Every finding on record at Wesley Towers Inc

The facility reported a census of 45 residents, including 13 residents in the sample. Based on observation, interview and record review the facility failed to Ensure adequate infection control practices related to clean Hoyer lift slings. Findings included:- On 03/10/26 at 09:30 AM, an observation of the clean linen room revealed wall pegs to hold the Hoyer lift (mechanical device used to transfer individuals between surfaces) slings, 14 slings were placed on the pegs in the clean linen room these pegs did not keep the slings or the straps from lying on the floor. On 03/10/26 at 11:30 AM, an interview with Housekeeping Staff V revealed the slings touching the floor in the clean laundry room were like this since Housekeeping Staff V started working at the facility. 03/10/26 at 11:40 AM, an interview with Housekeeping Staff U during the observation of the clean linen room storage room revealed the slings have always hung on the pegs attached to the wall and the slings have always touched the floor since starting here one and half years ago. 03/10/26 at 2:40 PM, during the second observation of the clean linen room, the slings were placed correctly on the pegs which prevented the slings and straps from touching the floor. On 03/10/26 at 2:45 PM, an interview with Administrative Staff D revealed she expected the staff to keep the slings off the floor. The facilities policy Infection Prevention and Control Policy, revised on 10/25, revealed the facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infection as pre accepted national stands and guidelines. Per Equipment Protocol, all reusable items and equipment requiring special cleaning, disinfection, or sterilization shall be cleaned in accordance with our current procedure governing the cleaning and sterilization of soiled or contaminated equipment.

The facility had a census of 45 residents. The sample included 13 residents, of which five residents were reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 2 received as-needed (PRN) Clonazepam (an antianxiety medication that would calm and relax people with excessive restlessness, nervousness and tension) without a 14 day stop date or definitive end date for use. Findings included: - Resident 2's diagnoses included anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), gastroparesis (a chronic condition where stomach muscles work poorly, causing delayed emptying of food into the small intestines without a physical blockage), and gastroesophageal reflux disease (GERD-backflow of stomach contents to the esophagus) and nausea. The quarterly Minimum Data Set (MDS), dated [DATE], recorded the R2 had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS recorded R2 received antianxiety (class of medications that calm and relax people) and antidepressant (class of medications used to treat mood disorders) medications. The Psychotropic Drug Use Care Area Assessment (CAA), dated 10/04/25, documented R2 received psychotropic medications, and staff would monitor R2 every shift for side effects and the physician would be notified of abnormal findings. The CAA documented that a pharmacist consultant would review R2's medications monthly and the primary care physician would review R2's medication with each visit. R2 received the medication due to a history of insomnia and anxiety. The Care Plan, dated 02/17/26, recorded R2 received Clonazepam (antianxiety medication) for anxiety including restlessness, worrying, frequent repetitive health concerns and questions, sleep disturbance, and refusal of care. The care plan documented staff would monitor R2 for adverse reactions, which included drowsiness, lack of energy, clumsiness, slurred speech, confusion, and impaired thinking and judgement. The Physician Order, dated 03/04/26, directed staff to administer Clonazepam, 0.5 milligrams, one tablet, every 12 hours as needed for anxiety. The resident's medical record lacked documentation the PRN Clonazepam had a 14 day stop date or specific date to stop the medication. On 03/10/26 at 07:50 AM, an observation revealed R2 in her recliner, dressed in pajamas. Licensed Nurse (LN) H administered the resident's morning medications. On 03/11/26 at 07:50 AM, Administrative Nurse D verified the resident PRN order for Clonazepam, one tablet every 12 hours as needed. Administrative Nurse D also stated R2 routinely used the medication twice daily and verified the order did not have a 14 day stop date and lacked an end date for use. The facility's Psychotropic Medication policy, dated December 2022, recorded residents were not administered psychotropic medications unless the medication was necessary to treat a specify 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. The policy documented PRN orders for all psychotropic medications would be used only when the medication was necessary to treat a diagnosed specific condition that is documented in the clinical record, and for a limited duration-such as 14 days. If the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she shall document their rationale in the resident's medical record and indicate the duration for the PRN order.

The facility had a census of 45 residents. The sample included 13 residents, with one reviewed for nutrition/hydration status. Based on observation, record review, and interview, the facility failed to update Resident (R) 11's care plan, who was at risk for elopement with a section with instructions to staff on interventions to prevent R11 from eloping. Findings included:- R11's Electronic Medical Record (EMR) documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), anxiety disorder (a progressive mental disorder characterized by failing memory and confusion), and psychotic disturbance (any major mental disorder characterized by a gross impairment in reality perception). R11's Quarterly Minimum Data Set (MDS), dated [DATE], documented she had a Brief Interview for Mental Status (BIMS) score of one, which indicated severely impaired cognition. The MDS documented R11 required supervision with ambulation and used a walker or wheelchair for mobility. The MDS documented R11 had no upper or lower extremity impairment. The MDS documented R11 had no falls since the prior assessment. The Elopement Assessment, dated 12/20/25, documented the resident had a score of five, which indicated R11 was at risk for elopement. R11's Care Plan, revised 12/23/25, documented R11 required supervision to substantial staff assistance with activities of daily living (ADLs). The care plan lacked a section regarding elopement with instructions to staff for interventions to prevent elopement. On 03/11/26 at 11:00 AM, observation revealed R11 sat in a chair by the dining room window in the front entrance hallway, eating a snack with her walker in front of her. On 03/11/26 at 08:30 AM, Administrative Nurse D verified R11's care plan lacked a section regarding elopement, and the 12/20/25 elopement assessment placed her at risk for elopement. Administrative Nurse D stated residents are assessed for elopement risk on admission, quarterly, with significant change, and annually. The facility's Comprehensive Care Plans Policy, revised 10/25, documented the comprehensive care plan would be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment, and significant change assessment.

