking to the dining table. The CNA stepped a few feet away to move the dining chair into place for Resident #35. At that time Resident #35 took her hand off of her walker to wave at someone and lost her balance. Resident #35 was sent to the emergency department for evaluation of her head, spine, hip and femur. All of the tests revealed no new injury. Resident #35 returned to the facility and staff was educated to walk with Resident #35 using a gait belt and not to step away from her. A fall/skin intervention document, dated 4/26/26, noted corrective actions put in place after the fall 4/26/26 were to ensure a gait belt was used with one-person assistance while ambulating. The fall committee binder, provided by the NHA on 8/31/26 at 2:30 p.m., documented the post-fall interventions for Resident #35's fall on 4/26/26 included a walker and gait belt with one-person assistance. The physical therapy (PT) note, dated 8/26/26 at 5:16 p.m., documented Resident #35 was able to stand from a seated position with a four-wheeled walker, and ambulate with minimal assistance for 60 feet with a four-wheeled walker and contact guard assistance with a gait belt. D. Staff interviews AA #1 was interviewed on 8/31/26 at 2:08 p.m. AA #1 said Resident #35 had been evaluated to be independent by therapy. She said she received this information through a verbal report. -However, record review revealed the resident required a one-person assist with a walker and a gait belt for ambulation (see record review above). CNA #4 was interviewed on 8/31/26 at 2:17 p.m. CNA #4 said Resident #35 did not require a gait belt with ambulation. She said this was based on the physical therapy assistant recommendations. -However, the physical therapy assistant recommended that staff use a gait belt and contact guard assistance for ambulating Resident #2 (see interview below). The physical therapy assistant was interviewed on 8/31/26 at 2:41 p.m. The physical therapy assistant said Resident #35 required contact guard assistance with a gait belt for ambulation and transfers. He said this was communicated to staff when the resident's status changed, and periodically, through verbal reports. The NHA and the DON were interviewed together on 9/1/26 at 9:40 a,.m. The NHA and the DON said that it was determined that after Resident #35's fall on 4/26/26, she required a walker and a gait belt with one-person assistance for ambulation. The NHA and the DON said since that time, she had regained strength and no longer required a gait belt with ambulation. Both the NHA and the DON acknowledged that therapy recommendations for Resident #2's ambulation of contact guard assistance with a gait belt should be the most current recommendations and should be followed. The NHA and the DON said the facility had weekly phone communication with the physical therapist but those conversations did not include specific instructions for transfers and ambulation statuses of residents. The NHA and the DON said the facility was in the process of implementing a formal written communication system between the therapy staff and the nursing staff.

Based on observations, record review and interviews, the facility failed to ensure proper storage of medications for one of four medication storage rooms and two of five refrigerators.Specifically, the facility failed to:-Ensure medication was only stored in medication storage refrigerators and not stored with food;-Ensure refrigerated medication was stored in a temperature controlled medication storage refrigerator; and,-Discard medications that had expired.Findings include:I. Facility policy and procedureThe Medication Storage policy, revised February 2026, was provided by the nursing home administrator (NHA) on 8/31/26 at 7:30 p.m. It read in pertinent part, It is the policy (of the facility) to ensure all medications housed on our premises will be stored in a secured area and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation and security. All drugs and biologicals will be stored in locked compartments (medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls. All medications requiring refrigeration are stored in refrigerators located in each medication room. Temperatures are maintained within 36 degrees Fahrenheit (F) to 46 degrees F. Temperature logs are kept for refrigerator and temperature levels and are recorded daily by the charge nurse or other designee. The pharmacy and all medication rooms are routinely inspected by the consultant pharmacist for discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing labels.II. Observations and interviewsOn 8/27/26 at 12:30 p.m. the medication storage room in the Harvest house unit was observed with licensed practical nurse (LPN) #1. The following items were found:-An opened seven-ounce jar of mayonnaise was in the door of the medication storage refrigerator, stored with residents' insulin pens;-There were seven single-pill floor stock packages of Clindamycin 150 milligrams (mg), which expired on 8/11/26;-There were four single-pill floor stock packages of furosemide 20 mg, which expired on 8/6/26; and,-There were two single-pill floor stock packages of warfarin 2 mg, which expired on 8/13/26.LPN #1 said a staff member must have placed their personal food item (jar of mayonnaise) in the medication storage refrigerator. LPN #1 said the mayonnaise should not be in the refrigerator as it was only for medication storage. She said medications that had expired might not be as effective and might lose potency after expiration. LPN #1 said the expired medications should have been removed before the expiration date.On 8/27/26 at 1:40 p.m. a staff refrigerator was observed in the administration building with the director of nursing (DON) and the NHA. A used vial of tuberculin purified protein derivative (PPD) (Aplisol) 5 TU/0.1 milliliters (ml), marked with an opened date of 8/21/26, was found on a shelf in the refrigerator. The refrigerator was 90% (percent) full of personal food items (sour cream, yogurt and personal plastic containers of food). There was not a thermometer in the refrigerator.The DON said the tuberculin medication had been in the staff refrigerator for a few days and would be returned to the medication storage refrigerator in the unit it was usually stored in. The DON said the refrigerator was for storage of staff food items and the tuberculin medication should not be stored in it. The DON said the refrigerator was not temperature controlled or monitored and medication required monitoring of refrigerator temperature and should not be stored with food. The DON said the tuberculin medication would be discarded and new medication obtained because the medication had not been stored properly.

Based on record review and interviews, the facility failed to ensure that routine dental services were provided to meet the needs of residents for one (#2) of three residents reviewed for ancillary services out of 26 sample residents. Specifically, the facility failed to schedule a routine dental appointment for Resident #2, per a physician's order, which resulted in a delay for the resident to receive necessary oral evaluation and care.Findings include:I. Facility policy and procedureThe Dental Services policy, undated, was provided by the nursing home administrator (NHA) on 9/1/26 at approximately 2:00 p.m. It read in pertinent part, It is the policy of this facility to assist residents in obtaining routine (to the extent covered under the state plan) and emergency dental care. The dental needs of each resident are identified through the physical assessment and minimum data set (MDS) assessment processes and are addressed in each resident's plan of care. The social services director (SSD), or designee, shall make appointments and arrange transportation.II. Resident #2A. Resident status Resident #2 age [AGE], was admitted on [DATE]. According to the August 2026 computerized physician orders (CPO), diagnoses included unspecified dementia, hemiplegia (paralysis), hemiparesis (weakness) following cerebral infarction affecting the right side, and generalized muscle weakness. The 6/10/26 MDS assessment revealed Resident #2 had severe cognitive impairment with a brief interview for mental status (BIMS) score of five out of 15.The MDS assessment documented Resident #2 required set up assistance for oral hygiene. B. Resident interview and observationResident #2 was interviewed on 8/2/26 at 2:39 p.m. Resident #2 said he had broken teeth in the back of his mouth. He said he had no pain and no difficulty chewing or eating. He said he did not know the last time he saw a dentist, but he would like to do so. During the interview, Resident #2's front teeth were observed to be discolored, but appeared intact without visible food or debris present. His back teeth were not visible.C. Record reviewA nursing progress note, dated 6/9/26 at 4:41pm., documented that during routine rounds, the attending physician evaluated Resident #2 and ordered a dental appointment to be made for teeth cleaning for the resident. A long term care evaluation progress note, dated 8/16/26 at 7:42 p.m., documented Resident #2 had his own natural teeth. It documented there were no obvious fragments, suspected cavities or broken teeth. There was no inflammation or bleeding gums, no mouth or facial pain and no difficulty chewing. The resident's oral cavity was clean, his mucous membranes were moist and oral care was performed frequently.-However Resident #2 expressed concern regarding broken teeth in the back of his mouth and expressed a desire to see the dentist (see resident interview above).III. Staff interview The NHA and the SSD were interviewed together on 8/31/26 at 2:11 p.m. The NHA said the physician's order given on 6/9/26 for Resident #2's teeth cleaning was not implemented. The SSD said she could not find any documentation that the dental appointment had been scheduled or that other arrangements had been made for Resident #2.

Based on observations, record review and interviews, the facility failed to ensure one (#19) of one resident reviewed for medication administration out of 26 sample residents was kept free from significant medication errors.Specifically, the facility failed to ensure Resident #19 was administered sliding scale insulin per physician orders.Findings include:I. Facility policy and procedureThe Medication Administration policy, revised November 2025, was provided by the nursing home administrator (NHA) on 8/31/26 at 7:30 p.m. It read in pertinent part, Medications are administered by licensed nurses, or other staff members who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Ensure that the six rights of medication administration are followed: right resident, right drug, right dosage, right route, right time, and right documentation. Sign the MAR (medication administration record) after administration. For those medications requiring vital signs, record vital signs onto the MAR. Report and document any adverse side effects or refusals. Correct any discrepancies and report to the director of nursing (DON) or designee.The Medication Error policy, revised February 2026, was provided by the NHA on 8/31/26 at 7:30 p.m. It read in pertinent part, The facility shall ensure medications will be administered as follows: according to physician orders, per manufacturer's specifications regarding the preparation and administration of the drug or biological and in accordance with accepted standards and principles which apply to professionals providing services. Medication errors, once identified, will be evaluated to determine if considered significant or not by utilizing the follow three general guidelines:If the resident's condition requires rigid control, such as strict intake and output measurement, daily weights, or monitoring of lab values; if the medication is from a category that usually requires the resident to be titrated to a specific blood level such as a medication with a narrow therapeutic index; Insulin errors are always considered a significant medication error; and,If an error is occurring repeatedly, such as an omission of a resident's medication several times.II. Resident #19A. Resident statusResident #19, age [AGE], was admitted on [DATE]. According to the August 2026 computerized physician orders (CPO), diagnoses included type 1 diabetes with diabetic polyneuropathy (damage to nerves in the hands and feet), chronic obstructive pulmonary disease (COPD) and major depressive disorder. The 7/28/26 minimum data set (MDS) assessment identified Resident #19 had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 11 out of 15. B. Resident interviewsResident #19 was interviewed on 8/26/26 at 4:17 p.m. Resident #19 said her blood sugar levels could change rapidly. She said there was a nurse who was sometimes afraid to give her too much sliding scale insulin. Resident #19 said the nurse had told her that she would rather her blood sugars be too high rather than too low, so sometimes the nurse did not give her the sliding scale dose of insulin that was ordered by the physician. Resident #19 said she had a continuous blood sugar level monitor implanted under her skin which beeped when her blood sugar level was too high or too low. Resident #19 said the nurse's phone also received communication about all of her continuous blood sugar levels and the alarms if her blood sugar level was too high or low.Resident #19 was interviewed a second time on 8/31/26 at 10:55 a.m. Resident #19 said even though one nurse often did not give her sliding scale insulin doses, she had not had significant physical outcomes from missing those insulin doses. However, Resident #19 said she often was more tired when her blood sugar levels were higher. Resident #19 said she did not refuse her insulin doses.C. ObservationOn 8/31/26 at 11:42 a.m., licensed practical nurse (LPN) #2 observed Resident #19's continuous blood sugar level monitor and said the resident's blood sugar was 182 milligrams/deciliter (mg/dl). LPN #2 said the physician's order indicated the resident should receive three units of insulin. LPN #2 asked Resident #19 if she wanted the insulin sliding scale dose. Resident #19 said she wanted the insulin to be administered to her. LPN #2 administered three units of Novolog insulin in the resident's left arm. D. Record reviewThe diabetes care plan, revised 5/11/26, revealed Resident #19 had a history of fluctuating blood sugar levels. Interventions included the use of a blood glucose monitoring device, blood sugars as ordered and diabetes medication (insulin) as ordered by the physician per sliding scale insulin and routine insulin orders.A review of Resident #19's August 2026 CPO revealed the following physician's orders for insulin administration:Insulin glargine subcutaneous solution pen injector 100 units/milliliter (ml), inject 12 units subcutaneously one time a day related to type 1 diabetes mellitus with diabetic neuropathy, ordered on 7/2/26.Novolog Flex Pen solution pen injector 100 units per ml (Insulin aspart), inject as per sliding scale. If blood sugar level is:-101 mg/dl to 150 mg/dl = 1 unit of insulin; -151 mg/dl to 200 mg/dl = 3 units of insulin; -201 mg/dl to 250 mg/dl = 4 units of insulin; -251 mg/dl to 300 mg/dl = 5 units of insulin; -301 mg/dl to 350 mg/dl = 6 units of insulin; -351 mg/dl to 400 mg/dl = 7 units of insulin; and, -401 mg/dl or greater = 8 units of insulin. Give subcutaneously three times a day (morning, midmorning and evening), ordered on 7/2/26.Novolog Flex Pen solution pen injector 100 units per ml (Insulin aspart), inject as per sliding scale. If blood sugar level is:-0 mg/dl to 150 mg/dl = 0 units of insulin; -151 mg/dl to 200 mg/dl = 0 units of insulin; -201 mg/dl to 250 mg/dl = 0 units of insulin; -251 mg/dl to 300 mg/dl = 2 units of insulin; -301 mg/dl to 350 mg/dl = 3 units of insulin; -351 mg/dl to 400 mg/dl = 4 units of insulin; and,-401 mg/dl or greater = 5 units of insulin subcutaneously one time a day at bedtime, ordered on 3/12/26.A review of Resident #19's August 2026 MAR, from 8/1/26 to 8/31/26, revealed the following documentation:On 8/2/26 at bedtime, Resident #19's blood sugar level was 268 mg/dl. The nurse documented Resident #19 refused insulin. Per the physician's order, Resident #19 should have received 2 units of insulin.On 8/4/26 in the evening, Resident #19's blood sugar level was 173 mg/dl. The nurse documented Resident #19 refused insulin. Per the physician's order, Resident #19 should have received 3 units of insulin.On 8/5/26 in the evening, Resident #19's blood sugar level was 184 mg/dl. The nurse documented Resident #19 refused insulin. Per the physician's order, Resident #19 should have received 3 units of insulin.On 8/6/26 in the morning, Resident #19's blood sugar level was 276 mg/dl. The nurse documented a partial dose of 3 units of insulin was administered. -However, per the physician's order, Resident #19 should have received 5 units of insulin.On 8/6/26 in the midmorning, Resident #19's blood sugar level was 180 mg/dl. The nurse documented Resident #19 refused insulin. Per the physician's order, Resident #19 should have received 3 units of insulin.On 8/6/26 in the evening, Resident #19's blood sugar level was 243 mg/dl. The nurse documented Resident #19 refused insulin. Per the physician's order, Resident #19 should have received 4 units of insulin.On 8/7/26 in the midmorning, Resident #19's blood sugar level was 198 mg/dl. The nurse documented Resident #19 refused insulin. Per the physician's order, Resident #19 should have received 3 units of insulin.On 8/7/26 in the evening, Resident #19's blood sugar level was 394 mg/dl. The nurse documented a partial dose of 5 units of insulin was administered.-However, per the physician's order, Resident # 19 should have received 7 units of insulin.On 8/11/26 in the midmorning, Resident #19's blood sugar level was 162 mg/dl. The nurse documented Resident #19 refused insulin. Per the physician's order, Resident #19 should have received 3 units of insulin.On 8/11/26 in the evening, Resident #19's blood sugar level was 174 mg/dl. The nurse documented Resident #19 refused insulin. Per the physician's order, Resident #19 should have received 3 units of insulin.On 8/12/26 in the morning, Resident 19's blood sugar level was 300 mg/dl. The nurse documented a partial dose of 3 units of insulin was administered.-However, per the physician's order, Resident #19 should have received 5 units of insulin.On 8/12/26 in the midmorning, Resident #19's blood sugar level was 177 mg/dl. The nurse documented Resident #19 refused insulin. Per the physician's order, Resident #19 should have received 3 units of insulin.On 8/12/26 in the evening, Resident #19's blood sugar level was 200 mg/dl. The nurse documented Resident #19 refused insulin. Per the physician's order, Resident #19 should have received 3 units of insulin.On 8/14/26 in the midmorning, Resident #19's blood sugar level was 145 mg/dl. The nurse documented Resident #19 refused insulin. Per the physician's order, Resident #19 should have received 1 unit of insulin.On 8/14/26 in the evening, Resident #19's blood sugar level was 117 mg/dl. The nurse documented Resident #19 refused insulin. Per the physician's order, Resident #19 should have received 1 unit of insulin.On 8/15/26 in the evening, Resident #19's blood sugar level was 149 mg/dl. The nurse documented Resident #19 refused insulin. Per the physician's order, Resident #19 should have received 1 unit of insulin.On 8/16/26 in the midmorning, Resident #19's blood sugar level was 130 mg/dl. The nurse documented Resident #19 refused insulin. Per the physician's order, Resident #19 should have received 1 unit of insulin.On 8/16/26 in the evening, Resident #19's blood sugar level was 250 mg/dl. The nurse documented Resident #19 refused insulin. Per the physician's order, Resident #19 should have received 4 units of insulin.On 8/17/26 in the morning, Resident #19's blood sugar level was 136 mg/dl. The nurse documented Resident #19 refused insulin. Per physician's order, Resident #19 should have received 1 unit of insulin.On 8/17/26 in the midmorning, Resident #19's blood sugar level was 165 mg/dl. The nurse documented Resident #19 refused insulin. Per the physician's order, Resident #19 should have received 3 units of insulin.On 8/17/26 in the evening, Resident #19's blood sugar level was 230 mg/dl. The nurse documented Resident #19 refused insulin. Per the physician's order, Resident #19 should have received 4 units of insulin.On 8/20/26 in the evening, Resident #19's blood sugar level was 123 mg/dl. The nurse documented Resident #19 refused insulin. Per the physician's order, Resident #19 should have received 1 unit of insulin. On 8/21/26 in the morning, Resident #19's blood sugar level was 134 mg/dl. The nurse documented Resident #19 refused insulin. Per the physician's order, Resident #19 should have received 1 unit of insulin.On 8/21/26 in the midmorning, Resident #19's blood sugar level was 122. The nurse documented Resident #19 refused insulin. Per the physician's order, Resident #19 should have received 1 unit of insulin.On 8/21/26 in the evening, Resident #19's blood sugar level was 243 mg/dl. The nurse documented Resident #19 refused insulin. Per the physician's order, Resident #19 should have received 4 units of insulin.On 8/22/26 at bedtime, Resident #19's blood sugar level was 348 mg/dl. The nurse documented Resident #19 refused insulin. Per the physician's order, Resident #19 should have received 3 units of insulin.On 8/24/26 in the evening, Resident #19's blood sugar level was 177. The nurse documented Resident #19 refused insulin. Per the physician's order, Resident #19 should have received 3 units of insulin.On 8/25/26 in the evening, Resident #19's blood sugar level was 320 mg/dl. The nurse documented Resident #19 refused insulin. Per the physician's order, Resident #19 should have received 6 units of insulin.On 8/29/26 in the evening, Resident #19's blood sugar level was 106 mg/dl. The nurse documented Resident #19 refused insulin. Per the physician's order, Resident #19 should have received 1 unit of insulin.On 8/30/26 in the evening, Resident #19's blood sugar level was 143 mg/dl. The nurse documented Resident #19 refused insulin. Per the physician's order, Resident #19 should have received 1 unit of insulin.-During the month of August 2026, Resident #29 was documented as refusing her sliding scale insulin on 27 occasions and receiving only a partial dose of sliding scale insulin on three occasions. However, there was no documentation to indicate the physician was notified of the missed or partial doses of the resident's sliding scale insulin.III. Staff interviewsLPN #2 was interviewed on 8/31/26 at 11:35 a.m. LPN #2 said she preferred Resident #19's blood sugar levels to be in the 200 mg/dl to 300 mg/dl range because the resident felt better when her blood sugar level was not below 200 mg/dl. LPN #2 said we refuse sliding scale insulin sometimes. LPN #2 said she had talked with Resident #19 about her blood sugar levels and then she and the resident had decided together whether to refuse the sliding scale insulin doses.The DON and the NHA were interviewed together on 8/31/26 at 2:15 p.m. The DON said if there were multiple refusals of insulin administration by Resident #19, she would expect the nurse to document the refusals and rationale in the nursing progress notes and notify the physician. The DON and the NHA said they did not know why LPN #2 had documented 30 refusals or partial doses administered of sliding scale insulin for Resident #19 during the months of August 2026 and the DON said they needed to research the situation further.The DON was interviewed a second time on 9/1/26 at 10:55 a.m. The DON said the physician's orders for blood sugar level management should be followed. She said if an insulin dose was not administered per nursing judgment or resident refusal, there should be detailed documentation as to why the sliding scale insulin was not administered. The DON said she was unsure if the physician had been contacted about any insulin refusals or partial doses administered for Resident #19. The DON said after interviewing the nurses involved with Resident #19's insulin administration, she found the nurses had consulted with Resident #19 about her blood sugar levels. She said the nurses and the resident made the decisions together to not administer the sliding scale insulin or administer partial doses of insulin to the resident. The DON said the sliding scale insulin orders were physician's orders and the nurses should have contacted the physician if they were not going to administer the insulin. She said LPN #2 was provided education that she should document in the nursing progress notes any time Resident #19 did not receive the sliding scale insulin as ordered and she should also notify the physician.The medical director was interviewed on 9/1/26 at 12:37 p.m. The medical director said Resident #19 sometimes refused her sliding scale insulin as ordered. She said the resident told nurses what she ate and what she needed. The medical director said LPN #2 had reported Resident #19's insulin refusals in the past; however the medical director said LPN #2 did not report the resident's refusals all of the time. The medical director said sometimes there was no documentation of what actually happened and she said there was likely a documentation issue.