The facility had a census of 45 residents. The sample included 13 residents, with one reviewed for activities of daily living (ADL). Based on observation, record review and interview, the facility failed to provide care and services for Resident (R)29 regarding personal hygiene and grooming. Findings included: - R29's Quarterly Minimum Data Set (MDS), dated [DATE], indicated the resident had a Brief Interview for Mental Status (BIMS) score of 15 indicating resident was cognitively intact. The MDS documented R29 was independent with staff oversight for personal hygiene; The MDS noted that a shower or bath was not attempted due to medical condition or safety concerns. R29's Care Plan, dated 01/31/26, indicated R29 had ADL self-care performance deficits and staff would check her nail length and trim and clean on bath days and as necessary and report any changes to the nurse. The care plan lacked further documentation on bathing needs. On 03/09/26 at 03:30 PM, observation revealed R29 sat in a recliner in her room, dressed in street clothes. Her hair was uncombed, and she had white hair visible on her chin. On 03/10/26 at 08:00 AM, observation revealed R29 sat at the dining room table with other residents eating lunch. Her hair was uncombed, and she had white hair visible on her chin. On 03/10/26 at 12:30 PM, Administrative Nurse D verified R29 had white hair stubble on her chin and said staff should shave R29's face on shower days. Administrative Nurse D stated the shower/bath sheets were for staff to documents if they shaved the residents and verified R29 had a shower on 03/06/26 and staff did not shave her face. The facility ADL policy, dated November 2023, documented all residents are bathed as often as necessary to maintain cleanliness, refresh, and stimulate circulation. Tub baths and showers are provided by all nursing staff two times a week, as tolerated, and/or as needed. Residents skin conditions are monitored with each bath. The policy documented that staff would assist the residents with bathing as needed and to dress and shave.

The facility had a census of 45 residents. The sample included 13 residents, with one reviewed for hydration. Based on observation, record review, and interview, the facility staff failed to consistently monitor Resident (R) 20's fluid intake related to a physician-ordered fluid restriction. Findings included:- R20's Electronic Medical Record (EMR) documented diagnoses of chronic respiratory failure and ascites (an abnormal buildup of fluid in the abdomen that may cause swelling). R20's Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview of Mental Status (BIMS) score of 13, which indicated intact cognition. The MDS documented R20 required supervision with upper body dressing and rolling left to right in bed; partial to moderate assist with toileting hygiene, showering, putting on and taking off footwear, personal hygiene, and transfers; substantial to maximal assist with lower body dressing. She was dependent on staff for mobility in a manual wheelchair. R20's Care Plan, revised on 01/18/26, documented she had a 1500 milliliter (ml) fluid restriction per day. The Physician Order, dated 03/05/26, instructed staff to provide R20 with a 1500 ml fluid restriction daily (650 ml 06:00 AM-02:00 PM, 650 ml 02:00 PM-10:00 PM, and 200ml 10:00 PM-06:00 AM) R20's March 2026 Medication Administration Record (MAR) lacked amounts of fluid intake on each shift. The [NAME] (computer documentation system) used by the nurse aides had documentation of fluid intake for one shift on two days. On 03/11/26 at 08:00 PM, observation revealed R20's bedside table had a pitcher on it with 600 ml of water. On 03/11/26 at 07:55 AM, Certified Nurse Aide (CNA) M stated the facility had one resident on a fluid restriction. CNA M stated that at the end of her shift, she gave the nurse a piece of paper with the amount of fluid R20 drank during that shift. On 03/11/26 at 08:00 AM, Licensed Nurse (LN) G verified R20's MAR lacked documentation regarding the amount of fluid R20 consumed on each shift and stated the CNAs should document the amounts intake. On 03/11/26 at 08:22 AM, Dietary Staff CC stated she did not record fluid intake for the residents at meals. Dietary Staff CC stated she was told to give R20 a 12-ounce glass of whatever fluid she requested. On 03/11/26 at 08:11 AM, Administrative Nurse D verified staff were not consistently documenting R20's fluid intake in the [NAME] system and stated they should be. The facility's Fluid Restriction Policy, revised 11/23, documented that fluid restrictions would be documented in the EMR records by CNA/CMA with a check mark noting that the CNA/CMA is aware of the fluid restriction. The CNA/CMA would document the fluid intake on the meal percentage sheet each meal, and at the end of the shift would give the total intake to the LN/CMA to document in the vital stats tab in the EMR.

The facility reported a census of 45 residents and two kitchens. Based on observation, interview, and record review, the facility failed to ensure staff served meals at safe and appetizing temperatures. This was evident by the low temperature of food items on the last meal tray (test tray) from the kitchen on 03/11/26. Findings included:- During an observation on 03/11/26 at 11:35 AM, Dietary Staff (DS) DD prepared six servings of cooked roast beef with a temperature of 171 degrees Fahrenheit (F), cooked mashed potatoes and brown gravy with a temperature of 152 degrees F, and cooked peas with a temperature of 158 degrees F. Dietary Staff DD placed the cooked food onto covered heated plates which were then placed onto an open serving cart. On 03/11/26 at 11:50 AM, upon delivering the last meal tray (test tray) from the kitchen to the surveyor, DS DD took the temperature of the food items upon the tray and reported: cooked roast beef temperature of 122 degrees F, and cooked peas temperature of 132 degrees F. During an interview on 03/11/26 at 11:50 AM, Dietary Staff DD stated he expected the temperature of all hot cooked food items served to residents to be around 145 degrees F. During an interview on 03/11/26 at 11:40 AM, Staff CC stated hot food should have a temperature of at least 145 degrees, before it is served to residents. During an interview on 03/11/26 at 11:50 AM, Dietary Staff BB stated she expected the dietary staff to serve hot food to residents at the appropriate temperatures, over 140 degrees F. Staff BB said she expected staff to not serve hot food to residents that was not at least 140 degrees F. During an interview on 03/10/26 at 2:00 PM, R40 stated the food was cold most of the time. During record review on 03/10/26, Summary of Resident Council Meeting Minutes for the year 2026 revealed resident complaints of cold food from 19 residents in attendance at the meeting. The facility's policy Food Preparation and Handling, dated 03/25/21, documented all food items and products served to elders that will be prepared or served from/in a central kitchen and/or neighborhood kitchen/serving area will be according to standardized recipes. Food items would be prepared using methods and techniques designed to preserve maximum nutritive value, enhance flavor and be free of injurious organisms and substances. The facility's policy lacked the holding temperature of food.

The facility had a census of 42 residents. Based on observation, record review, and interview, the facility failed to employ a full-time Certified Dietary Manager (CDM) for the 42 residents who resided in the facility and received their meals from the kitchen. This placed the residents at risk for inadequate nutrition. Findings included: - On 05/06/24 at 12:06 PM, observation revealed dietary staff preparing meals for the midday meal. Dietary Staff (DS) BB reported she was the dietary manager and was enrolled in a Certified Dietary Manager course. DS BB reported she worked under the supervision of a registered dietician and had completed the first module of the training. The facility's Certified Dietary Manager Job Summary, dated 03/2024, documented the CDM is responsible for providing quality nutritional care to the residents according to facility policy and procedures and federal and state regulations. The qualifications require successful competition of the Certified Dietary Manager exam following the approved training program, certification as a Certified Food Protection Professional preferred and prior experience in healthcare food service also preferred. The facility failed to employ a full-time Certified Dietary Manager for the 42 residents who resided in the facility, which placed the residents at risk for inadequate nutrition.

The facility had a census of 42 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to ensure an error rate of five percent (%) or less, when staff failed to prime (a procedure used to remove the air from the needle and cartridge that may collect during normal use) ) insulin (a hormone that lowers the level of glucose in the blood) KwikPens (a disposable prefilled pen containing insulin) prior to administration to Resident (R) 21. This deficient practice resulted in a medication error rate of 6.06 % and placed all residents who received insulin at risk for medication errors. Findings included: - On 05/07/24 at 09:33 AM, observation during medication administration revealed Licensed Nurse (LN) G turned the dial on R21's Humalog (fast-acting insulin) KwikPen to 36 units and the Lantus (long-acting insulin) KwikPen to 80 units but did not prime either pen. LN G entered R21's room and asked the resident where he would like his insulin administered; R21 replied in his abdomen. Further observation revealed LN G used an alcohol pad on R21's right lower abdomen and without priming the Humalog pen, administered the 36 units. Further observation revealed LN G used the same procedure to administer the 80 units of Lantus insulin in a different spot on R21's lower abdomen. On 05/07/24 at 09:33 AM, LN G verified she had not primed either insulin KwikPen and stated it was not the facility policy to prime insulin KwikPens prior to administration. The Humalog KwikPen Instruction Sheet, instructed staff to use the following procedure before administrating the physician-ordered dosage of the medication: For each injection: 1. Select a dose of 2 units 2. Take off the outer needle cap (save it) and inner needle cap (throw it away) 3. With the pen pointing up, tap the insulin to move the air bubbles to the top 4. Press the button all the way in and make sure insulin comes out of the needle The Lantus KwikPen Instruction Sheet, instructed staff to use the following procedure before administrating the physician-ordered dosage of the medication: 1. Remove the pen cap with clean hands. Check the reservoir to make sure the insulin is clear and colorless and has no particles-if not, use another pen. 3. Attach the needle. 4. Dial a test dose of 2 Units. Hold the pen with the needle pointing up and lightly tap the insulin reservoir so the air bubbles rise to the top of the needle. This will help you get the most accurate dose. Press the injection button all the way in and check to see that insulin comes out of the needle. The dial will automatically go back to zero after you perform the test. On 05/07/24 at 02:07 PM, Administrative Nurse D stated she expected the nurse to prime Humalog and Lantus KwikPens before administration. The facility's Specific Medication Administration Procedures Policy, revised in April 2020, instructed staff to administer medications via subcutaneous (beneath the skin), intradermal (between the layers of the skin), and intramuscular (into, a muscle) routes in a safe, accurate, and effective manner. The facility failed to ensure residents received their medications with an error rate of five percent or less when staff failed to prime a Humalog and Lantus KwikPen before administration resulting in an error rate of 6.06% and placed the residents who received insulin at risk for medication errors.