Based on observations, record review and interviews, the facility failed to provide necessary respiratory care and services consistent with professional standards of practice for one (#35) of one resident reviewed for respiratory services out of 26 sample residents. Specifically, the facility failed to ensure Resident #35 received oxygen therapy in accordance with the physician's orders.Findings include:I. Professional referenceAccording to the National Library of Medicine, National Center for Biotechnology Information, update 1/22/25, retrieved on 9/2/26 from https://www.ncbi.nlm.nih.gov/books/NBK551617/, Oxygen therapy is a critical medical intervention that ensures adequate oxygen delivery to the body's cells, supporting essential functions and preventing life-threatening conditions. The absence of sufficient oxygen, or hypoxia, can result in severe complications such as organ dysfunction, brain damage, and cardiac arrest.II. Facility policy and procedureThe Oxygen Administration policy, revised November 2025, was provided by the nursing home administrator (NHA) on 9/1/26 at approximately 2:00 p.m. It read in pertinent part, Oxygen is administered to residents, consistent with professional standards of practice, physician's orders, the comprehensive person-centered care plans, and residents'goals and preferences. Oxygen is administered under orders of a physician, except in the case of emergency. In such cases oxygen is administered and orders for oxygen are obtained as soon as practicable when the situation is under control. The resident's care plan or physician's orders shall identify the interventions for oxygen therapy.III. Resident #35A. Resident statusResident #35, age [AGE], was admitted on [DATE]. According to the August 2026 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease with dependence on supplemental oxygen and weakness.According to the 6/17/26 minimum data set (MDS) assessment, Resident #35 had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 12 out of 15.The MDS assessment identified Resident #35 required oxygen therapy.B. ObservationsOn 8/26/26 at 12:00 p.m. Resident #35 was observed to be short of breath on room air while walking in her room without her oxygen. On 8/27/26 at 11:36 a.m. Resident #35 was sitting in her room sitting in her chair without her oxygen. Her oxygen concentrator was running at a flow rate of 3 liters per minute (LPM) with the nasal cannula stored in a plastic bag. Resident #35 said she only wore her oxygen when she felt short of breath. On 8/27/26 at 12:03 p.m. Resident #35 was ambulating slowly with her walker to the common area for lunch with an unidentified staff member. The resident was not wearing oxygen. On 8/31/26 at 12:51 p.m. Resident #35 was in her room sitting in her chair wearing a nasal cannula in her nose and connected to a room oxygen concentrator. The oxygen concentrator was set to an oxygen flow rate of 2.5 LPM. Resident #35 said she was feeling short of breath and had placed herself on oxygen. C. Record reviewReview of Resident #35's August 2026 CPO revealed the following physician's order:Oxygen via nasal cannula at 2 LPM, may titrate to maintain oxygen saturation (level of oxygen in the blood) greater than 90% (percent), related to chronic obstructive pulmonary disease, ordered 6/4/26. Resident #35's oxygen therapy care plan, revised 9/23/25, revealed the resident had oxygen therapy. Interventions included delivering oxygen by nasal cannula at 2 LPM routinely, monitoring for symptoms of respiratory distress, and administering medications as ordered by the physician.A nursing progress note, dated 7/18/26 at 9:42 a.m., documented Resident #35's oxygen saturation level was 78% on room air. The note documented her oxygen saturation level increased to 92% when she was on 2 LPM of oxygen.IV. Staff interviewsCertified nurse aide (CNA) #6 was interviewed on 8/31/26 at 11:32 p.m. CNA #6 said Resident #35 did not wear oxygen outside of her room.Licensed practical nurse (LPN) #2 was interviewed on 8/31/26 at 1:32 p.m. LPN #2 said Resident #35 did not require her oxygen when she was up and about and out of her room. CNA #4 was interviewed on 8/31/26 at 2:15 p.m. CNA #4 said Resident #35 only required oxygen when resting in her chair or in bed. CNA #4 said the resident did not require oxygen when she was out of her room. CNA #4 said this was communicated through reports from nurses and CNAs. The director of nursing (DON) was interviewed on 9/1/26 at 10:09 a.m. The DON said Resident #35 only required oxygen while sleeping or in her room. The DON reviewed the resident's physician's order for oxygen via nasal cannula at 2 LPM and the resident's oxygen therapy care plan, which included the intervention to deliver oxygen by nasal cannula at 2 LPM routinely, (see record review above). The DON said after reviewing Resident #35's physician's order for oxygen and her oxygen care plan, the resident should be wearing oxygen at all times.

Based on observations and interviews, the facility failed to ensure residents received notices orally and in writing which included a written description of their legal rights.Specifically, the facility failed to ensure the State Survey Agency's (SSA) contact information, including the phone number, address and email address, were posted in a manner accessible and understandable to all residents.Findings include:I. Facility policy and procedureThe Resident Rights policy, revised 7/8/24, was provided by the nursing home administrator (NHA) on 8/31/26 at 7:30 p.m. It read in pertinent part, A posting of names, addresses and phone numbers of all pertinent state client advocacy groups will be available in the facility. The resident has the right to receive notices orally (meaning spoken) and in writing in a format and a language he or she understands. The facility must furnish to each resident a written description of legal rights which include a list of names, addresses (mailing and email), and telephone numbers of all pertinent State regulatory and informational agencies, resident advocacy groups such as the State Survey Agency, the State licensure office, the State Long-Term Care Ombudsman program, the protection and advocacy agency, adult protective services where state law provides for jurisdiction in long-term care facilities, the local contact agency for information about returning to the community. A statement that the resident may file a complaint with the State Survey Agency. Information and contact information for State and local advocacy organizations, including but not limited to the State Survey Agency, the State Long-Term Care Ombudsman program and the protection and advocacy system.II. Resident group interviewA group interview was conducted on 8/31/26 at 11:00 a.m. with eight residents (#1, #20, #26, #27, #28, #33, #35 and #39) who were deemed interviewable through the facility and assessment.All eight of the residents said they had not been given information on how to contact the SSA. They said there was no SSA contact information posted in the facility. III. ObservationsOn 8/31/26 at 11:50 a.m. a walk-through of the facility was conducted and did not reveal a posting for the SSA's contact information, to include the agency's phone number, address and email address.IV. Staff interviewsCertified nurse aide (CNA) #1 was interviewed on 8/31/26 at 1:56 p.m. CNA #1 said she was not aware of the State Agency's contact information being posted in the facility. She said if a resident requested the State Agency's contact information, she would notify the management team.The NHA was interviewed on 8/31/26 at 2:09 p.m. The NHA confirmed the required SSA contact information was not posted in the facility. She said she would obtain the contact information from the SSA website and post it in the facility.

Based on observations and staff interviews, the facility failed to maintain an infection control and prevention program designed to provide a sanitary environment to help prevent the development and transmission of communicable diseases and infections.Specifically, the facility failed to follow proper infection control practices during insulin injection via insulin pen by using Resident #3 insulin pen to inject insulin to Resident #1. Findings include:I. Professional referenceThe Centers for Disease Control and Prevention (CDC), Considerations for Blood Glucose Monitoring and Insulin Administration (revised 8/7/24) was retrieved on 2/17/26 from https://www.cdc.gov/injection-safety/hcp/infection-control/. It read in read in pertinent part, Insulin pens and other medication cartridges and syringes are for single patient use only. Never use them for more than one person. II. Facility policy and procedureThe Insulin Pen Use Policy, dated November 2025, read in pertinent part Insulin pens contain multiple doses of insulin but are used for a single elder only. III. Resident #1A. Resident statusResident #1, age [AGE], was admitted on [DATE]. According to February 2026 computerized physician orders diagnoses included type 2 diabetes mellitus with diabetic chronic kidney disease and unspecified dementia, unspecified severity, with mood disturbance.The 1/21/26 minimum data set (MDS) revealed that the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of six out of 15. The resident required partial to moderate assistance with activities of daily living. The MDS assessment indicated there was a change in the insulin order. B. Record reviewThe facility's investigation, dated 1/9/26, documented Resident #1 was prescribed 5 units of Lantus (insulin). Licensed practical nurse (LPN) #2 looked in the emergency kit of the facility and it did not contain Lantus. LPN #2 then used Resident #3's insulin pen for Lantus, using a new needle, to inject the 5 units of Lantus to Resident #1. On 1/9/26 the LPN #2 was re-educated and disciplined by the director of nursing (DON) regarding proper use of the insulin pen. -However, the re-education for the LPN #2 failed to address infection control in regards to safe medication administration pertaining to infection control, specifically bloodborne pathogens. In addition, the re-education dated 1/9/26 for all other nurses failed to address infection control in regards to safe medication administration pertaining to infection control, specifically bloodborne pathogens. IV. Staff interviewsLPN #1 was interviewed on 2/10/26 at 12:50 p.m. LPN #1 said the facility had an emergency kit for medication. LPN #1 said the emergency kit was supplied with both short and long acting insulin for emergency use. She said if a new high risk medication (blood thinner, insulin, antibiotic) was ordered by the physician and the medication was not in the emergency kit, the pharmacy could deliver the medication with a STAT status within two hours at the latest. LPN #1 said that if the medication was not available at the pharmacy, there were two nearby hospitals that could provide the medication. LPN #1 said the pharmacy was 45 minutes away. She said there was a hospital within 30 minutes of the facility.The DON was interviewed on 2/10/26 at 1:03 p.m. The DON said she completed an investigation on 1/9/26 when she learned about the incident which occurred in the evening of 1/8/26. The DON said insulin pens should never be used for more than one person because of risk for contamination with blood borne pathogens. She said all of the other nurses received training on The Insulin Pen Use policy. The DON said Resident #1 and Resident #3 were tested for hepatitis B and C with negative results.

Based on record review and interviews the facility failed to ensure one (#1) of three residents received treatment and care in accordance with professional standards of practice out of three sample residents.Specifically, the facility failed to ensure Monitor Resident #1's blood sugar after long acting insulin was administered to ensure the effectiveness of the medication. Findings include:I. Professional ReferenceAccording to the manufacturer, Sanofi, Patient Information Lantus Insulin Glargine Injection, 2025, retrieved on 2/20/26 from https://www.lantus.com/new-to-insulin/starting-insulin The most common side effect of insulin, including [NAME], is low blood sugar (hypoglycemia), which may be serious and life threatening. It may cause harm to your heart or brain. Symptoms of serious low blood sugar may include shaking, sweating, fast heartbeat, and blurred vision.II. Resident #1A. Resident statusResident #1, age [AGE], was admitted on [DATE]. According to February 2026 computerized physician orders (CPO), diagnoses included type 2 diabetes mellitus with diabetic chronic kidney disease and unspecified dementia, unspecified severity, with mood disturbance.The 1/21/26 minimum data set (MDS) revealed that the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of six out of 15. The resident required partial to moderate assistance with activities of daily living. The assessment indicated the resident's insulin order changed. B. Record review Review of Resident #1's electronic medical record (EMR) revealed the resident's blood sugar level measured on 1/8/26 with the value of 439 milligrams per deciliter (mg/dL). Review of the January 2026 CPO revealed the following physician's order:Lantus, subcutaneous solution pen injection 100 unit/ milliliter (ml). Inject 5 units one time a day for type 2 diabetes, ordered on 1/8/26.Review of Resident #1's EMR did not reveal documentation regarding the resident was monitored after being administered Lantus, which was a newly prescribed medication, to evaluate the effectiveness of the treatment and necessary monitoring for possible side effects of the new medication. C. Staff interviewsThe physician was interviewed on 2/10/26 at 1:00 p.m. The physician said the nurse called to report the high blood sugar value for Resident #1 on 1/8/26. The physician said she ordered of Resident #1 to receive 5 units of Lantus. The director of nursing (DON) was interviewed on 2/10/26 at 1:03 p.m. The DON said upon a review of Resident #1's EMR, there was no follow up for re-evaluation of Resident #1 elevated blood sugar value post receiving the 5 units of Lantus per physician's order by licensed practical nurse (LPN) #2. The DON said In addition she confirmed that there is no documentation regarding the incident and receiving the order in the Resident #1 and Resident #3 electronic health records.