The facility reported a census of 32 residents with 12 residents selected in the sample. The facility identified 32 residents that lacked a Care Area Assessment (CAA) and analysis findings of the triggered care areas. Based on interview and record review, the facility failed to complete the CAAs for the comprehensive assessments for the residents that resided in the facility. The deficient practice of failure to complete the care area assessment and analysis of findings of the care areas also included Resident (R) 4, R6, R8, R9, R11, and R14. Findings included: - Review of the Physician Orders, dated 10/10/22 for Resident R4 indicated major depressive disorder (a major mood disorder). The annual Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. R4 displayed physical and verbal behavioral symptoms directed towards others between one and three days out of seven during the look back period. Review of the Care Area Assessment (CAA) dated 01/12/22 lacked analysis completion by staff. Interview on 11/16/22 at 11:35 AM with Administrative Nurse B, reported the MDS coordinator did not follow the Resident Assessment Instrument(RAI) on providing the information as indicated for care planning. Interview on 11/17/22 at 01:04 PM with Administrative Nurse C, reported she lacked training on how to complete the CAA's. Administrative Nurse C confirmed she had not completed the CAA areas for over a year on all 32 residents in the facility. The Resident Assessment Instrument, (R.A.I.) Manual, Section 2.7 titled The Care Area Assessment (CAA) Process and Care Plan Completion, dated 2019, documentation included . Federal statute and regulations require nursing homes to conduct initial and periodic assessments for all their residents. The assessment information is used to develop, review, and revise the resident's plans of care that will be used to provide services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The RAI process, which includes the Federally mandated MDS, is the basis for an accurate assessment of nursing home residents. The MDS information and the CAA process provide the foundation upon which the care plan is formulated. There are 20 problem-oriented CAAs, each of which includes MDS-based trigger conditions that signal the need for additional assessment and review of the triggered care area. Detailed information regarding each care area and the CAA process, including definitions and triggers, appear in Chapter 4 of the manual. Chapter 4 also contains detailed information on care planning development utilizing the RAI and CAA process. CAA(s) completion is required for comprehensive assessments. The facility failed to complete the Care Area Assessment (CAA analysis of findings) related to the comprehensive assessment for this resident, as required. - Review of the Physician Orders, dated 10/10/22, for Resident R11 indicated anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) spinal stenosis (stiffness and severe back pain). The annual Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. R11 displayed the use of medication for seven days during the look back period of seven days the use of antianxiety and opioid medication. Review of the Care Area Assessment (CAA) dated 01/12/22 lacked analysis completion by staff. Interview on 11/16/22 at 11:35 AM with Administrative Nurse B, reported the MDS coordinator did not follow the Resident Assessment Instrument(RAI) on providing the information as indicated for care planning. Interview on 11/17/22 at 01:04 PM with Administrative Nurse C, reported she lacked training on how to complete the CAA's. Administrative Nurse C confirmed she had not completed the CAA areas for over a year on all 32 residents in the facility. The Resident Assessment Instrument, (R.A.I.) Manual, Section 2.7 titled The Care Area Assessment (CAA) Process and Care Plan Completion, dated 2019, documentation included . Federal statute and regulations require nursing homes to conduct initial and periodic assessments for all their residents. The assessment information is used to develop, review, and revise the resident's plans of care that will be used to provide services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The RAI process, which includes the Federally mandated MDS, is the basis for an accurate assessment of nursing home residents. The MDS information and the CAA process provide the foundation upon which the care plan is formulated. There are 20 problem-oriented CAAs, each of which includes MDS-based trigger conditions that signal the need for additional assessment and review of the triggered care area. Detailed information regarding each care area and the CAA process, including definitions and triggers, appear in Chapter 4 of the manual. Chapter 4 also contains detailed information on care planning development utilizing the RAI and CAA process. CAA(s) completion is required for comprehensive assessments. The facility failed to complete the Care Area Assessment (CAA analysis of findings) related to the comprehensive assessment for this resident, as required. - Review of the Physician Orders, dated 10/10/22 for Resident R9 indicated dementia (progressive mental disorder characterized by failing memory, confusion) major depressive disorder (a major mood disorder) The annual Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 10, indicating moderate impaired cognition. R9 displayed the use of medication for seven days during the look back period of seven days the use of antianxiety and antipsychotics were received on a routine basis medication. Review of the Care Area Assessment (CAA) dated 01/12/22 lacked analysis completion by staff that included Cognitive Loss/ Dementia, Mood state, and Psychotropic Drug Use. Interview on 11/16/22 at 11:35 AM with Administrative Nurse B, reported the MDS coordinator did not follow the Resident Assessment Instrument(RAI) on providing the information as indicated for care planning. Interview on 11/17/22 at 01:04 PM with Administrative Nurse C, reported she lacked training on how to complete the CAA's. Administrative Nurse C confirmed she had not completed the CAA areas for over a year on all 32 residents in the facility. The Resident Assessment Instrument, (R.A.I.) Manual, Section 2.7 titled The Care Area Assessment (CAA) Process and Care Plan Completion, dated 2019, documentation included . Federal statute and regulations require nursing homes to conduct initial and periodic assessments for all their residents. The assessment information is used to develop, review, and revise the resident's plans of care that will be used to provide services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The RAI process, which includes the Federally mandated MDS, is the basis for an accurate assessment of nursing home residents. The MDS information and the CAA process provide the foundation upon which the care plan is formulated. There are 20 problem-oriented CAAs, each of which includes MDS-based trigger conditions that signal the need for additional assessment and review of the triggered care area. Detailed information regarding each care area and the CAA process, including definitions and triggers, appear in Chapter 4 of the manual. Chapter 4 also contains detailed information on care planning development utilizing the RAI and CAA process. CAA(s) completion is required for comprehensive assessments. The facility failed to complete the Care Area Assessment (CAA analysis of findings) related to the comprehensive assessment for this resident, as required. 41302 - Review of Resident (R) 8's Electronic Health Record (EHR), documented the following diagnosis: major depressive disorder (major mood disorder,) type II diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), and essential hypertension (elevated blood pressure). The 09/30/22 Admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The Care Area Assessment (CAA) documented the ADL Function/Rehabilitation Potential, Urinary Incontinence and Indwelling Catheter, Falls, Dental Care, Pressure Ulcer/Injury, and Psychotropic Drug Use areas all triggered. The 09/30/22 Care Area Assessment (CAA) for R8 lacked analysis completion by staff. Interview on 11/16/22 at 11:35 AM with Administrative Nurse B, reported the MDS coordinator did not follow the Resident Assessment Instrument(RAI) on providing the information as indicated for care planning. Interview on 11/17/22 at 01:04 PM with Administrative Nurse C, reported she lacked training on how to complete the CAA's. Administrative Nurse C confirmed she had not completed the CAA areas for over a year on all the residents in the facility. The Resident Assessment Instrument, (R.A.I.) Manual, Section 2.7 titled The Care Area Assessment (CAA) Process and Care Plan Completion, dated 2019, documentation included . Federal statute and regulations require nursing homes to conduct initial and periodic assessments for all their residents. The assessment information is used to develop, review, and revise the resident's plans of care that will be used to provide services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The RAI process, which includes the Federally mandated MDS, is the basis for an accurate assessment of nursing home residents. The MDS information and the CAA process provide the foundation upon which the care plan is formulated. There are 20 problem-oriented CAAs, each of which includes MDS-based trigger conditions that signal the need for additional assessment and review of the triggered care area. Detailed information regarding each care area and the CAA process, including definitions and triggers, appear in Chapter 4 of the manual. Chapter 4 also contains detailed information on care planning development utilizing the RAI and CAA process. CAA(s) completion is required for comprehensive assessments. The facility failed to complete the Care Area Assessment (CAA analysis of findings) related to the comprehensive assessment for this resident, as required. - Review of Resident (R) 6's Electronic Health Record (EHR), documented the following diagnosis: major depressive disorder (major mood disorder,) type II diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), and essential hypertension (elevated blood pressure). The 05/25/22 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of nine, indicating moderately impaired cognition. The Care Area Assessment (CAA) documented the Cognitive Loss/Dementia, ADL Function/Rehabilitation Potential, Urinary Incontinence and Indwelling Catheter, Falls, Dehydration/Fluid Maintenance, Pressure Ulcer/Injury, and Psychotropic Drug Use areas all triggered. The 05/25/22 Care Area Assessment (CAA) for R6 lacked analysis completion by staff. Interview on 11/16/22 at 11:35 AM with Administrative Nurse B, reported the MDS coordinator did not follow the Resident Assessment Instrument(RAI) on providing the information as indicated for care planning. Interview on 11/17/22 at 01:04 PM with Administrative Nurse C, reported she lacked training on how to complete the CAA's. Administrative Nurse C confirmed she had not completed the CAA areas for over a year on all the residents in the facility. The Resident Assessment Instrument, (R.A.I.) Manual, Section 2.7 titled The Care Area Assessment (CAA) Process and Care Plan Completion, dated 2019, documentation included . Federal statute and regulations require nursing homes to conduct initial and periodic assessments for all their residents. The assessment information is used to develop, review, and revise the resident's plans of care that will be used to provide services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The RAI process, which includes the Federally mandated MDS, is the basis for an accurate assessment of nursing home residents. The MDS information and the CAA process provide the foundation upon which the care plan is formulated. There are 20 problem-oriented CAAs, each of which includes MDS-based trigger conditions that signal the need for additional assessment and review of the triggered care area. Detailed information regarding each care area and the CAA process, including definitions and triggers, appear in Chapter 4 of the manual. Chapter 4 also contains detailed information on care planning development utilizing the RAI and CAA process. CAA(s) completion is required for comprehensive assessments. The facility failed to complete the Care Area Assessment (CAA analysis of findings) related to the comprehensive assessment for this resident, as required. - Review of Resident (R) 14's Electronic Health Record (EHR), documented the following diagnosis: dementia (progressive mental disorder characterized by failing memory, confusion,) major depressive disorder (major mood disorder,) type II diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). The 08/03/22 Annual Minimum Data Set (MDS), documented R14 had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The Care Area Assessment (CAA) documented the ADL Function/Rehabilitation Potential, Urinary Incontinence and Indwelling Catheter, Falls, Nutritional Status, Pressure Ulcer/Injury, and Psychotropic Drug Use areas all triggered. The 08/03/22 Care Area Assessment (CAA) for R14 lacked analysis completion by staff. Interview on 11/16/22 at 11:35 AM with Administrative Nurse B, reported the MDS coordinator did not follow the Resident Assessment Instrument(RAI) on providing the information as indicated for care planning. Interview on 11/17/22 at 01:04 PM with Administrative Nurse C, reported she lacked training on how to complete the CAA's. Administrative Nurse C confirmed she had not completed the CAA areas for over a year on all the residents in the facility. The Resident Assessment Instrument, (R.A.I.) Manual, Section 2.7 titled The Care Area Assessment (CAA) Process and Care Plan Completion, dated 2019, documentation included . Federal statute and regulations require nursing homes to conduct initial and periodic assessments for all their residents. The assessment information is used to develop, review, and revise the resident's plans of care that will be used to provide services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The RAI process, which includes the Federally mandated MDS, is the basis for an accurate assessment of nursing home residents. The MDS information and the CAA process provide the foundation upon which the care plan is formulated. There are 20 problem-oriented CAAs, each of which includes MDS-based trigger conditions that signal the need for additional assessment and review of the triggered care area. Detailed information regarding each care area and the CAA process, including definitions and triggers, appear in Chapter 4 of the manual. Chapter 4 also contains detailed information on care planning development utilizing the RAI and CAA process. CAA(s) completion is required for comprehensive assessments. The facility failed to complete the Care Area Assessment (CAA analysis of findings) related to the comprehensive assessment for R14, as required.

The facility reported a census of 32 residents. Based on observation, interview, and record review, the facility failed to store, prepare, and serve food under sanitary conditions for the residents of the facility. Findings included: - Observation of the [NAME] satellite kitchen, on 11/14/22 at 04:37 PM, with Dietary Staff AA, revealed the following areas of concern: 1. In the stand-alone freezer; six plastic baggies that contained pre-cooked bacon, open and undated. 2. In the dry storage area was one bag of potato chips, resealed with plastic-wrap and lacked an opened date. In addition, observation of the main kitchen on 11/14/22 at 04:55 PM with Dietary Staff AA, revealed the following concerns: 1. The walk-in freezer contained a clear plastic container of discolored lima beans resealed with plastic wrap with a Use-by date obscured and unreadable. 2. A vegetable washing sink drain lacked a two-inch air gap between the discharge line and the floor drain. 3. An ice machine lacked two-inch air gap between the discharge line and the floor drain. On 11/14/22 at 04:55 PM, Dietary Staff AA verified all opened food items should be in a closed container and labeled with a use by date. Staff should discard foods by the use by date of seven days from the date the food opened if the food remained in the original packaging, or 72 hours if food not stored in the original container. Frozen foods that have been opened should be thoroughly wrapped or packaged to ensure product was not compromised. On 11/21/22 at 02:40 PM, with Dietary Staff AA, Administrator A and Administrative Nurse B revealed that the drains for the vegetable sink and ice machine should have gaps between the discharge lines and the floor drains. The facility's policy for Labeling of Food Items dated 11/2022 revealed all opened food items would be labeled with the day and the date the product opened. If food was perishable, the container would be labeled with an expiration date of 72 hour from opening the package. After an item had been opened, staff were to use the manufacturer expiration date, or seven days from opening, whichever came first. Frozen foods that were opened would be packaged in a manner to avoid compromising the contents. In addition, the facility's policy Food Preparation and Handling Policy dated 03/2021, documented Food with an abnormal appearance would be discarded immediately. All food items would be checked by the cook daily for expiration dates or use by dates. The facility failed to store, prepare, and serve food under sanitary conditions for the residents in the facility.