Based on record review and staff interviews, the facility failed to develop and implement a comprehensive care plan for three (#38, #24 and #3) of five residents reviewed for care plans out of 19 total sample residents. Specifically, the facility failed to: -Ensure Resident #38 had a care plan for the use of an anticoagulant medication; -Ensure Resident #24 had a care plan for the use of supplemental oxygen; and, -Ensure Resident #3 had a care plan for the use of a diuretic medication. Findings include: I. Facility policy and procedure The Care Plan policy, revised 8/12/24, was provided by the nursing home administrator (NHA) on 9/25/24 at 2:53 p.m. It read in pertinent part, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. The comprehensive, person-centered care plan includes measurable objectives and timeframes describing the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. When possible, interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. II. Resident #38 A. Resident status Resident #38, age greater than 65, was admitted on [DATE]. According to the September 2024 computerized physician orders (CPO), diagnoses included atrial fibrillation (irregular heartbeat), gross hematuria (blood in the urine), personal history of other venous (vein) thrombosis (blood clot) and embolism (blockage inside a blood vessel), cardiac murmur and long term current use of anticoagulants. The 9/1/24 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score (BIMS) score of six out of 10. She required moderate assistance with bathing, repositioning, dressing, personal hygiene, transfers and toilet use. The assessment indicated the resident received an anticoagulant medication daily. B. Record review The September 2024 CPO revealed the resident had a physician's order for Eliquis (a blood thinner) 5 mg (milligrams) twice a day with a start date of 7/10/24. -There was no care plan addressing the use of the anticoagulant medication or its side effects. C. Staff interviews Licensed practical nurse (LPN) #2 was interviewed on 9/24/24 at 1:41 p.m. LPN #2 said she was not sure if the use of an anticoagulant medication needed to have a care plan or not. She said the nurses gave input when there was a new admission but the management team was responsible for updating the residents' care plans. She said nurses did not have a lot to do with care plans. The director of nursing (DON) was interviewed on 9/25/24 at 10:47 a.m. The DON said a care plan should be in place to address the use of Resident #38's anticoagulant. She said the care plan should include watching for signs and symptoms of side effects related to anticoagulant medication use, such as excessive bruising, excessive bleeding and blood in the urine and stool. She said it was very important to monitor for these side effects, especially if the resident was scheduled for surgery. The DON said she would immediately ensure a care plan was initiated for the use of the anticoagulant medication. The NHA was interviewed on 9/25/24 at 11:21 a.m. The NHA said a care plan should be in place for Resident #38's anticoagulant medication use. She said an anticoagulant was a significant medication with risk factors and needed a reason for use. She said the care plan should address the monitoring of side effects or complications. She said having a care plan in place was important so all staff would know how to care for the resident and the risks involved. She said the minimum data set (MDS) coordinator was responsible for initiating the comprehensive care plans. The NHA said she did not know how the implementation of a care plan for the use of Resident #38's anticoagulant medication was missed. 47064 III.Resident #24 A. Resident status Resident #24, age greater than 65, was admitted on [DATE]. According to the September 2024 CPO, diagnoses included Parkinson's (chronic brain disorder that affects movement), dementia (decrease cognitive thinking), hypoxemia (low levels of oxygen in the blood) and hypertension (increased blood pressure). The 7/21/24 MDS assessment revealed the resident was moderately cognitively impaired with a BIMS score of 10 out of 15. The assessment indicated the resident required supplemental oxygen but it did not reveal if oxygen was to be administered continuously or intermittently. B. Record review -Review of Resident #24's comprehensive care plan failed to reveal a care plan focus for supplemental oxygen use. The September 2024 CPO revealed the following physician's orders for oxygen: Supplemental oxygen per nasal cannula at 2 liters per minute (LPM) to keep oxygen at or above 90% (percent), ordered 2/1/23. May apply oxygen to continuous positive airway pressure (CPAP) machine at night if oxygen saturations (level of oxygen in the blood) were below 90%, ordered 2/16/23. The Kardex (a tool used by the certified nurse aides (CNA) to provide consistent care) failed to document how much supplemental oxygen Resident #24 was to receive. C. Staff interviews CNA #3 was interviewed on 9/24/24 at 1:56 p.m. CNA #3 said CNAs did a verbal report during shift change and that was how staff knew how much oxygen a resident should be on. LPN #1 was interviewed on 9/24/24 at 2:16 p.m. LPN #1 said she would look at the physician's orders to know how many liters of oxygen a resident should be on. LPN #1 said the use of supplemental oxygen should be care planned. LPN #1 said she was unable to locate oxygen on Resident #24's care plan. CNA #1 was interviewed on 9/25/24 at 11:16 a.m. CNA #1 said staff had access to residents' Kardex and she said the oxygen liter flow should be documented on the Kardex. CNA #1 reviewed the Kardex for Resident #24 and said she was unable to identify how much oxygen Resident #24 should be receiving. CNA #1 said she knew Resident #24 was on oxygen because she had gotten the information in report. The DON was interviewed on 9/25/24 at 12:20 p.m. The DON said it was her assistant director of nursing (ADON)/MDS coordinator's responsibility to ensure care plans were updated. The DON said care plans should include all care provided to a resident, including supplemental oxygen use. 50219 IV. Resident #3 A. Resident status Resident #3, age greater than 65, was admitted on [DATE]. According to the September 2024 CPO, diagnoses included dementia and hypertensive chronic kidney disease. The 8/7/24 MDS assessment revealed the resident was significantly cognitively impaired with a BIMS score of one out of 15. The MDS did not indicate Resident #3 was taking a diuretic medication. B. Record review The incontinence care plan, revised 12/9/2020, revealed Resident #3 had mixed bladder incontinence. Pertinent interventions included encouraging fluids during the day to promote prompted voiding responses. The hypertension care plan was revised 12/9/24. Pertinent interventions included monitoring for edema, monitoring and documenting any abnormalities in urinary output and giving anti-hypertensive medications as ordered. The September 2024 CPO revealed a physician's order for Lasix (furosemide) 40 mg with instructions to give one tablet by mouth one time a day for edema, ordered 1/16/24. The 8/14/24 care plan conference notes revealed Resident #3's care plan was reviewed by the director of nursing (DON) and assistant director of nursing (ADON) but no changes were noted at that time. -The comprehensive care plan did not include a care plan focus related to chronic kidney disease or diuretic medication monitoring. C. Staff interviews LPN #1 was interviewed on 9/25/24 at 9:49 a.m. LPN #1 said Resident #3 did not have any fluid restrictions. LPN #1 said Resident #3 was prescribed Lasix and potassium and explained that Lasix was a diuretic medication. LPN #1 said Resident #3 had good fluid intake and drank well, so the nursing staff did not have to push more fluids for the resident but needed to monitor her for edema. LPN #1 said interventions related to Resident #3's hydration status would be found in the care plan. LPN #1 said all facility staff worked on the residents' care plans but they were primarily maintained by the ADON. The ADON was interviewed on 9/25/24 at 1:10 p.m. The ADON said she maintained the majority of residents' care plans but that the management team worked on them as well. The ADON said she had not put any specific care plan focus into any residents' comprehensive care plans for medications such as diuretics. The ADON said it was important to have a diuretic care plan because of the resident's risk of dehydration or fluid overload. The ADON said Resident #3 should also have a care plan focus for her chronic kidney disease.

Based on interviews, observations and record review, the facility failed to promote care for residents in a manner and in an environment that maintained or enhanced their dignity and respect for one (#35) of three residents reviewed for dignity out of 19 sample residents. Specifically, the facility failed to ensure Resident #35's fall intervention sensor alarm was discussed with the resident on how it made her feel. Findings include: I. Facility policy and procedure The Elder rights policy, revised 7/8/24, was provided by the nursing home administrator (NHA) on 9/25/24/at 2:53 p.m. It read in pertinent part, All elders will be treated equally regardless of age, race, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation, or gender identity or expression. The campus will ensure that all staff members are educated on the rights of elders and the responsibility of the campus to properly care for its elders. II. Resident status Resident #35, age above 65, was admitted on [DATE]. According to the September 2024 computerized physician orders (CPO), diagnosis included unspecified dementia, abnormal posture, insomnia, repeated falls and abnormal weight loss. The 6/30/24 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairments with a brief interview for mental status score (BIMS) of 11 out of 15. She had no behaviors and did not reject care. She used a walker and a wheelchair. She required assistance with transfers and moving between surfaces. She was able to propel herself in her wheelchair and reposition herself in bed. She was always continent of bowels and bladder. She had two or more falls with injury since admission. A motion sensor alarm was used daily. III. Resident interviews Resident #35 was interviewed on 9/23/23 at 10:04 a.m. She said she felt like she was treated differently than the other residents. She said the facility used an alarm to track her movements which restricted her movements. She said when she tried to reposition herself in bed, the alarms would activate. She said she would stop moving around or have to crawl between the touch call lights that were on her bed. She said there were also two motion sensor alarms, one at the foot of the bed and one on the other side of the room that would activate when she placed her feet on the ground. She said no one had ever asked her how the alarms made her feel. She said everyone in the house knew when she was moving around. Resident #21 was interviewed on 9/25/24 at 11:49 a.m. Resident #21 said the jingle that was heard throughout the house, was Resident #35's motion sensor alarm notifying everyone that she was moving. She said staff would immediately respond to the alarm. IV. Observations On 9/23/24 at 10:00 a.m. observations of Resident #35's room revealed she had two motion sensor alarms. One at the foot of the bed and one across from the bed. On 9/24/24 at 9:34 a.m. Resident #35 was observed sitting in the common area in a recliner watching television. Two push call lights were observed. One on top of each arm of the chair. The resident tried to reposition herself and the push call light, on the right arm of the chair, fell off and activated. Staff immediately responded and asked her if she needed anything. V. Record review The September 2024 CPO revealed the resident had an order to monitor the motion sensor for proper placement and functioning every day and night shift for motion sensor use, ordered on 8/14/24. An incident note, dated 3/4/24 at 10:21 a.m., documented a motion sensor alarm was placed in Resident #35's room to alert staff when she was attempting to get up. A health status noted, dated 6/4/24 at 3:30 a.m., documented Resident #35 was restless most of the night as evidence of the motion sensor alarming frequently throughout the night When staff entered the room to ask how she was or what she needed, the resident was either quiet with no response or when asked if she was alright she responded yes. A behavior note, dated 6/20/24 at 1:00 a.m., documented Resident #35 was fidgety and up to the toilet four times since going to bed and the sensor alarm rang often throughout the night. A behavior note, dated 8/25/24 at 12:04 a.m,. documented Resident #35 had been restless as evidence of the sensor alarm chiming frequently since the resident went to bed at 6:30 p.m. VI. Staff interviews Certified nurse aide (CNA) #4 was interviewed on 9/24/24 at 9:49 a.m. CNA #4 said she did not know why Resident #35 had two touch call lights and was not aware of a motion sensor alarm. She said she usually worked in a different house. CNA #5 was interviewed on 9/24/24 at 10:05 a.m. CNA #5 said Resident #35's motion alarm was used to notify the staff that she was attempting to get out of her bed, wheelchair or recliner. She said the alarm was audible for everyone to hear. She said the alarm sounded in the common area of the facility. She said she did not feel the motion alarm was very effective. The director of nursing (DON) was interviewed on 9/25/24 at 10:47 a.m. The DON said Resident #35 was a difficult resident to keep free from falling. She said the facility had placed the two push call lights near the resident. She said the resident would climb around them. She said the facility then decided to place the two motion sensors along with the push call lights in the resident's room. She said the resident was able to climb around the motion sensors as well. She said the alarms were activated frequently due to the resident putting her feet on the ground or bumping the push call lights when moving. The DON said she was not aware of how the alarms affected the resident or made her feel. She said she never asked her. She said the social services director (SSD) may have spoken with her but she was not sure. She said she would speak with the resident about how it made her feel and figure out something different. The NHA was interviewed on 9/25/24 at 11:26 a.m. The NHA said she was not aware of how the motion alarms made the resident feel. She said she had never asked her. She said when the facility first decided to use the motion sensor alarm the resident was willing to try them. The NHA said they had never reassessed how the resident felt about the alarms. The SSD was interviewed on 9/25/24 at 1:22 p.m. The SSD said she was not involved with the initiation of the motion sensor alarms and had not interviewed Resident #35 on how she felt.

Based on record review and interviews, the facility failed to ensure drug regimens were free from unnecessary medications for one (#38) of five residents reviewed for unnecessary medications out of 19 sample residents. Specifically, the facility failed to ensure Resident #38 was adequately monitored and side effects were documented for the use of an anticoagulant medication. Findings include: I. Facility policy and procedure The Anticoagulant policy, revised 8/24/24, was provided by the nursing home administrator (NHA) on 9/25/24 at 2:53 p.m. It read in pertinent part, As part of the initial assessment, the physician and staff will identify individuals who are currently anticoagulated. For example, those with a recent history of deep vein thrombosis (DVT), or heart valve replacement, atrial fibrillation or those who have had recent joint replacement surgery. Assess for any signs or symptoms related to adverse drug reactions due to the medication alone or in combination with other medications. Assess for evidence of effects related to the subtherapeutic or greater than therapeutic drug level related to that particular drug (for example, a resident with an above therapeutic level of an anticoagulation medication should be assessed for bleeding). The staff and physician will monitor for possible complications in individuals who are being anticoagulated, and will manage related problems. If an individual on anticoagulation therapy shows signs of excessive bruising, hematuria, hemoptysis (bleeding from the mouth), or other evidence of bleeding, the nurse will discuss the situation with the physician before giving the next scheduled dose of anticoagulant. The physician will order measures to address any complications, including holding or discontinuing the anticoagulant as indicated. II. Resident #38 A. Resident status Resident #38, age greater than 65, was admitted on [DATE]. According to the September 2024 computerized physician orders (CPO), diagnoses included atrial fibrillation (irregular heartbeat), gross hematuria (blood in the urine), personal history of other venous (vein) thrombosis (blood clot) and embolism (blockage inside a blood vessel), cardiac murmur and long term current use of anticoagulants. The 9/1/24 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score (BIMS) score of six out of 10. She required moderate assistance with bathing, repositioning, dressing, personal hygiene, transfers and toilet use. The assessment indicated the resident received an anticoagulant medication daily. B. Record review The September 2024 CPO revealed the resident had a physician's order for Eliquis (a blood thinner) 5 mg (milligrams) twice a day with a start date of 7/10/24. -There was no care plan addressing the use of the anticoagulant medication or its side effects. Cross reference F656 for failure to have a care plan for the use of an anticoagulant medication. III. Staff interviews Licensed practical nurse (LPN) #2 was interviewed on 9/24/24 at 1:41 p.m. LPN #2 said the nurses should be monitoring for side effects of the anticoagulant medication, such as increased bleeding or a change in cognition. She said she could not remember the other signs to monitor for when a resident was on an anticoagulant medication. The director of nursing (DON) was interviewed on 9/25/24 at 10:47 a.m. The DON said the care plan should include watching for signs and symptoms of side effects related to anticoagulant medication use, such as excessive bruising, excessive bleeding and blood in the urine and stool. She said it was very important to monitor for these side effects, especially if the resident was scheduled for surgery. The DON said she would immediately ensure Resident #38 was being monitored for possible side effects or complications related to the use of the anticoagulant medication. The NHA was interviewed on 9/25/24 at 11:21 a.m. The NHA said an anticoagulant was a significant medication with risk factors and needed a reason for use. She said the care plan should address the monitoring of side effects or complications. She said there should be a physician's order to monitor the resident for side effects and/or complications related to the use of an anticoagulant medication.

Based on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of infectious diseases. Specifically, the facility failed to ensure nursing staff followed proper infection control procedures for a resident on enhanced barrier precautions (EBP). Findings include: I. Professional reference The Centers for Disease Control and Prevention (CDC) Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) (4/2/24), was retrieved on 9/26/24 from https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html. It read in pertinent part, Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. EBP may be indicated (when contact precautions do not otherwise apply) for residents with wounds or indwelling medical devices, regardless of MDRO colonization status. II. Facility policy and procedure The Infection Prevention and Control Program policy, revised 8/12/24, was received from the nursing home administrator (NHA) on 9/25/24 at 2:50 p.m. It read in pertinent part, The designated infection preventionist serves as a consultant to our staff on infectious diseases, elder room placement, implementing of isolation precautions, staff and elder exposures, surveillance, and epidemiological investigations of exposures of infectious diseases. Staff shall use personal protective care equipment (PPE) according to established campus policy governing the use of PPE. -The policy did not include specifics for EBP. III. Resident interview Resident #29 was interviewed on 9/24/24 at 2:29 p.m. Resident #29 said he had a urinary catheter. Resident #29 said the nursing staff helped him with his catheter care by emptying his catheter bag whenever he needed it and switching from a night bag to a leg bag each morning. Resident #29 said the nursing staff only wore gloves when they helped him perform catheter care. Resident #29 said he had not seen the nursing staff wear gowns while helping him perform catheter care. IV. Observations On 9/23/24 at 10:06 a.m. there was no PPE observed in or outside Resident #29's room. On 9/24/24 at 2:29 p.m. there was no PPE observed in or outside Resident #29's room. V. Record review The incontinence care plan, revised 9/14/23, revealed Resident #29 had a urinary catheter in place. Pertinent interventions included changing Resident #29's catheter as needed, cleansing the catheter daily, and assisting Resident #29 with emptying his catheter bag and catheter care every shift and as needed. -Review of the resident's electronic medical record (EMR) did not reveal any information regarding the use of EBP or PPE while performing care. VI. Staff interviews Certified nurses aide (CNA) #6 was interviewed on 9/24/24 at 3:05 p.m. CNA #6 said the nursing staff helped Resident #29 with his urinary catheter, which included switching from his night bag to his leg bag, cleaning the bag, changing his urinary catheter, and helping Resident #29 dress his bottom half. CNA #6 said she applied gloves whenever she needed to provide catheter care for Resident #29. CNA #6 said she did not wear a gown or any other PPE while providing catheter care. Licensed practical nurse (LPN) #1 was interviewed on 9/25/24 at 9:49 a.m. LPN #1 was not sure what EBP entailed. LPN #1 said for urinary catheter care she only needed to wear gloves. LPN #1 said if a resident had any sort of infection she would be more likely to wear PPE. LPN #1 said the CNAs helped Resident #29 change his catheter bag each morning and wiped the catheter area with alcohol. LPN #1 said the CNAs only wore gloves to perform this care but that she would advise them to wear a gown just in case any urine splattered during the process. LPN #1 said the CNAs were not required to wear a gown unless the resident had something that was contagious. The infection preventionist (IP) and the NHA were interviewed together on 9/25/24 at 1:10 p.m. The IP and NHA said did not know what EBP were or what they entailed. The IP said she did not know the nursing staff needed to wear PPE unless the resident had an infection. The IP acknowledged the facility did not have a system in place to notify if residents were on EBP.

Based on observations, record review and interviews, the facility failed to implement appropriate nutritional interventions for one (#26) out of 20 sample residents to maintain acceptable parameters of nutritional status. Resident #26, age 90, was admitted to the facility on [DATE] with diagnoses of heart failure, type 2 diabetes mellitus, chronic obstructive pulmonary disease (COPD), peripheral vascular disease, history of falling and anxiety. Resident #26 sustained a weight loss of 10.6% (20.5 lbs) from admission on 1/13/23 through 1/31/23, which was considered significant. According to Resident #26's nutrition care plan, pertinent interventions initiated 3/4/23 included to monitor, record and report to the physician as needed any signs and symptoms of malnutrition such as significant weight loss and obtain and monitor lab/diagnostic work as ordered. Report results to the physician and follow up as indicated. Resident #26's labwork, dated 2/17/23, revealed his Albumin was 2.8 (ranges 3.4-5) indicating it was low. Review of the physician progress notes revealed no documentation of the resident's significant weight loss and poor nutritional status. There was no documentation on expected or unplanned weight loss, or updated care plan goals and interventions. The dental care plan was initiated on 2/22/23 (six weeks after Resident #26 admission) revealed he was edentulous and chose not to wear dentures. Pertinent interventions included to consult with the dietitian and change the resident's diet (regular diet) if chewing/swallowing problems were noted; encourage to eat meals, and observe for any difficulty with chewing and swallowing. Findings include: I. Facility policy and procedure The Weight Monitoring Policy, dated October 2022, was provided by the nursing home administrator (NHA) on 5/17/23 at 2:48 p.m. The policy read in pertinent part, Based on resident's comprehensive assessment, the facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident's preferences indicate otherwise. The facility will utilize a systemic approach to optimize a resident's nutritional status. This process includes: a. Identifying and assessing each resident's nutritional status and risk factors b. Evaluating/analyzing the assessment information c. Developing and consistently implementing pertinent approaches d. Monitoring the effectiveness of interventions and revising them as necessary Documentation: a. The physician should be informed of a significant change in weight and may order nutritional interventions b. The physician should be encouraged to document the diagnosis or clinical conditions that may be contributing to the weight loss c. Meal consumption information should be recorded and may be referenced by the interdisciplinary care team as needed d. If the interdisciplinary care team desires to explore specific meal consumption information for a resident, the Registered Dietician, Dietary Manager, or the nursing department may initiate this process. II. Resident #26 Resident #26, age 90, was admitted on [DATE]. According to the May 2022 clinical physician orders (CPO), the diagnoses included heart failure, type 2 diabetes mellitus, chronic obstructive pulmonary disease (COPD), peripheral vascular disease, history of falling and anxiety. The 2/26/23 minimum data set (MDS) significant change in status assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score 13 out of 15. No behaviors or rejection of care were documented. He required extensive assistance of two staff with bed mobility and transfers, extensive assistance of one person with dressing, toilet use and personal hygiene and supervision with eating. He was continent. He sustained two or more falls with no injuries since admission. Section K (Swallowing/Nutrition Status) revealed the resident height was 71 inches (five foot 11 inches) and weight was 177 pounds. Loss of weight was documented as not on physician prescribed weight-loss regimen. The resident complained of difficulty with swallowing. Section L (Oral/Dental Status) documented no natural teeth. He received an antianxiety, anticoagulant, antibiotic and diuretic medications. The 1/20/23 MDS admission assessment revealed the resident's weight was 191 pounds, no weight loss and he did not complain of difficulty with swallowing. III. Resident interview and observations Resident #26 was interviewed on 5/15/23 at 2:23 p.m. He said he was not eating much because he did not have an appetite and could not chew. He said he had no teeth. Resident #26 was observed in the dining room, during the lunch meal on 5/15/23, 5/16/23 and 5/17/23. Each meal he took a few bites of food and consumed approximately 25%. Resident #26 was interviewed on 5/17/23 at 12:40 p.m. He said he was unable to chew the meat (BBQ pork rib) and had difficulty swallowing it. He said the staff did not offer him different food choices. IV. Record review A. Nutritional care plan The nutritional care plan, initiated 1/22/23, documented, Elder (resident) has unintentional weight loss. Interventions included: Invite the resident to activities that promote additional intake. Monitor/record/report to MD (physician) PRN (as needed) s/sx (signs/symptoms) of malnutrition (initiated on 3/4/23). Obtain and monitor lab/diagnostic work as ordered, report results to MD (physician) and follow up as indicated. Offer alternative meal choices as needed. Provide and serve supplements as ordered, Magic cup BID (two times a day) (initiated 3/4/23). Provide, serve diet as ordered, monitor intake and record q (every) meal. RD (registered dietitian) to evaluate and make diet change recommendation PRN (as needed). B. Dental care plan The dental care plan, initiated 2/22/23, documented, Elder is edentulous. He has dentures, but chooses not to wear them saying that he eats fine without them. Interventions included: Diet as ordered. Consult with dietitian and change if chewing/swallowing problems are noted. Encourage him to eat meals and offer snacks, observe for any difficulty with chewing and swallowing his food related to edentulous status. C. Physician orders -RCS/CC (reduced concentrated sweets/carbohydrate control) diet, regular texture; -Magic cup (nutritional ice cream supplement), two times a day for weight loss, order date 2/2/23; and, -Lasix oral tablet 80 mg (Furosemide) (diuretic), give one tablet by mouth one time a day related to heart failure. D. Resident #26's weights The Hospital Summary, dated 1/13/23, revealed the resident's weight on 1/9/23 was 94.5 kg (207.9 lbs). Resident #26 weights were documented in the medical record as follows: -On 1/13/23 the resident weighed 192 lbs (15.9 lbs difference from the hospital weight obtained the same day); -On 1/17/23 the resident weighed 182.5 lbs (9.5 lbs or 5% weight loss); -On 1/31/23 the resident weighed 171.5 lbs (20.5 lbs or 10.5% weight loss); -On 3/14/23 the resident weighed 176.7 lbs; and, -On 5/3/23 the resident weighed 176 lbs. E. Nutritional progress notes On 1/22/23 the RD documented: Attended weekly weight meeting on 1/19/23 via phone .Diet RCS/CC. Eating 56% average/day. Skin intact. Edema: none noted. No new recommendations. Continue current interventions. -The RD note did not document the weight difference from the hospital (15.9 lbs). No edema was noted with the resident being on diuretic medication. No nutritional interventions were put in place with the resident's weight loss and on average poor intake. On 1/28/23 RD documented: Attended weekly weight meeting on 1/26/23 via phone .Diet RCS/CC. Eating 54% average/day .Weight 1/24/23 182.5 lbs .Skin intact. Edema: none noted. No new recommendations. Continue current interventions. On 2/2/23 interdisciplinary team (IDT) note revealed: (Resident) is on weekly weight monitoring related to new admission with weight loss. Elder states he has difficulty swallowing at times and in the past has had his esophagus dilated. Appointments are being made regarding this. (Physician) is aware of weight loss and stools are being heme tested . His average PO (oral) intake is 46% and his average daily fluid intake is 789 ml. He accepted one snack and refused two meals. Magic cup has been ordered and elder will be offered one twice daily. Continue current interventions and weekly monitoring. On 2/4/23 RD documented: Attended weekly weight meeting on 2/2/23 via phone. Following weekly r/t (related to) new admission, weight loss. Diet RCS/CC. Eating 46% average/day . Edema: none noted. Recommendation: Magic cup BID (two times a day). Continue current interventions. -The resident had 20.5 lbs weight loss on 1/31/23 and a supplement was not offered until 2/2/23 when the resident had consistent poor intake. The resident was on diuretic medication with no edema noted in the RD documentation. On 2/23/23 IDT note revealed: (Resident) is on weekly weight monitoring related to weight loss. His average PO (oral) intake is 56% and his average daily fluid intake is 1029 ml. He accepted two snacks and did not refuse any meals .He accepted 11 out of 14 Magic Cup administrations. Continue current interventions and weekly monitoring. On 2/24/23 RD documented: Attended weekly weight meeting on 2/23/23 via phone. Following weekly weight loss. Diet: RCS/CC. Eating 56% average/day. Supplements: Magic cup BID (two times a day). Accepted 11 out of 14. Magic cup provides 260 kcal/9 gm protein per serving. Fluids: Average of 1029 ml of fluid/day from meals/supplement, plus additional water in room. Weight: 2/21/23 167 lbs. BMI: 23.3-within normal limits for height. c/o (complained of) difficulty swallowing .Edema: none noted. Recommendation: none at this time. Continue current interventions. Continue to follow weekly until weight stabilizes. -The interdisciplinary team and the RD failed to address the resident's swallowing difficulty that was noted when he was having significant weight loss. The resident was not evaluated for different food consistency, mechanical soft diet. F. Laboratory report The 2/17/23 labwork report revealed Albumin level 2.8 (low) (reference range 3.4 - 5.0) -The interdisciplinary team and the RD failed to address the resident's low Albumin level. G. Meal intakes Meal intake records/amount eaten, were reviewed for January 2023 and May 2023 revealed the documented food consumed by Resident #26 averaged approximately 50%. -However, per observations (see above) the resident ate approximately 25% for three lunch meals and per staff interviews (see below) the resident often did not eat much (25-50%) and refused at times. H. Physician notes Review of the physician notes, dated 2/16/23 and 3/21/23, revealed no documentation related to Resident #26 significant weight loss, difficulty swallowing and low Albumin level. V. Staff interviews Certified nurse aide (CNA) #1 was interviewed on 5/17/23 at 11:27 a.m. She said she knew the resident well since his admission. She said she worked with Resident #26, usually five days per week. She said the resident did not eat well at any of his meals. She said he never finished his meals and frequently he had just a few bites. She said most of his meal intake was 26% to 50% and occasionally he refused to eat. She said the resident was on a regular diet. She said the resident's weekly weights were documented on the weights sheet and given to the nurse who would record the weights in the resident's electronic medical record. CNA #2 was interviewed on 5/17/23 at 12:43 p.m. She said she worked with the resident since his admission and knew him well. She said the resident was independent with eating however he did not eat much of his meals. She said the resident ate very little, he liked sweets. She said she was not aware the resident had difficulty swallowing his food. The NHA and the director of nursing (DON) were interviewed on 5/17/23 at 1:30 p.m. The NHA said the RD was a contractor not a full time employee and was coming to the facility every couple of weeks. She said the RD attended the weights meeting by calling on her phone. The DON said Resident #26 experienced a significant weight loss after his admission however his weight stabilized after a few weeks. She said the interdisciplinary team did not review the resident's medications during the weights meeting. She said the resident's physician was contacted after each meeting, however she was not aware the physician did not document the resident's significant weight change. She said the RD and the IDT were aware of Resident #26's difficulty chewing and swallowing, however she did not realize his diet texture change was not addressed as well as a swallow evaluation. She said the resident's low Albumin level was not addressed during the weights meeting and no other interventions and supplements were taken under consideration. She said she would provide staff training to ensure all residents' food intake was documented accurately. The RD was not available for an interview and did not return a phone call.

Based on observation, records review and interviews, the facility failed to adequately monitor the resident for unnecessary psychotropic medications needed to provide effective and person-centered care for one (#19) of five residents reviewed for use of psychotropic medication out of 20 sample residents. Specifically, the facility failed to for Resident #19: -Ensure staff monitored the resident for effectiveness of antidepressant medication therapy since the resident was prescribed two antidepressant medications with one being used for a diagnosis of insomnia; -Ensure staff identified depressive target behaviors; -Ensure staff accurately monitored the resident for depressive target behaviors and hours of sleep for the antidepressant being used for insomnia; and, -Ensure staff monitored the resident for her response to antidepressant medication. Findings include: I. Facility policy The Use of Psychotropic Medication, undated, was received on 5/16/23 from the nursing home administrator (NHA), which read in pertinent part: Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s). The effects of the psychotropic medications on a resident's physical, mental, and psychosocial wellbeing will be evaluated on an ongoing basis such as: -Upon physician evaluation; -During the pharmacist's monthly medication regimen review; -During MDS (minimum data set) review and; -In accordance with nurse assessment and medication monitoring parameters consistent with clinical standards of practice, manufacturer's specifications, and the resident's comprehensive plan of care. The resident's response to the medication(s), including progress towards goals and presence or absence of adverse consequences, shall be documented in the resident's medical record. II. Resident status Resident #19, age 68, was admitted on [DATE]. According to the May 2023 computerized physician orders (CPO), the resident's diagnoses included hypertension, sleep apnea, depression, anxiety and epilepsy. The 4/2/23 minimum data set (MDS) assessment revealed the resident had no cognitive impairments with a score of 15 out of 15 on the brief interview for mental status (BIMS) assessment. The resident was independent with all activities of daily living. III. Resident interview and observation Resident #19 was interviewed on 5/15/23 at 10:12 a.m. Resident #19 said she had bad depression and she felt sad a lot of the time. She said she was depressed since moving into the facility and had chronic pain. She said she took medication for depression and she had been able to see a behavioral health specialist but did not feel her depression had improved. The resident fell asleep twice while speaking during the interview. IV. Record review A review of the May 2023 computerized physician orders (CPO) revealed the resident was prescribed the following antidepressant psychotropic medications: -Venlafaxine, 100 mg twice a day, prescribed for depression on 4/13/21; -Trazodone 100 mg once a day, prescribed for insomnia on 4/10/23. -The resident was on two antidepressant medications, with Trazadone being used for insomnia. The resident's care plan dated 4/12/23 revealed the resident had depression at risk for adverse reactions to antidepressant medication. The focus area for psychotropic medications was to include interventions to monitor, document, and report as needed adverse reactions to antidepressant medications, and to monitor and document side effects and effectiveness of the antidepressant therapy every shift. The care plan documented the staff should document, report signs and symptoms of depression, including hopelessness, anxiety and sadness. -The resident's CPO failed to include orders to monitor the resident for adverse reactions to antidepressant therapy or side effects and effectiveness of the antidepressant medications. -A review of the resident's May 2023 medication and treatment records revealed there was no documented monitoring for adverse reactions, side effects or effectiveness of the antidepressant medications. In addition, the resident's hours of sleep were documented and the resident self-reported and did not include hours of sleep observed by facility staff. The NHA located a psychiatrist note signed on 4/27/23. The psychiatrist noted the resident had residual depression and recommended an increase with the Venlafaxine dosage. -There was no documentation in the medical record that indicated the psychiatrist recommendation was forwarded to the resident's physician for consideration. On 5/16/23 the NHA provided an email document sent to her from the resident's counselor on 5/16/23 at 3:52 p.m. The counselor documented on 5/9/23 the resident had returned from a doctor appointment, was sleepy and declined her appointment. The counselor documented the resident was sleeping at the table. On 5/11/23, the counselor documented the resident spoke with monosyllabic (using brief words) speech, was observed very sleepy, and the resident reported she was depressed and in a lot of pain. -There was no documentation in the medical record that indicated the counselor updated the facility staff with the resident's status. -The resident was sleepy per documentation and observations (see above), there was no review of her antidepressant medications. V. Staff interviews Licensed registered nurse (LPN) #1 was interviewed 5/16/23 at 10:30 a.m. LPN #1 said when the staff track specific behaviors for residents the information was recorded on the individual resident's medication administration record. She said staff could track, monitor and document medication side effects or adverse reactions when ordered by the physician. LPN #1 said when a resident has depression staff should monitor the resident for changes in mood. LPN #1 said she was familiar with the resident and she felt the resident was sleeping more frequently. The LPN said she was aware the resident had depression and took antidepressant medication but was unable to recall the resident's specific causes of depression but felt it might be chronic pain. The LPN said when the nurse documented hours of sleep, the number of hours was provided from the resident and recorded on the resident's medication administration record. The LPN said she thought the resident slept more hours than the resident thought, but the resident's time was self reported (not recorded by staff). The LPN said a side effect of Venlafaxine was sleepiness. The NHA and director of nursing (DON) were interviewed together on 5/17/23 at 11:45 a.m. The NHA said tracking for antidepressant medication was recorded on the resident's medication administration record. The NHA was unable to locate documentation on behavior or mood tracking for the resident or documentation the facility monitored the resident for medication effectiveness or for adverse reactions in regards to the antidepressant therapy. The NHA and DON stated they had observed the resident to have increased sleepiness. The DON stated the facility tracks hours of sleep and the documented information would be available for the physician to review during the psychotropic medication review committee.