The facility reported a census of 32 residents with 12 residents selected for review included 2 residents sampled for Bowel/Bladder/Catheter or Incontinence Care. Based on observation, interview, and record review, the facility failed to provide appropriate care of Resident (R)6's perineum (area of the body including genitals and anus) during incontinence care. Findings included: - Review of R6's diagnoses from the 09/05/22 Physicians Orders in the Electronic Health Record (EHR) revealed the following diagnoses: neuromuscular dysfunction of the bladder (dysfunction of the urinary bladder caused by a lesion of the nervous system), cerebral palsy ([CP], a progressive disorder of movement, muscle tone or posture caused by injury or abnormal development in the immature brain, most often before birth) and intellectual disabilities (a neurodevelopmental condition that develops in childhood can affect the ability to learn and perform self-care tasks such as feeding and hygiene). The quarterly Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 8, indicating moderately impaired cognition. The resident required extensive one-person assistance with personal hygiene and had an indwelling urinary catheter (insertion of a catheter into the bladder to drain the urine into a collection bag). The annual MDS dated [DATE], revealed a BIMS of 9, indicating moderately impaired cognition. The resident required extensive one-person assistance with personal hygiene and had an indwelling urinary catheter. Review of the 05/25/22 Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA), lacked documentation related to perineal care. Review of 09/05/22 care plan revealed instructions for staff to provide perineal care as needed. Observation of R6 on 11/21/22 at 10:34 AM, revealed Certified Nurse Aide (CNA) J and CNA K provided resident cares. CNA J used warm soapy washcloths to perform catheter and perineal care. CNA J used the same washcloth for two swipes on the urinary catheter. The edge of the wet washcloth became soiled after the washcloth came in direct contact with the resident's skin between the first and second swipe of the same washcloth during the catheter care. CNA J then utilized a single washcloth to clean R6's groin folds (the crease where the thighs join the trunk) and used the same washcloth on the resident's perineum. Interview on 11/21/22 at 10:40 AM with CNA J reported the same cloth or wipe could be used more than one swipe if a clean portion of the cloth or wipe used for an additional swipe. Interview on 11/21/22 at 10:42 AM with Licensed Nurse (LN) E and LN F reported that normal procedure for cleansing is to use One swipe per wipe when performing incontinence care, catheter care or perineal care. Interview on 11/21/22 at 10:50 AM with Administrative Nurse B, revealed that all staff received training related to incontinence and perineum care during a Skills fair event the previous month. Administrative Nurse B stated that it was the individual preference of the caregiver to use One swipe per wipe or to fold the wipe and use a clean area for an additional swipe. The facility's policy for Perineal Care, dated 07/2017, revealed staff should perform female perineal care and wipe from front to back, and use one swipe per wipe. The facility failed to provide appropriate care of R6's perineum during incontinence care, increasing her risk for developing urinary tract infections.