Based on record review and interviews, the facility failed to ensure a safe environment and adequate supervision to prevent accidents for three (#3, #1 and #2) residents out of the five sample residents reviewed. Specifically, the facility failed to: -Ensure new, person centered, appropriate, and effective interventions were continuously initiated for Resident #3, #1 and #2 after each fall; -Ensure fall interventions were care planned and implemented for Resident #3, #1 and #2; and, -Ensure neurological checks were accurate and completed entirely for Resident #3, #1 and #2 when required after a fall. These failure resulted in Resident #3 having nine falls in four months, Resident #1 having 11 falls in six months and Resident #2 having four falls in four months. Findings include: I. Facility policy and procedure The Falls-Clinical Protocol policy and procedure, last revised [DATE], provided by the social worker on [DATE] at 2:15 p.m., revealed in pertinent part, For an individual who has fallen, the staff and practitioner will begin to try to identify possible causes within 24 hours of the fall. The staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling. Staff will try various relevant interventions until falling reduces or stops or until a reason is identified for its continuation. The staff and physician will monitor and document the individuals response to interventions intended to reduce falling or the consequences of falling. If interventions have been successful in fall preventions, the staff will continue with current approaches and will discuss periodically with the physician whether these measures are still needed. If the individual continues to fall, the staff and physician will re-evaluate the situation and reconsider possible reasons for the residents falling and also reconsider the current interventions. II. Resident #3 A. Resident status Resident #3, age 96, was admitted [DATE]. According to the [DATE] computerized physician orders (CPO), diagnoses included dementia without behavioral disturbances and a history of falling. The [DATE] minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of three out of 15. She required the extensive assistance of two people for her activities of daily living (ADL) including bed mobility and transferring. She had one fall with no injury and two or more falls with injury (not major) since the previous assessment. B. Record review 1. Fall risk evaluation and care plan The [DATE] fall risk evaluation revealed the resident was a high risk for falling with a score of 55. According to the evaluation, a score of ,d+[DATE] was low risk, ,d+[DATE] was moderate risk, and 45 and higher was high risk. The fall care plan, initiated [DATE], revealed the resident was at risk for falls related to deconditioning, gait and balance problems, incontinence, poor communication and comprehension and hearing problems. Interventions included: -Anticipate and meet the resident's needs; and -Be sure call light is within reach and encourage her to use it for assistance as needed. She needs prompt response to all requests for assistance. 2. [DATE] fall A [DATE] incident progress note revealed the resident was found lying on her right side on the floor next to the bed, incontinent of urine. It indicated she obtained a 4.5 centimeter (cm) by 2 cm skin tear to her right hand and 6 cm by 4 cm by 2 cm raised bump to her right forehead and first aid was provided. -It did not indicate what interventions were initiated or added to the care plan to prevent another fall. Review of the record on [DATE] revealed the fall was not reviewed by the interdisciplinary team (IDT) until [DATE] at which time a new fall risk evaluation was completed and the care plan was updated (19 days later). According to the IDT progress note on [DATE], the resident was leaning over from a sitting position on the side of her bed to pick up something on the floor and slid off of her bed. It indicated the resident was encouraged to ask for assistance. The [DATE] fall risk evaluation revealed the resident was a high risk for falling with a score of 70. The care plan was updated on [DATE] to include: Encourage the elder to ask for assistance for getting items off of the floor. The neurological checks for this fall were reviewed and revealed to be incomplete. The resident's motor and verbal responses, pupil size and reaction, and extremity strength were not assessed on [DATE] at 10:55 p.m. 3. [DATE] fall A [DATE] incident progress note revealed the resident was lying on her right side on the floor next to the bed, incontinent of urine. It indicated the resident stated she did not fall but got down on the floor to fix something on the bed even though she was not able to describe what needed fixing. -It did not indicate what interventions were initiated immediately to prevent another fall. Review of the record revealed the IDT reviewed the fall on [DATE] and updated the care plan. The [DATE] IDT progress note revealed the resident stated she did not fall but put herself on the floor to fix something. It indicated the staff would encourage the elder to ask for assistance. The care plan was updated on [DATE] to include: Encourage the resident to ask for assistance if she thinks something needs to be fixed. The [DATE] fall risk evaluation, not completed until [DATE] (after the resident had two more falls), revealed the resident was a high risk for falling with a score of 95. 4. [DATE] fall A [DATE] health status progress note revealed the resident was found lying on her right side on the floor next to her bed, incontinent of urine. It indicated the resident stated she did not fall but she was trying to go to the bathroom. She obtained a 5 cm by 2 cm bruise to her right upper extremity. It indicated a fall mat was placed beside the bed and a bolster was placed to the right side of the bed to prevent the resident from trying to get up. Review of the record revealed the IDT reviewed this fall on [DATE] (after the resident had another fall, see below) and updated the care plan. The [DATE] IDT progress note revealed the resident had fluctuating cognition, recent physical health decline and refused to allow staff to assist her at times with personal care. It indicated the staff put a fall mat next to the bed, placed an easy touch call light and added a bolster to the bed. It indicated the resident had also started working with physical therapy (PT). The care plan was updated on [DATE] to include: Easy touch call light provided and fall mat put in place. The use of the bolster was not included on the care plan. 5. [DATE] fall The [DATE] incident progress notes revealed the resident was found lying on her right side on the floor next to her bed on the fall mat after attempting to get out of bed. It indicated one of the bolsters was not on the bed. The resident had a one cm abrasion to the right back side of her head and a bruise to her right wrist. -It did not indicate what interventions were initiated to prevent another fall. The [DATE] IDT progress note for this fall revealed that when the resident was attempting to move in bed and/or sit up in bed, she used her walker (which was near the head of the bed) and bedside table to assist her in moving. It indicated a quarter side rail was to be placed to the right side of the bed for a positioning device. It also indicated the bed would be left at the lowest height that would still allow the resident to safely stand. The care plan was updated on [DATE] to include: one side rail to the right side of her bed to help with turning, sitting up and security. -The required height of the bed was not included on the care plan. The [DATE] fall risk evaluation, not completed until [DATE], revealed the resident was a high risk for falling with a score of 95. The [DATE] quarterly fall risk evaluation revealed the resident was a high risk for falling with a score of 105. 6. [DATE] fall A [DATE] health status progress note revealed the resident had an unwitnessed fall in the early morning hours with no injuries. -It did not indicate what interventions were initiated to prevent another fall. Review of the record revealed the IDT reviewed this fall on [DATE] (after the resident had another fall, see below). The IDT progress note for this fall revealed the resident was encouraged to use her call light for assist with transfers and staff were to encourage the resident to allow them to assist her with lying in the center of the bed rather than on the side of the bed where she tended to lay. -This was not added to the care plan. The neurological checks for this fall were reviewed and revealed to be incomplete. The resident's motor and verbal responses, pupil size and reaction, and extremity strength were not assessed on [DATE] at 5:00 a.m. and the resident's vital signs (pulse, respirations, temperature, blood pressure and oxygen saturation) were not assessed on [DATE] at 6 a.m. 7. [DATE] fall A [DATE] incident progress note revealed the resident was found lying in the fetal position on her left side and said she did not fall but got weak walking back from the bathroom, sat on the floor then laid down to wait. It indicated the resident was undressed from the waist down except for slipper socks and her brief and pants were found in the bathroom where the resident had voided in the toilet. -It did not indicate what interventions were initiated to prevent another fall. Review of the record revealed the IDT reviewed this fall on [DATE] and updated the care plan. The IDT progress note for this fall revealed the staff was to encourage the resident to call for assistance with transfers and place the soft touch call light beside her while in bed. The care plan was updated on [DATE] to include: Place soft touch call light near hip when in bed. The neurological checks for this fall were reviewed and revealed to be incomplete. The resident's motor and verbal responses, pupil size and reaction, and extremity strength were not assessed on [DATE] at 1:35 p.m. due to the resident sleeping (less than five hours after the resident had an unwitnessed fall) and were not completed on [DATE] at 6:00 p.m. 8. [DATE] fall A [DATE] incident progress note revealed the resident was found sitting on the floor on the fall mat next to her bed. It indicated the resident was reminded to use her call light and was positioned from the edge of the bed. Review of the record revealed the IDT reviewed this fall on [DATE], completed a new fall risk evaluation and updated the care plan. The [DATE] IDT progress note revealed the resident had fluctuating cognition and often overestimated her abilities. It indicated the staff would ensure the bed was in a normal height position to allow the resident to stand with less difficulty. The care plan was updated on [DATE] to include: Staff will ensure the bed is in a normal height position to allow the resident to stand with less difficulty. The [DATE] fall risk evaluation revealed the resident was a high risk for falling with a score of 90. The neurological checks for this fall were reviewed and revealed to be incomplete. The resident's motor and verbal responses, pupil size and reaction, and extremity strength were not assessed on [DATE] at 1:45 a.m. and 2:45 a.m. due to the resident sleeping (less than two and three hours after the resident had an unwitnessed fall) and were not completed on [DATE] in the morning. 9. [DATE] fall A [DATE] incident progress note revealed the resident was found on the floor on her knees on the floor mat beside the bed, unsure how or why she got there. -It did not indicate what interventions were initiated to prevent another fall. Review of the record revealed the IDT reviewed this fall on [DATE] and updated the fall risk evaluation however, no new interventions were initiated or care planned. The [DATE] IDT progress note revealed the resident often overestimated her abilities and attempted to perform her ADLs independently. It indicated she had a fall mat and the bed was being kept in the lowest appropriate position to still allow the resident to stand independently and she had an easy touch call light. The staff would anticipate the resident's needs and provide assistance as the resident would allow. The [DATE] fall risk evaluation revealed the resident was a high risk for falling with a score of 95. 10. [DATE] fall The [DATE] incident progress note revealed the resident was found sitting on the bathroom floor in front of the toilet. It indicated the resident stated she did not fall but slid herself off her bed then crawled to the bathroom hoping to find something to stand up with. It indicated the resident was encouraged to use her call bell for help as needed. Review of the record revealed this fall was reviewed by the IDT on [DATE] however no new interventions were initiated and the care plan was not updated. The [DATE] IDT progress note for this fall revealed the resident had fluctuating cognition, was resistive to care at times and had impaired balance. It indicated the staff would ensure the bed was at the proper height to allow the resident to easily stand and would continue the use of the easy touch call light placed near the resident while in bed. The facilities failures to implement person centered care plan for Resident #3 who continued to fall while residing at the facility between the dates of [DATE] and [DATE] totalling nine falls. Four of the falls indicated the resident was found to be incontinent of urine or relating to the bathroom. The facility failed to implement appropriate interventions for a resident who had a BIMS score of three out of 15 to anticipate the residents needs. III. Resident #1 A. Resident status Resident #1, age 85, was admitted on [DATE] and expired at the facility on [DATE]. According to the [DATE] CPO, diagnoses included dementia with behavioral disturbance, anxiety, reduced mobility and repeated falls. The [DATE] MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of two out of 15. She required extensive assistance of one person for her ADLs. The resident had two or more falls with no injury and two or more falls with injury (not major) since the previous assessment. B. Record review 1. Fall risk evaluation and care plan The fall care plan, initiated [DATE], revealed the resident was at risk for falls related to confusion, gait and balance problems, incontinence, psychoactive drug use and wandering. Interventions included: -Anticipate and meet the resident's needs; -Be sure call light is within reach and encourage her to use it for assistance as needed. She needs prompt response to all requests for assistance; -Dycem (non-slip mat) placed in recliner; -Encourage the resident to not utilize recliner footrest while in recliner. Assist her to place feet on wheelchair or other object for elevation; -Ensure that the resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair; -Fall mat next to the bed; -Place bed in lowest position. Low bed in use; -Self-locking brakes placed on wheelchair; -Winged mattress; and, -Monitor the resident's whereabouts. The [DATE] fall risk evaluation revealed the resident was a high risk for falling with a score of 55. 2. [DATE] fall A [DATE] health status progress note revealed the resident was found sitting on the floor in her room in front of her wheelchair with no injuries. It indicated she was taken into the hearth area to watch television. Review of the record revealed the IDT reviewed this fall on [DATE] and completed a new fall risk evaluation, however the care plan was not updated with any new interventions. The [DATE] IDT progress note revealed the fall mat was in place next to the bed and the resident stated she stumbled. It indicated an order for physical therapy (PT) to evaluate would be obtained, a merry walker would be attempted for the resident to be more independent with ambulation and the staff was to remove the fall mat when the resident was not in bed. -There was no documentation to indicate a PT evaluation had been completed or the merry walker use being attempted. -Removing the fall mat when the resident was not in bed was not added to the care plan until [DATE]. The [DATE] fall risk evaluation revealed the resident was a high risk for falling with a score of 55. The neurological checks for this fall were reviewed and revealed to be incomplete. The resident's motor and verbal responses, pupil size and reaction, extremity strength and vital signs were not assessed on [DATE] at 8:15 p.m. due to the resident sleeping (only seven hours after the resident had an unwitnessed fall) and vital signs were not completed on [DATE] at 4:15 a.m. 3. [DATE] fall A [DATE] health status progress note revealed the resident was found on the floor in the fetal position on her left side in the middle of her room with no injuries. -It did not indicate what interventions were initiated immediately to prevent another fall. A [DATE] IDT progress note revealed the pharmacy was alerted to the fall and a complete medication review was requested. A [DATE] pharmacy progress note revealed the resident was on three medications, [MEDICATION(S)] (supplement used for sleep), [MEDICATION(S)] used for urinary incontinence) and [MEDICATION(S)] (blood pressure/cardiac medication), that should be discontinued or reduced to a minimal effective dose to reduce the fall risk from side effects of dizziness and drowsiness. A [DATE] pharmacy progress note revealed the medication review was sent to the primary care physician (PCP). Review of the record revealed the IDT reviewed this fall on [DATE] and completed a new fall risk evaluation but did not update the care plan with any new interventions to prevent another fall. The [DATE] IDT progress notes revealed the resident was found on the floor in her room in the fetal position on her left side. It indicated the resident had no recent falls from bed following the placement of the winged mattress to the fall mat was to be removed from the room at that time. -The care plan was not updated with this information. The [DATE] fall risk evaluation revealed the resident was a high risk for falling with a score of 65. A [DATE] physician progress note revealed the physician was recommending discontinuing the [MEDICATION(S)] if the resident's daughter was in agreement. A [DATE] response to the physician recommendation revealed the daughter wanted the resident to continue to take the [MEDICATION(S)]. It indicated the daughter stated the medication was not the reason the resident was falling, it was because she was getting stronger and the daughter felt the facility did not provide enough supervision for the resident. 4. [DATE] fall A [DATE] incident progress note revealed the resident was found sitting on the floor in the kitchen in front of the hand washing sink with her back against the cabinets and both legs stretched out in front of her. It indicated she had a 0.5 cm skin tear to her right upper arm, a one cm skin tear to her left elbow, a 3 cm by 1.5 cm faint bruise to her right forearm, a 5 cm by 3 cm bruise with a small 1.0 cm skin tear and another 0.5 cm skin tear within the bruise to her left lower leg. -It did not indicate what interventions were initiated to prevent another fall. Review of the record revealed the IDT reviewed this fall on [DATE] (after the resident had another fall, see below) and completed a new fall risk evaluation. -No new interventions were initiated or care planned. The [DATE] IDT progress note revealed the resident had attempted to pick up something off the floor, lost her balance and fell back. It indicated the staff monitored the whereabouts of the resident frequently. -No new interventions were recommended and the care plan was not updated. The [DATE] fall risk evaluation revealed the resident was a high risk for falling with a score of 55. 5. [DATE] fall A [DATE] health status progress note revealed the resident was found on the floor with her knees bent and sitting on her heels in front of and facing the recliner in the hearth area with no injuries. It indicated the resident stated she put herself down there. -It did not indicate what interventions were initiated to prevent another fall. Review of the record revealed the IDT reviewed this fall on [DATE] and completed a new fall risk evaluation. -The care plan was not updated. The [DATE] IDT progress note revealed the resident was found on the floor in the hearth area after being seen getting out of her chair and crawling on the floor to another chair and crouching behind it watching staff, having delusions of military experiences. It indicated the resident was being transferred to a behavioral health unit due to having delusions. Review of the record revealed the resident was discharged to a behavior health unit from [DATE] until [DATE]. 6. [DATE] fall A [DATE] incident progress note revealed the resident was found on the floor beside the dining room table and counter after slipping out of her wheelchair. It indicated the resident stated she was looking for her horse. -It did not indicate what interventions were initiated to prevent another fall. Review of the record revealed the IDT reviewed this fall on [DATE], completed a new fall risk evaluation and updated the care plan. The [DATE] IDT progress note revealed the resident had a fall in the dining room after she removed her shoes and placed them on the floor then was bending over to pick up something off the floor when her wheelchair tipped, startled her, causing her to fall. It indicated the wheelchair brakes would be evaluated and adjusted if needed and the wheelchair would also be evaluated for proper stability. It also indicated the staff were to be encouraged to be aware of what television shows were on that had the potential for sudden loud noises. The care plan was updated on [DATE] to include: evaluate wheelchair brakes and wheelchair stability as needed and be aware of shows on TV with potential for sudden, loud noises. The [DATE] fall risk evaluation revealed the resident was a high risk for falling with a score of 55. 7. [DATE] fall A [DATE] health status progress note revealed the resident was found sitting in front of her wheelchair in the dining area stating she was trying to go somewhere but was unable to say where but later stated she had to pee real bad. It indicated the resident had a 4.5 cm by 1.0 cm skin tear to her left forearm, a 1.0 cm by 1.0 cm abrasion to her left knee and a fluid filled area to her left elbow. -It did not indicate what interventions were initiated to prevent another fall. -Review of the record revealed no neurological checks were completed for this fall. The nursing home administrator (NHA) confirmed on [DATE] at 3:00 p.m. that neurological checks for [DATE] for Resident #1 could not be located. Review of the record revealed the IDT reviewed this fall on [DATE], completed a new fall risk evaluation and updated the care plan. The [DATE] IDT progress note revealed the resident was found on the floor in the dining area in front of her wheelchair and had stated later after the fall that she needed to go to the bathroom. It indicated the resident was working with physical and occupation therapies and the resident was to be placed on an every two hour toileting schedule. The [DATE] fall risk evaluation revealed the resident was a high risk for falling with a score of 55. The care plan was updated on [DATE] to include: Every two to three hour toileting. 8. [DATE] fall A [DATE] incident progress note revealed the resident was found sitting on the floor next to her wheelchair and bed with no injuries. -It did not indicate what interventions were initiated to prevent another fall. Review of the record revealed the IDT reviewed this fall on [DATE], completed a new fall risk evaluation and updated the care plan. The [DATE] IDT progress note revealed the resident was found sitting in her room on the floor next to her wheelchair and bed. It indicated she was on an every two hour toileting schedule with frequent monitoring and interaction with staff and was to be moved to a different room in a different house. The care plan was updated on [DATE] to include: move to Homestead house and fall mat next to bed to be removed when not in bed. The [DATE] fall risk evaluation revealed the resident was a high fall risk with a score of 55. The neurological checks for this fall were reviewed and revealed to be incomplete. The resident's motor and verbal responses, pupil size and reaction, extremity strength and vital signs were not assessed on [DATE] at 11:55 p.m. and [DATE] at 1:55 a.m. due to the resident sleeping (less than five and seven hours after the resident had an unwitnessed fall) and vital signs were not completed on [DATE] at 6:00 p.m. and no assessment was completed on [DATE] at 6:00 a.m. 9. [DATE] fall A [DATE] incident progress note revealed the resident was on the floor on her hands and knees picking up a cell phone with no injuries. A [DATE] IDT progress note revealed the resident was found on her hands and knees on the floor under the table and has stated she was picking up the cell phone that another resident had dropped. It indicated the staff was to keep the floor swept to decrease the resident's temptations to bend over and/or take self out of her wheelchair to pick up the item. The care plan was updated on [DATE] to include: Staff will keep the floor swept to decrease the temptation of the resident to bend over and/or take herself out of the chair to pick up. The [DATE] fall risk evaluation revealed the resident was a high fall risk with a score of 75. 10. [DATE] fall A [DATE] incident progress note revealed the resident stood up from her wheelchair and fell on to her right knee then to her left side. It indicated the fall was witnessed and the resident did not hit her head. -It did not indicate what interventions were initiated to prevent another fall. Review of the record revealed the IDT reviewed this fall on [DATE], completed a new fall risk assessment but did not update the care plan. The [DATE] IDT progress note revealed the resident had a witnessed fall as she stood from her wheelchair and fell . It indicated the anti-roll back brakes would be assessed for appropriate tightness. -There was no documentation the brakes had been checked. The [DATE] fall risk evaluation revealed the resident was a high fall risk with a score of 75. 11. [DATE] fall A [DATE] incident progress note revealed the resident was found sitting on the floor on her left side after attempting to walk and stating she was going home. It indicated the resident had a 0.5 cm skin tear to her right and left elbows. -It did not indicate what interventions were initiated to prevent another fall. Review of the record revealed the IDT reviewed this fall on [DATE], completed a new fall risk evaluation and updated the care plan. The [DATE] IDT progress note revealed the resident was found lying on her left side in the dining room after previously being in her wheelchair stating she was going home. It indicated a trial of a different wheelchair cushion and wheelchair, if needed, would be completed. -There was no documentation of a new wheelchair cushion or wheelchair being trialed and the results of the trial. The care plan was updated on [DATE] to include: trial of new wheelchair cushion. The [DATE] fall risk evaluation revealed the resident was a high risk for falling with a score of 55. The neurological checks for this fall were reviewed and revealed to be incomplete. The resident's motor and verbal responses, pupil size and reaction, extremity strength were not completed on [DATE] at 3:15 p.m. or 5:15 p.m. and on [DATE] during the day shift. The resident's motor and verbal responses, pupil size and reaction, extremity strength and vital signs were not assessed on [DATE] at 9:15 p.m. due to the resident sleeping (less than twelve after the resident had an unwitnessed fall) and no assessment was completed on [DATE] at 1:15 a.m. and [DATE] day shift. 12. [DATE] fall A [DATE] health status progress note revealed the staff found the resident lying on the floor when she was trying to go to the bathroom and lost her balance. -It did not indicate what interventions were initiated to prevent another fall. Review of the record revealed the IDT reviewed this fall on [DATE], completed a new fall risk evaluation and updated the care plan. The [DATE] IDT progress note revealed the resident was found on the floor in her bedroom with no injuries. It indicated a low bed was in use and the resident was encouraged to wear gripper socks and accept a snack prior to bed. The care plan was updated on [DATE] to include: Encourage the resident to accept a snack prior to bed. The [DATE] fall risk evaluation revealed the resident was a high risk for falling with a score of 75. IV. Resident #2 A. Resident status Resident #2, age 94, was admitted on [DATE]. According to the [DATE] CPO, diagnoses included traumatic brain injury (TBI), dementia without behaviors, abnormalities of gait and mobility and history of falling. The [DATE] MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of two out of 15. She required the extensive assistance of one person to transfer and supervision with one person physical assistance for walking in her room and corridor and with locomotion on the unit. The resident had one fall without injury since the previous assessment. B. Record review 1. Fall risk and care plan The [DATE] fall risk evaluation revealed the resident was a high risk for falling with a score of 90. The fall care plan, revised [DATE], revealed the resident was at risk for falls related to gait and balance problems, incontinence, history of falls, history of TBI, use of antidepressant medication, dementia without behavioral disturbance and lumbar wedge compression fracture. Interventions included: -Anticipate and meet the resident's needs; -Be sure call light is within reach and encourage her to use it for assistance as needed. The resident needs prompt response to all requests for assistance; -Ensure resident is wearing appropriate footwear when ambulating; -Ensure walker is within reach; -She needs a safe environment with even floors, free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night and personal items within reach; -Keep bed in lowest position while in bed; and -Monitor placement of recliner control when the resident is in recliner. 2. [DATE] fall An [DATE] incident progress note revealed the resident was found on the floor in her bathroom with her pants down, leaning against her walker behind her with her feet towards the toilet with no injuries. It indicated the resident was assisted up onto the shower chair and then

Based on record review and interviews, the facility failed to ensure individuals with a finding entered into the State nurse registry concerning abuse, neglect, exploitation, mistreatment of [REDACTED]. Specifically, the facility failed to ensure residents were free from employee negligence by employing LPN #5 with a known history of negligence entered into the State nurse registry. Cross reference: F690 (Catheters), the facility failed to follow physician's orders [REDACTED].#4. Findings include: I. Facility policy and procedure The Background Screening policy and procedure, not dated, was provided by the nursing home administrator (NHA) on 11/21/19 at 1:10 p.m. It revealed, in pertinent part, Our campus conducts employment background screening checks, reference checks and criminal conviction investigation checks on direct access employees. For any licensed professional applying for a position that may involve direct contact with elders, his/her respective licensing board will be contacted to determine if any sanctions have been assessed against the applicant's license. Should the background investigation disclose any misrepresentation on the application form or information indicating that the individual has been convicted of abuse, neglect, mistreatment of [REDACTED]. [NAME] Record review Licensed practical nurse (LPN) #5 employee record was reviewed on 11/20/19 at 9:00 a.m. It revealed LPN #5 was initially hired in (MONTH) (YEAR), left employment shortly after being hired and was hired again by the facility in (MONTH) 2019. The (MONTH) (YEAR) hire records for LPN #5 indicated the resident had a nursing license with the State of Wyoming. The Wyoming license verification, pulled on 3/8/18 at 3:16 p.m. revealed action was taken against LPN #5 for negligence, patient neglect, unprofessional conduct and substandard or inadequate care. B. Staff interviews The director of nursing (DON) was interviewed on 11/20/19 at 10:03 a.m. She said LPN #5 was hired by the facility for a short time in (MONTH) (YEAR). She said LPN #5 left shortly after she was hired because of a family concern. She said the facility conducted a background check and license verification on 3/8/18. She confirmed LPN #5 had action taken against her license for negligence, patient neglect, unprofessional conduct and substandard or inadequate care. She said LPN #5 had applied to work at the facility in (MONTH) 2019. She said she was hired, however was not put on the schedule until (MONTH) 2019. She said LPN #5 had to move before she was available to work. She said the facility conducted a license check of LPN #5 for the State of Colorado. She said when the facility ran the license check, it came back clear. She said following the incident with Resident #4, the facility ran another license check. She said the license check came back suspended as of 9/28/19. She said she was informed by the board of nursing, LPN #5 had falsified her application and did not indicate any criminal charges in her history. She said she was not sure of the details surrounding the criminal charges. She said the facility background check had not indicated any criminal charges. She said when a staff member left the facility, she would indicate on their employment record whether the staff member was rehirable. She said she was unable to locate documentation to show if the staff member was rehirable from her previous employment in (MONTH) (YEAR). She said she was not aware, when she made the decision to rehire LPN #5 of the history on her Wyoming nursing license. She confirmed the license check was present in the employee file. She said she did not read LPN #5 employee file in its entirety. The NHA was interviewed on 11/20/19 at 10:30 a.m. She confirmed the facility was aware of the action against LPN #5 State of Wyoming nursing license. She said LPN #5 had met the stipulations on her license. She confirmed the facility re-hired LPN #5 with knowledge she had action against her State of Wyoming license for negligence, patient neglect, unprofessional conduct and substandard or inadequate care.