The facility reported a census of 32 residents, with 12 sampled, including one for accuracy of assessments in the Minimum Data Set (MDS). Based on interview and record review, the facility failed to document resident (R) 14 regarding hospice or comfort care (palliative and supportive treatment for patients who are suffering from a terminal illness). Findings included: - Review of the quarterly Minimum Data Set (MDS), dated [DATE], documented R14 did not receive special treatments or procedures. The MDS lacked documentation that the resident received hospice services. Review of the quarterly MDS, dated [DATE], lacked documentation the resident received hospice services. Review of the quarterly MDS, dated [DATE], lacked documentation the resident received hospice services. Review of the annual MDS, dated [DATE], lacked documentation the resident received hospice services. Review of the quarterly MDS, dated [DATE], lacked documentation the resident received hospice services. The Physician's orders included to admit the resident to hospice on 10/06/21. On 11/21/22 at 01:56 PM, Administrative Nurse B verified staff should document comfort care/ hospices services on the MDS for accuracy of the MDS. The facility used the Resident Assessment Instrument (RAI) manual for guidance in completing the MDS's. The facility failed to accurately code the MDS for this resident that received hospice services.

The facility reported a census of 32 residents all receiving meals from one kitchen. Based on observation, staff interview, and record review the facility failed to store food under sanitary conditions by the failure to dispose of undated food items. Findings included: - On [DATE] at 01:30PM, during the initial tour of the main kitchen, the following items were undated/expired: six bags of corn chips, one bag of rice cereal, five containers of horseradish, and one bag of shredded carrots. Also, on the initial tour of the staging kitchen, the following items were undated/expired: one bag of frosted flakes cereal and one bag of corn flakes cereal. During an interview on [DATE] at 01:45 PM, dietary staff A threw away all expired items and stated she expected all staff to monitor food items more closely for expiration dates. All open perishable foods were to be used within seven days of opening or by the expiration date, which ever came first. Opened dry goods were to be used within 90 days of opening or by the expiration date, whichever came first. Dietary staff A stated she expected all staff to remove all expired items from the shelf to prevent them from being used. Review of the Food Service Policies and Procedures dated ,[DATE] documented, All non-perishable food items will be maintained no longer than 3 months. This will be identified by a date that states when product was opened. Food will not be used and will be disposed of 90 days from opened date. The facility failed to store food in accordance with professional standards for food service safety to prevent the outbreak of foodborne illness when observations revealed expired food in the kitchen.