Based on observations, record review and interview, the facility failed to ensure the environment remained as free of accident hazards as possible and provide adequate supervision and assistance devices to prevent accidents for three (#18, #23, #34 and #36) of ten residents reviewed for falls out of 26 sample residents. Specifically, the facility failed to: -Implement care planned fall interventions for Resident #18 and the resident fell 25 times within a five month time frame and as a result some of the falls resulted in major injuries, such as a [MEDICAL CONDITION], pelvis and bruising to the head. -Ensure a consent was obtained for a wanderguard for Resident #23. -Ensure interventions were put into place following falls for Residents #10, #12 and #36. Findings include: I. Facility policy and procedure The Fall Risk Assessment policy was provided by the nursing home administrator (NHA) on 11/21/19 at 1:10 p.m. It read in pertinent part, The nursing staff, attending physician and pharmacist will review medications that relate to fall risk, the attending physician and nursing staff will evaluate the signs vital signs a dhn assess the medical condition or sensory impairments that may predispose to falls, assessment will be used to identify underlying medical conditions that may increase falls the staff and attending physician will evaluate functional and psychological factors that may increase falls, the staff and attending physician will collaborate to identify and address modifiable risk factors and intervention to try to minimize the consequences of risk factors that are not modifiable. II. Resident #18's [NAME] Resident status Resident #18, age 83 ,was admitted on [DATE]. According to the computerized physicians orders (CPO) [DIAGNOSES REDACTED]. The 9/22/19 minimum data set (MDS) assessment the resident was severely cognitively impaired with a brief interview for mental status (BIMS) score of six out of 15. The resident required extensive assistance with bed mobility, transfers, dressing, toileting, personal hygiene and bathing. She required supervision with eating.The resident had two falls with no injuries, two falls with minor injuries and two falls with major injuries. B. Observations On 11/18/19 at approximately 12:00 p.m the resident was sitting in a recliner in front of the television in the common area. She attempted to climb over the left arm rest of the recliner. A staff member assisted her back into a sitting position. C. Record review The nurses notes, interdisciplinary team (IDT) notes, and care plan were reviewed. The nurses notes documented the resident had fallen at least 25 times between 6/6/19 and 11/14/19. Some of the falls resulted in major injuries. -On 8/25/19 at 6:55 a.m. the resident fell in her room. She complained of a headache and left arm pain. She was taken to the emergency room by her daughter and had sustained a displaced fracture to the left clavicle. The interdisciplinary note dated 8/26/19 documented the resident fell in her room. She was found on her buttocks between the wall and heater unit. She prefers to be independent with care and staff attempts to anticipate care. Staff will continue to attempt to anticipate needs.The care plan was updated on 8/30/19 to include adding self locking brakes on the wheelchair. The resident had not been documented to fall from the wheelchair on 8/25/19. The facility failed to determine the root cause and implement effective interventions. There were no other interventions added. This was the residents eighth fall. -On 9/9/19 the resident fell twice. She fell at 9:45am in the lobby. She had climbed out of a recliner. At 2:00 p.m. she fell in her room. On 9/10/19 the resident complained of right hip pain. The daughter took her to the emergency room . The x-ray results confirmed a [MEDICAL CONDITION] pubic ramus. The interdisciplinary notes were dated 9/13/19, four days after the falls. The IDT note indicated the resident was to be encouraged to be in the lobby area. However, the resident fell while in the lobby area. There were no specific instructions for when she is to be in the lobby or how often to check her. She had a recent decrease in antidepressant therapy. The care plan was updated on 9/19/19 to include, monitor residents whereabouts.There were no other specific interventions added. This was the residents 12th and 13th falls. -On 11/13/19 she fell on the floor in the dining room and obtained bruising to the right side of her face.The interdisciplinary note was requested and not received. The care plan was last updated 9/30/19. There were no new interventions related to this fall. There was no root cause determination or new effective interventions put in place. The IDT note on 11/20/19 documented to continue to anticipate needs. This was the 24th time the resident had fallen. The care plan was written on 5/17/19. In total it was only updated three times after 25 falls. The care plan interventions included: be sure the call light is within reach, encourage resident to ask for assistance, dycem (non skid pad) to recliner (9/30/19), educate resident family and caregivers about safety reminders and what to do if a fall occurs, RN to assess the resident after falls, ensure the resident is wearing appropriate footwear, fallow facility fall protocol, monitor residents whereabouts (9/16/19), review post fall and attempt to determine the cause, self locking brakes on wheelchair (8/30/19). All except three of these interventions were initiated 5/1719, before the falls with major injury. A physician's note dated 10/7/19 documented the residents daughter had asked to speak with her because the facility staff had told the daughter that her mother needed to be placed in another facility due to her increased needs. The physician note further documented she would be ordering physical therapy for the resident and if that wasn't possible she would ask the staff to start walking her. She further documented the resident had gotten worse since admission and had a [MEDICAL CONDITION] and right pubic ramus. D. Interviews Licensed practical nurse (LPN) # 3 was interviewed on 11/20/19 at 2:30 p.m. regarding fall interventions in place for Resident #18. She said we tried to keep her busy, but she was quick and would fall as soon as you looked away. Certified nurse aide (CNA) #9 was interviewed on 11/29/19 at 2:45 p.m. regarding fall interventions for Resident #18. She said the resident use to have a walker but did not use it correctly and use to drag it behind her. She doesn't walk anymore because her balance was not good. CNA # 8 was interviewed on 11/20/19 at 2:53 p.m., said we have tried to keep an eye on her and walk her if she was agitated. The director of nursing (DON), nursing home administrator (NHA) and LPN # 1 were interviewed together on 11/20/19 at 12:30 p.m. The DON said the process for falls was, the licensed nurse will do the initial evaluation of injury and notify the RN. The CNA started vital signs. Neuro checks are started to determine if the resident needed to be sent out. The nurse who was on shift at the time completed an incident report. The IDT team reviewed the incident reports every Monday, Wednesday and Friday. The IDT team includes the DON, assistant director of nursing (ADON) or nursing home administrator (NHA) dietary or social services depending on the day. There were at least three people on the committee. She said the IDT discussed interventions in place prior to fall, and they have a list of items they checked.The ADON updated the care plan after falls. The NHA said the resident has had several falls, but she was tough. She said she will stand up no matter how close we were to her. She said we do not use alarms and we do not provide one to one care She said we do not have the staffing for that. The NHA said we have asked families to come in and sit with family members. The DON said after the fall on 8/25/19 they moved her furniture around so the bed was closer to the door and decreased her [MEDICATION NAME] (antidepressant). She said the resident had returned from the emergency room with an order for [REDACTED]. She said she did not not know what new interventions were put in place, if any after the fall, hitting her head, sustaining a black eye on 11/13/19. LPN #1 said she had recently started a fall committee in 9/2019 because the falls were a real problem and increased number of falls She said they have had 99 falls since January. She said her goal was to get the falls down to five falls per month. She said the facility had 13 falls in (MONTH) but she did not know how many they had in (MONTH) or as of this date in November. She said she had a performance improvement plan as of 9/2019 that includes, obtaining staff to be on the committee, weekly meeting starting 9/19/19, look at all aspects of the fall to determine cause and have the pharmacy review the medications. The committee met on Thursdays. However, the resident fell again on 11/13/19 after the start of the performance improvement plan and fall committee. She said the IDT team did not meet until 11/20/19. There were no new interventions for this resident. Staff were to continue to anticipate needs and encourage meaningful activity. The care plan was not updated (cross reference F-657 failure to revise comprehensive care plans). II. The facility failed to ensure an RN assessment for injury was completed prior to moving a resident who had fallen [NAME] Resident #36 1. Resident status Resident #36, age 88, was admitted on [DATE] and readmitted on [DATE]. According to the (MONTH) 2019 computerized physician orders [REDACTED]. The 10/29/19 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score of three out of 15. She required extensive assistance of two people with bed mobility, dressing, toileting and personal hygiene. It indicated the resident had a fracture related to a fall prior to the resident's readmission to the facility and had hip replacement surgery. 2. Record review The fall care plan, initiated on 1/17/17 and revised on 9/13/19, revealed the resident was at risk for falls related to confusion, psychoactive drug use. It indicated the resident would get down on the floor to clean. Cross reference to F657 (Care Plan Timing and Revision) because the facility failed to revise the care plan with new interventions following falls for Resident #36. The behavior care plan, initiated on 12/6/18 and revised on 1/3/19, revealed the resident had potential to be physically aggressive related to dementia with behavioral disturbance and poor impulse control. The interventions included: when the resident becomes agitated, intervene before agitation escalates, guide away from the source of distress, engage calmly in conversation, and staff to walk away if the resident becomes aggressive. The 9/4/19 fall risk evaluation revealed the resident was a high risk for falls. It indicated the resident had a history of [REDACTED]. The 10/18/19 nursing progress note revealed the resident had a broom in one hand and a dust pan in the other hand and began chasing a certified nurse aide (CNA) wanting trash bags. The CNA asked for help from other staff, then Resident #36 lost her footing and fell to the ground, landing on her right hip. The resident asked for help up off the ground. The CNA assisted the resident off the floor to a chair prior to the registered nurse (RN) assessment for potential injury. Resident #36 sat in the chair crying and stated, they are trying to kill me and stated she could not walk when the RN entered the room. The resident continued to hold onto her right posterior hip. The physician was notified and ordered for the resident to be sent to the hospital for evaluation. Cross reference to F659 because the facility failed to ensure an RN assessment was completed timely following a fall. The 10/18/19 nursing progress note revealed the nurse received an update from the hospital. The resident was transferred to another hospital for surgery related to a right [MEDICAL CONDITION]. The 10/18/19 fall investigation revealed the resident was chasing and swinging a broom at the staff when she sustained a fall. The CNA assisted the resident off the floor and into a chair prior to the nurse arriving to assess the resident for injury. The nurse indicated the resident was very guarded to the right lower extremity, yelling and crying. The physician was notified and ordered for the resident to be sent to the hospital for an evaluation. 3. Staff interviews CNA #6 was interviewed on 11/20/19 at 2:30 p.m. She said when a resident sustained [REDACTED]. She said if the resident was not injured, then the staff should assist the resident off the floor. She said staff should never move the resident prior to the nurse assessment because they would not know if the resident had an injury and could injure the resident even more. Licensed practical nurse (LPN) #3 was interviewed on 11/21/19 at 3:05 p.m. She said when a resident sustained [REDACTED]. She said the resident should not be moved off the ground until an assessment has been completed of the resident to determine if an injury was sustained. The director of nursing (DON) and NHA were interviewed on 11/20/19 at 12:30 p.m. The DON said she was at the facility when Resident #36 sustained a fall on 10/18/19. She said she was called to the house by the LPN on duty to conduct an assessment of the resident. She said the resident was chasing a CNA with a broom. When the CNA yelled for help, the resident lost her footing and fell to the ground on her right side. She said the CNA assisted the resident off the floor prior to her arriving to the house to perform an assessment of the resident. She said staff should never move a resident after a fall unless the RN has completed an assessment and determined the resident did not sustain an injury. 4. Facility provided information The DON provided a document which indicated the two CNAs on shift during the resident's fall on 10/18/19 had been provided education that the nurse was required to conduct an assessment of the resident for potential injury prior to assisting the resident off the floor. The document did not have a date to indicate when the education had been provided to the CNAs. III. The facility failed to ensure consents were obtained prior to the use of a wanderguard [NAME] Facility policy The Wandering and Elopements policy, revised (MONTH) 2019, was provided by the nursing home administrator (NHA) on 11/21/19 at 1:10 p.m. It documented in pertinent part: -The facility would identify residents who were at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. -If identified as at risk for wandering, elopement, or other safety issues, the residents care plan would include strategies and interventions to maintain the resident's safety. B. Resident #34 status Resident #34, age 53, was admitted on [DATE]. According to the (MONTH) 2019 CPO, the [DIAGNOSES REDACTED]. The 11/3/19 MDS assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status score of nine out of 15. She required extensive assistance of one person with bed mobility, transfers, dressing, eating, toileting and personal hygiene. It indicated the resident had not wandered during the assessment period. 1. Observations The resident was observed on 11/18/19 at 10:34 a.m. A wanderguard bracelet was observed on the resident's left wrist. 2. Record review The (MONTH) 2019 CPO revealed the following physician orders: - may use wanderguard for safety - ordered 6/27/17 - test the wanderguard functioning daily for functioning every night shift for wanderguard - ordered 7/26/17 - change the wanderguard bracelet annually and as needed every day shift every 12 months starting on the 8th for one day for monitoring of the device and as needed for safety - ordered 11/8/19. The 10/30/19 wandering assessment revealed the resident was ambulatory and had a history of [REDACTED]. The elopement care plan, initiated on 6/27/17 and revised on 1/3/19, revealed the resident was an elopement risk due to [MEDICAL CONDITION]. The 9/13/19 nursing progress note revealed the resident exited the patio and just made it past the threshold when the staff were able to reach the resident and provide redirection. It indicated the alarms and pagers alerted staff the resident was attempting to elope from the patio. The resident's medical record was reviewed on 11/19/19 at 12:38 p.m. It did not reveal a consent for the use of a wanderguard. 2. Staff interviews Licensed practical nurse (LPN) #3 was interviewed on 11/21/19 at 3:05 p.m. She said the facility used a wanderguard for resident's who posed a risk of elopement from the facility. She said a physician's orders [REDACTED]. She said a consent should be signed prior to use of the wanderguard. She said each consent was scanned into the resident's electronic medical record. The director of nursing (DON), nursing home administrator (NHA) and LPN #3 were interviewed on 11/20/19 at 1:28 p.m. The DON said the facility used a wanderguard for resident's who wandered and attempted to elope from the facility. She said a consent from the resident's responsible party should be obtained prior to use of the wanderguard. She said the consent should be scanned into the resident's electronic medical record. The NHA said the facility was unable to locate documentation to show the resident's responsible party provided consent prior to the use of the wanderguard. C. Resident #23's status Resident #23, age 93, was admitted on [DATE] and readmitted on [DATE]. According to the (MONTH) 2019 computerized physician orders [REDACTED]. The 10/6/19 minimum data set (MDS) assessment revealed, the resident had moderately impaired cognition with a brief interview for mental status (BIMS) score of 10 out of 15. The resident required extensive assistance from staff for most activities of daily living and she used a walker. She received oxygen therapy and had a wander guard. 1. Record review The elopement care plan, revised 1/4/19, documented the resident had a history of [REDACTED]. The (MONTH) 2019 computerized physician orders [REDACTED]. -Check wander guard for function every night shift for elopement risk -ordered on [DATE] -Change wander guard annually and as needed -ordered on [DATE] The resident's medical record was reviewed on 11/19/19. It did not reveal a consent for the use of a wanderguard. Staff interviews The director of nursing (DON) was interviewed on 11/20/19 at 12:30 p.m. She said consents should be obtained prior to the use of the wander guard. The nursing home administrator (NHA) was interviewed on 11/20/19 at 12:30 p.m. She said the consents should be scanned into the resident's medical record. This resident's consent was not provided.

Based on record review, interview, and review of facility policies, it was determined the facility failed to provide the appropriate care and services for one resident (#4) of one with a suprapubic catheter with a total sample of 26 residents. Specifically, the facility failed to: -Insert the indwelling catheter into the superpubic area, for Resident #4. The indwelling catheter was wrongly inserted into the penis meatus which resulted in bleeding, bruising and pain (Cross Reference F 606 failure to not employ staff with a history of negligence). Findings include: I. Professional reference According to Potter, P., Perry, [NAME], Stockert, P., & Hall, [NAME] (2017) Fundamentals of Nursing (9th ed.), p.1112, .A suprapubic catheter is a urinary drainage tube inserted surgically into the bladder through the abdominal wall above the symphysis pubis. The catheter may be sutured to the skin, secured with an adhesive material, or retained in the bladder with a fluid-filled balloon similar to an indwelling catheter. Suprapubic catheters are placed when there is blockage of the urethra (e.g., enlarged prostate, urethral stricture, after urological surgery) and in situations when a long-term urethral catheter causes irritation or discomfort or interferes with sexual functioning . II. Facility policy and procedure The undated policy titled, Suprapubic Catheter Replacement was received from the nursing home administrator (NHA) on 11/21/19 at 1:10 p.m. The policy documented the first step .verify that there was a physician's orders [REDACTED]. III. Resident #4 [NAME] Resident status Resident #4, age 83, was admitted on [DATE]. According to the (MONTH) 2019 computerized physicians orders (CPO) [DIAGNOSES REDACTED]. The 11/10/19 minimum data set assessment (MDS) documented the resident was severely cognitively impaired with a brief interview for mental status (BIMS) score of six out of 15. He required extensive assistance with bed mobility, transfers, toileting, personal hygiene, dressing, bathing and eating. He was coded as having an indwelling catheter. B. Record Review The (MONTH) 2019 CPO showed an order dated 9/27/19 to change the suprapubic catheter one time per day every 21 days related to urinary tract infections. In addition, he had an order dated 5/22/19 to change supra pubic catheter as needed. On 10/7/19 at 7:04 a.m., licensed practical nurse (LPN) # 5 documented in the nurse ' s note the catheter had come out and was replaced using an 18 french catheter and the balloon inflated with 20 milliliters of normal saline. The note further documented there was some blood on return of the urine. At 8:11 a.m. the nurse ' s note documented the physician was notified because the catheter had been inserted into the penis and not into the suprapubic site. On 10/8/19 at 10:36 a.m., the nurse ' s note documented the resident continued to have bleeding from the meatus and the, penis shaft was bruised and scrotum was purple, black with swelling. On 10/9/19 at 11:11 p.m., the nurse ' s note documented the resident had blood in his brief at the head of the penis, dark red in color. He continued to have dark purple bruising to his penis and testicles. On 10/10/19 at 11:16 p.m., the nurse ' s note documented the resident continued to bleed in brief dark red color. He continued to have bruising, .dark purple in color to penis and scrotum and along lower buttocks near scrotum. Swelling continues to area of penis and scrotum. On 10/11/19 at 11:24 a.m., the nurse note documented the, ,,,bruising to penis and scrotum has increased .entire penile shaft and scrotal sack are dark purple black in color and bruising extends to perineal floor nearly to rectum .continues to ooze bright red blood from meatus with scant amount of bleeding in brief bright red. On 10/14/19 at 8:06 a.m., the nurse ' s note documented the resident continued to have bruising and blood drainage from meatus .area cleansed which causes facial grimacing the resident said the area was tender. The nurses notes continued to document bruising, swelling and bleeding from the penis through 10/28/19. On 10/29/19 at 5:31 p.m., the nurse notes documented the daughter requested a urinary analysis because the resident ' s urine was dark and cloudy. On 10/30/19 at 12:20 a.m. The nurse notes documented the resident went to the emergency roiagnom on [DATE] per the daughters request because he just did not seem right. On 10/10/19 at 1:25 p.m. an interdisciplinary note was written by the director of nurses (DON), the note documented LPN #5inserted the catheter in the penis and urine and blood were noted. The Medical director was notified assessed the resident. The medical director instructed the staff to monitor the bleeding and she would call the urologist for further orders. There was documentation for further orders. The medical directors note on 10/7/19 documented the resident has a history of urethral stricture, adn [MEDICAL CONDITION] so I suspect when the Foley (catheter) was placed it caused significant irritation and therefore bleeding. On 10/11/19 at 7:49 p.m. health status note documented the urologist said to notify him if the bleeding increased. Urology notes after the incident were requested from the DON on 11/20/19 but not received. The only urology note provided was on 9/23/19 before the incident. IV. Interviews Certified nurse aide (CNA) #3 was interviewed on 11/10/19 at 3:02 p.m. CNA #3 said she was working the morning of 10/7/19 and was assigned to Resident #4. She said LPN #5 had gone in to replace the resident ' s indwelling catheter that had come out. She said she could hear the resident outside his door while the nurse was in the room replacing the catheter. She said he was screaming, stop it hurts. She said she went in to see the resident after the nurse had left. She said she observed a large amount of blood in his catheter bag and went to tell the nurse. LPN #5 told her that was normal. CNA #3 said she went back to the resident ' s room and observed the catheter was in the penis and not in the lower stomach where it normally was. She said she went back and told the nurse that she had put the catheter in the wrong spot. She said the LPN #5 looked surprised and said she would fix it. CNA #3 said the resident bled for several days in his catheter bag and from his penis. She said he was in so much pain for the first three days they could hardly clean his penis or peri area without him crying out. She said his penis and scrotum swelled bigger than a baseball and there were blood clots coming from his penis for several days afterwards. CNA # 1 was interviewed on 11/20/19 at 2:05 p.m. CNA #1 said she was assigned to the resident ' s area that day but had been moved to a new resident area and was not there when the nurse inserted the catheter, she said to speak to CNA # 3 who was assigned to Resident #4 that day, CNA #4 told her she heard Resident #4 crying and yelling in distress when the catheter had been inserted on 10/7/19. She said she was assigned to Resident #4 the next day and observed his penis and scrotum were swollen and he had dark purple bruising, almost black, over his entire peri area up the right side of his abdomen and around to his anus. She said it did not start to fade for several weeks. The assistant director of nursing (ADON) was interviewed on 11/19/19 at 1:18 p.m. The ADON said she was aware of LPN #5 inserting the the catheter in the penis rather than the suprapubic site on 10/7/19. She said the LPN #5 failed to check the physician order [REDACTED]. The ADON orders always needed to be checked before a catheter was inserted. The order would direct the cather type, size, and balloon size. She said the director of nursing (DON) had investigated the situation. The DON and NHA were interviewed together on 11/19/19 at 10:23 a.m. The DON said when she arrived that day the catheter had already been removed from the penis and was in the suprapubic (opening in abdominal wall into the bladder for catheter insertion) site. She said there were clots by the tip of the penis. The DON said she called the physician who instructed her to monitor the area and the physician would come in. The DON said the resident had deep purple bruising from the entire groin to anus with penial and scrotal swelling. She said she interviewed LPN #5 who said she had not checked the physician order. She saw the catheter tubing lying on the bed next to his penis and assumed that was where the tubing came from. The DON said she educated LPN #5 on catheter care that day which included checking the physician's orders [REDACTED]. The DON said catheter care education was not provided to any of the other licensed nurses. She said the nurse was oriented to the facility and to this specific resident during her floor orientation when she was hired. She said this did not include competencies for catheter care.

Based on record review and interviews; the facility failed to maintain acceptable parameters of nutritional status for one (#23) of two residents reviewed for nutrition out of 26 sample residents. Specifically, Resident #23, diagnosed with [REDACTED]. On 5/3/19 the resident's weight was recorded at 143.0 lbs (pounds) and six months later on 10/16/19 the resident weighed 125.0 lbs. This was a 17.5 lbs significant weight loss, which was 12.24% over six months. On 9/3/19 the resident weighed 141.3 lbs and 18 days later on 9/21/19 the resident weighed 129.5 lbs. This was an 11.8 lbs significant weight loss, which was 7.8%. On 9/21/19 the resident weighed 129.5 lbs and 26 days later on 10/16/19 the resident weighed 125.0 lbs. This was a 4.5 lbs and 3.8% weight loss. Review of the resident's medical records revealed the facility continued to review and document the resident's weight loss from 1/4/19 to 11/20/19, but failed to implement nutritional interventions to prevent further weight loss. Findings include: I. Facility's policy and procedure The Weight Monitoring policy, revised (MONTH) (YEAR), was provided by the nursing home administrator (NHA) on 11/21/19 at 1:10 p.m. It documented in pertinent part, -The facility would ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight, unless the resident's clinical condition demonstrates that it was not possible or resident preferences indicate otherwise. -Weight can be a useful indicator of nutritional status. Significant unintended changes in weight (loss or gain) may indicate a nutritional problem. -The physician should be informed of a significant change in weight and may order nutritional interventions. -The Registered Dietitian (RD) should be consulted to assist with interventions and actions recorded in the nutritional progress notes. [NAME] Resident status Resident #23, age 93, was admitted on [DATE] and readmitted on [DATE]. According to the (MONTH) 2019 computerized physician orders [REDACTED]. The 10/6/19 minimum data set (MDS) assessment revealed, the resident had moderately impaired cognition with a brief interview for mental status (BIMS) score of 10 out of 15. The resident required extensive assistance from staff for most activities of daily living. She had a weight loss of 5% or more in the last month or a loss of 10% or more in the last six months and was not on a physician prescribed weight loss regimen. She had a mechanically altered diet and was edentulous. She needed supervision, encouragement, cueing and set up when eating. 1. Record review The nutritional care plan, revised 1/30/18, documented the resident had a potential nutritional problem related to refusal of food/fluids at times. Pertinent interventions were to monitor fluid intake/[MEDICAL CONDITION]. Monitor weight. Monitor/record/report to physician as needed for signs and symptoms of malnutrition such as emaciation, muscle wasting, significant weight loss: three lbs in a week, 5% in one month, 7.5% in three months or 10% in six months. Offer alternates/choices/favorite foods. Offer alternative meal choice. RD to evaluate and make diet change recommendations as needed. The (MONTH) 2019 CPO included an order, dated 10/17/19, to weigh the resident weekly, every Tuesday. The CPO did not include orders for additional nutrition interventions. The weight records revealed she had a 12.24% weight loss in six months: -On 5/3/19 the resident's weight was recorded at 143.0 lbs (pounds) -6/3/19 at 141.0 lbs -7/3/19 at 138.0 lbs -8/3/19 at 141.0 lbs -9/3/19 at 141.3 lbs -9/21/19 at 129.5 lbs -10/16/19 at 125.0 lbs -11/19/19 at 125.5 lbs, which was a 17.5 lbs weight loss at 12.24%, indicating a significant weight loss greater than 10% over six months. Cross reference to F580 (Notify of Changes) because the facility failed to ensure the physician was notified of Resident #23's weight loss. Review of nutrition progress notes from 1/4/19 to 11/20/19 revealed: -The 1/4/19 dietary manager (DM) note documented the resident was on a regular mechanical soft diet and that her average intake was between 26% to 50% of meals. Current weight was 142.0 lbs and she had [MEDICAL CONDITION]. She made her own meal choices and fed herself in her room. She often chose not to eat full meals at meal time but would eat small meals and snacks throughout the day. No supplements or devices needed. No recommendations at this time. -The 4/11/19 RD note documented no concerns were voiced. Continue with current interventions and provide food requests as menu permits. -The 7/5/19 DM note documented the residents average intake was between 51% to 75% of meals. No supplements or devices needed. No recommendations at this time. -The 11/20/19 RD note documented the resident was sleeping and did not awaken for the interview. Weight was 125.5 lbs, stable for the month. Continue with current interventions. Review of the physician progress notes [REDACTED]. Review of the weekly weight interdisciplinary team (IDT) meeting notes revealed: -The 10/17/19 weight review note documented the assistant director of nursing (ADON), the director of nursing (DON) and the DM were in attendance. It revealed the resident was started on weekly weights related to weight loss following a hospitalized from [DATE] to 9/21/19. -The 10/28/19 weight review note documented resident was on weekly weight monitoring related to weight loss after hospitalization . The resident's intake varied and she was noted to have specific food preferences and often ate small meals throughout the day and night. Continue to monitor weekly. Staff interviews Certified nurse aide (CNA) # 4 was interviewed on 11/21/19 at 9:33 a.m. CNA #4 said the nurse or the CNA were responsible for weighing the resident monthly or weekly depending on the resident's need. If the weight was off by four pounds the resident would be reweighed for accuracy. She said We fill out the weight sheet given to us. We report weight changes and turn in the weight sheet to the nurse. Licensed practical nurse (LPN) #2 was interviewed on 11/21/19 at 9:45 a.m. She said the CNA or the nurse weighed the residents and the nurse inputted the weights into the resident's medical record. She said if there was a five pound difference in weight, they put the resident on weekly weights. She said the nurse then reported it to the DM or DON. She said she believed the DM notified the RD. She confirmed that the physician and RD were not notified of Resident #23's weight loss. The DM was interviewed on 11/21/19 at 9:51 a.m. She said the CNA was responsible for obtaining the weights. She said she gave them the weight sheets at the beginning of the month and they had three days to complete them. She said if there was a five pound discrepancy they were to reweigh the resident for accuracy. She said if the weight loss was accurate they would start the resident on weekly weights and give weekly weight notes to the physician. She said the RD was notified on her monthly visit when she was given a list of residents with weight loss or nutritional issues. She said they had just found out last month that the resident was losing weight and started her on weekly weights and to continue to monitor. The ADON was interviewed on 11/21/19 at 9:55 a.m. She said herself, the DM and a nurse have a weekly weight meeting to discuss weight loss. She said they did not add any new interventions for Resident #23 except to check weekly weights. She said she sent copies of weekly weights to the physician. She said they did not follow up with the physician or the RD for Resident #23's weight loss. The RD was interviewed on 11/22/19 at 3:31 p.m. She said when a resident had a significant weight loss, the DM sent her a text message and she would review the resident's medical record from home. She said when she needed to communicate with staff, she wrote a progress note with interventions or new orders. She said interventions would include supplements, snacks or special meals. She said she did not take part in the weight committee because she only visited the facility monthly. She said the DM gave her a list of residents who had a change of condition, weight loss, new admission or skin issues. She said the DM did not tell her that Resident #23 had a significant weight loss. She said Resident#23 was not put on her list of residents to see. She said nursing staff was responsible for communicating with the physician.

Based on record review and interviews, the facility failed to develop and revise comprehensive care plans for each resident that included the instructions needed to provide effective and person-centered care for four (#36, #12, #10, and #18) out of 26 sample residents. Specifically, the facility failed to: -Ensure the care plan was revised and updated with fall interventions for Resident #36, #12, #10 and #18; -Ensure the care plan was revised and updated with Resident #10 current functional status, recent functional decline and newly developed pressure ulcers; and -Ensure the care plan was revised and updated following a suicidal ideation by Resident #10. Cross reference to F689 (Free of Accident Hazards/Supervision/Devices), the facility failed to consistently implement specific, effective, interventions to attempt to prevent Resident #18 from a [MEDICAL CONDITION], pelvis and bruising to the head; and ensure interventions were put into place following falls for Residents #10, #12 and #36. Findings include: I.Failure to ensure the care plan was revised and updated with fall interventions. [NAME]Resident #36's status Resident #36, age 88, was admitted on [DATE] and readmitted on [DATE]. According to the (MONTH) 2019 computerized physician orders [REDACTED]. The 10/29/19 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments with a brief interview for mental status score of three out of 15. She required extensive assistance of two people with bed mobility, dressing, toileting and personal hygiene. It indicated the resident had a fracture related to a fall prior to the resident's readmission to the facility and had hip replacement surgery. 1.Record review The fall care plan, initiated on 1/17/17 and revised on 9/13/19, revealed the resident was at risk for falls related to confusion, psychoactive drug use. It indicated the resident would get down on the floor to clean. The interventions included details of the fall the resident sustained [REDACTED]. The resident ran after the CNA, the resident lost her footing and fell , landing on the right hip and buttocks area. It did not include any interventions to prevent further falls or behaviors. The behavior care plan, initiated on 12/6/18 and revised on 1/3/19, revealed the resident had potential to be physically aggressive related to dementia with behavioral disturbance and poor impulse control. The interventions included: when the resident becomes agitated, intervene before agitation escalates, guide away from the source of distress, engage calmly in conversation, and staff to walk away if the resident becomes aggressive. It did not include any interventions to prevent further falls or behaviors. The 10/24/19 incident progress note revealed the interdisciplinary team met to review the sustained fall by Resident #36 on 10/18/19. It indicated the fall committee felt this was an isolated event and no interventions were needed. It did not indicate the resident's behaviors or behavioral care plan being reviewed or revised with new behavioral interventions. B.Resident #12's status Resident #12, age 102, was admitted on [DATE]. According to the (MONTH) 2019 CPO, the [DIAGNOSES REDACTED]. The 9/8/19 MDS assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score of three out of 15. She required extensive assistance of one person with bed mobility, dressing, toileting and personal hygiene. She required extensive assistance of two people with transfers. The resident required limited assistance of one person for walking in her room and corridor and extensive assistance of one person with locomotion on the unit. 1.Record review The fall risk care plan, initiated and revised on 11/27/17, revealed the resident was a low fall risk related to confusion, deconditioning, gait and balance problems and incontinence. The interventions included details of the fall sustained by the resident on 8/21/19. It indicated the resident was found lying on the floor on the right side, near the bed with her head near the nightstand. It did not indicate the care plan was revised with any interventions following the fall sustained by the resident on 8/21/19. C.Resident #10's status Resident #10, age 91, was admitted on [DATE]. According to the (MONTH) 2019 CPO, the [DIAGNOSES REDACTED]. The 9/1/19 MDS assessment revealed the resident moderate cognitive impairment with a brief interview for mental status score of eight out of 15. He required limited assistance of one person with bed mobility and transfers. He required extensive assistance of one person with dressing, toileting and personal hygiene. 1.Record review The fall care plan, initiated and revised on 3/15/19, revealed the resident was a high risk for falls due to confusion, gait and balance problems, incontinence, psychoactive drug use and vision and hearing problems. Interventions included details surrounding the falls on 10/13/19 and 10/25/19, however did not include any updated interventions following each fall. The care plan was last revised on 9/9/19 with non-skid strips on the floor in front of the toilet and on 9/16/19 the resident may utilize the wheelchair if shaky or weak. 2.Staff interviews The director of nursing (DON), nursing home administrator (NHA), LPN #1 and MDS coordinator were interviewed on 11/20/19 at 3:36 p.m. The DON said the interdisciplinary team (IDT) reviewed each fall to determine the root cause and put interventions into place. She said the care plan should be updated during the IDT review with new interventions. The MDS coordinator said she was responsible for updating each resident's care plan with the fall information and new interventions. She confirmed she was documenting the details of each fall in the intervention section of the care plans. She said that was how the facility had always done it, so she continued. She confirmed the details of the falls were not considered interventions to prevent further falls. She confirmed the care plans for Residents #36, #12 and #10 had not been updated with fall interventions following each sustained fall. II. Failure to ensure the care plan was updated with current functional status, recent decline and development of pressure ulcers for Resident #10. [NAME] Record review The self-care care plan, initiated and revised on 3/15/19, revealed the resident had an activity of daily living (ADL) self-care performance deficit related to confusion and impaired balance. The interventions included the resident was able to eat independently with set-up and occasional supervision; revised on 3/15/19. It did not indicate the resident had a recent decline in his ADL status and functional mobility. The pressure ulcer care plan, initiated and revised on 3/18/19, revealed the resident had potential for pressure ulcer development related to impaired mobility. The care plan did not indicate the resident's newly developed pressure ulcers and had not been updated or revised since 3/18/19. B. Staff interviews CNA #5 was interviewed on 11/21/19 at 9:14 a.m. She said Resident #10 had declined over the past few weeks. She said he used to be able to walk with a walker and now the resident used a wheelchair. She said the resident was eating 50% (percent) or less of his meals. She said the resident was unable to stand on his own anymore. She said the resident was unable to stand on his own and required staff assistance. She said she was not aware of care interventions for the resident's decline. Registered nurse (RN) #2 was interviewed on 11/21/19 at 9:56 a.m. She said Resident #10 had been experiencing a decline over the last couple of months. She said the resident had recently developed a stage 2 pressure ulcer. She said nursing was responsible for updating the care plan with the resident's current functional status and the development of pressure ulcers. The director of nursing (DON), nursing home administrator (NHA), LPN #1 and MDS coordinator were interviewed on 11/20/19 at 3:36 p.m. LPN #1 said the resident had recently declined in his functional mobility. She said she was the nurse who documented the change of condition on 11/7/19. She said she was the unit manager of that unit. She said she was responsible for updating care plans of residents throughout the unit. She said she did not update Resident #10 care plan to include his recent decline or the development of the resident's pressure ulcers. The DON said the MDS coordinator was responsible for updating and revising each resident's plan of care for nursing concerns, such as an ADL decline and the development of pressure ulcers. The MDS coordinator confirmed she was responsible for updating each resident's plan of care. She said she would review the plan of care in accordance with the MDS schedule. She said she attempted to update each care plan with any changes daily, however was unable to catch everything. III. Failure to ensure the care plan was updated following a suicidal ideation by Resident #10. [NAME] Record review The 10/23/19 nursing progress note revealed the certified nurse aide (CNA) reported to the nurse, Resident #10 asked for a gun and a knife that morning. It indicated the resident did not know what he wanted to do with the knife and gun. The mood care plan, initiated on 3/14/19 and revised on 6/7/19, revealed the resident had mood concerns related to [MEDICAL CONDITION] disorder. It indicated the resident symptom of [MEDICAL CONDITION] disorder was a change in sleeping patterns or not sleeping for days. The interventions included: monitor, record and report to the physician as needed any acute episode of feeling sadness, loss of pleasure and interest in activities, feelings of worthlessness or guilt and observe for signs and symptoms [MEDICAL CONDITION] hypomania, racing thoughts or euphoria, increased irritability and frequent mood changes. It did not indicate the resident had a history of [REDACTED]. It did not reveal a plan of care indicating the resident had made [MEDICAL CONDITION] in the past, asking for a gun and knife, or had been updated to include the resident's recent statement made on 10/23/19. B. Staff interviews Licensed practical nurse (LPN) #3, unit manager, was interviewed on 11/21/19 at 3:05 p.m. She said if a resident made a suicidal ideation, staff should notify the social services department immediately. She said if they were not at the facility, staff should conduct a lethality assessment to determine the resident's suicide risk and if the resident had a plan. She said she would be responsible for ensuring the suicidal ideation interventions in place on the care plan. She said interventions should be documented in the resident's medical record and in the plan of care. She said nursing and/or social service departments were responsible for updating the care plan to include the resident's suicidal ideation. The director of nursing (DON), nursing home administrator (NHA), LPN #1 and social services (SS) were interviewed on 11/20/19 at 3:36 p.m. LPN #1 said that she was the nurse that wrote the nursing progress note on 10/23/19 when the resident asked for a knife and gun. She said she did not conduct a lethality assessment of the resident following the resident's request for a gun and a knife. She said she did not update the resident's care plan to include the resident's suicidal ideation. SS said it was not uncommon for the resident to ask for a knife. She said Resident #10 used to carry a pocket knife with him. She said it was not documented on the resident's plan of care that he would ask for a knife. The DON said following a statement requesting a gun and a knife, an assessment should have been performed on the resident to determine if the resident was making a suicidal ideation and if the resident had a plan. She said the care plan should have been updated following the resident's request for the weapon on 10/23/19. IV.Ensure the care plan was revised and updated with fall interventions for Resident #18. [NAME]Resident #18's status Resident #18, age 83 ,was admitted on [DATE]. According to the computerized physicians orders (CPO) [DIAGNOSES REDACTED]. The 9/22/19 minimum data set (MDS) assessment the resident was severely cognitively impaired with a brief interview for mental status (BIMS) score of six out of 15. The resident required extensive assistance with bed mobility, transfers, dressing, toileting, personal hygiene and bathing. She required supervision with eating. The resident had two falls with no injuries, two falls with minor injuries and two falls with major injuries. 1.Record review The care plan, dated 5/17/19, read the care plan interventions included to ensure the call light was within reach, encourage resident to ask for assistance, non-sliding surface to recliner that was added to the intervention list on 9/30/19, educate resident family and caregivers about safety reminders and what to do if a fall occurs, registered nurse (RN) to assess the resident after falls, ensure the resident wearing appropriate footwear, follow facility fall protocols, monitor residents whereabouts that was added to the intervention list on 9/16/19, review post fall and attempt to determine the cause, self locking brakes on wheelchair that was added to the intervention list on 8/30/19. The interventions were initiated on 5/17/19, (unless otherwise indicated) prior to 25 falls, three with major injury. There were no specific interventions as to when to check on the resident for safety, walking with the resident, therapy evaluation for safety in the recliner, balance, strengthening, or activity involvement. Review of the interdisciplinary team (IDT) notes from 6/6/19 to 11/14/19 revealed the resident had fallen at least 25 times between 6/6/19 and 11/14/19. Three of the falls resulted in major injuries. 2.Staff interviews Licensed practical nurse (LPN) # 3 was interviewed on 11/20/19 at 2:30 p.m. She said, We try to keep her busy, but she is quick and can fall as soon as you look away and she will go down. She was unsure of what was written in the resident's care plan for fall prevention. The director of nursing (DON), nursing home administrator (NHA) and LPN #1 were interviewed together on 11/20/19 at 12:30 p.m. The DON said the IDT discussed interventions in place prior to fall, and they had a list of items they checked. She said the ADON updated the care plan after falls. The NHA said the resident has had several falls, but she was tough. She said there were no interventions in the care plan that specified having the family sit with the resident to prevent falls and offer comfort when agitated. There were no specific intervention in place to check the resident frequently, or specific time frames for checking the resident for safety by the facility staff. The DON said that after the fall 8/25/19 they moved her furniture around so the bed was closer to the door and decreased the dosing of the antidepressant. These interventions were not in the resident's care plan. She said no interventions were established for the two falls on 9/9/19 and the fall on 11/13/19 to add to the care plan. She said that they had moved the resident's room closer to the common area on 11/6/19 so that she could see the staff. This was not included in the care plan. LPN #1 said the resident fell again on 11/13/19 but there were no new fall preventative interventions added to the resident's care plan.