The facility reported a census of 37 residents with eight cognitively impaired, mobile residents noted. Based on observation and interview the facility failed to provide an environment free from accident hazards over which the facility had control when the facility staff left poisonous chemicals in an unlocked cabinet to which residents had access. Findings included: - Observation on 07/31/19 at 05:28 PM revealed an unlocked shower room door on the 200 hallway with a chemical noted in an unlocked cabinet. The chemical was noted as 73 Acid bathroom cleaner and a label which noted the chemical as poisonous. Interview with Certified Nurse Aide (CNA) Q on 07/31/19 at 05:30 PM revealed the shower room doors should be locked and the chemicals should not be in unlocked cabinets. Interview with Administrative staff A on 07/31/19 at 07:02 PM revealed the shower room doors should be locked. The facility failed to provide a policy regarding environment/unlocked chemicals requested on 07/31/19. The facility failed to provide an environment free from accident hazards over which the facility had control when the facility staff left poisonous chemicals in an unlocked cabinet to which residents had access.

The facility reported a census of 37 residents with 13 residents included in the sample. Based on observation, interview, and record review the facility failed to ensure staff immediately identified and reported allegations of abuse, neglect, exploitation or mistreatment immediately to the administrator of the facility as per facility policy and regulatory requirements for Resident (R) 9. Findings included: - During a confidential interview on survey, a staff member stated two to three weeks ago R9 told him/her of an allegation of abuse against Certified Nurse Aid (CNA) Q from 2 years ago and R9 reported she did not like CNA Q. The unidentified staff member assumed it had been dealt with, due to the age of the incident. The unidentified staff member said he/she knew to go to administrative staff with allegations of abuse, neglect and exploitation (ANE) but said he/she froze and did not know what to say but informed a licensed nurse. The unidentified staff member said when R9 told him/her of the abuse allegation R9 asked him/her to take her back to her room a different way to avoid CNA Q. The unidentified staff said no other residents had complaints about CNA Q. Interview during the resident council meeting on 07/31/19 at 10:00 AM revealed after the surveyor asked if any staff had made the residents feel afraid, humiliated, or degraded, R25 said R9 did not like CNA Q. R9 stated she did not want to talk about it at that time. Interview with R9 on 08/01/19 at 11:12 AM revealed an allegation of ANE involving CNA Q from (YEAR). R9 said she had reported to everyone that I do not care for him. R9 said she figured if she stayed away from CNA Q, I would not have to worry about it, but I wonder if he has hurt anyone else. Further interview with R9 revealed she was not fearful of CNA Q but did not care for him. Interview with CNA U on 08/05/19 at 03:00 PM revealed she knew R9 did not like CNA Q and everyone knew that because R9 told everyone she saw. CNA U said R9 had never told her why she did not like CNA Q, and R9 was never really willing/would talk about it. CNA U said the resident never displayed fear of CNA Q. Interview with CNA M on 08/05/19 at 03:05 PM revealed R9 had always said she did not like CNA Q, but CNA M did not ask R9 for the reason. Interview with Certified Medication Aide (CMA) R on 08/05/19 at 03:12 PM revealed she asked the resident why she rearranged her room and R9 said she was tired of seeing CNA Q walk up and down the hallway. CMA R said R9 said it jokingly and said a lot of residents did not like CNA Q. Interview with Licensed Nurse (LN) H on 08/01/19 at 11:56 AM revealed she received a report R9 had a dislike for CNA Q, but stated no other details were relayed to her, and she did not report it further. LN G said R9 had never really said why she did not like CNA Q and said no other residents had voiced a concern regarding CNA Q. Interview with Administrative Staff B on 08/01/19 at 11:30 AM revealed the facility had not had any complaints against CNA Q in the last five years. Interview with Administrative Staff A on 08/01/19 at 02:27 PM revealed the facility suspended CNA Q. Administrative Staff A revealed CNA Q had worked at the facility since 2006 with no investigations in his file. Administrative Staff A revealed upon notification of the ANE allegation today, the facility had appropriately reported the ANE allegation. Review of the policy and procedure for abuse, neglect, and exploitation (ANE), date unknown, revealed ANE would be covered in employee training and through ongoing yearly in-services. The training would reflect on what constitutes ANE, the detection of, interventions for, reporting of, prevention of to include reasonable suspicion of a crime against a resident. All employees would complete a mandatory in-service quiz upon completion of the review of the facility policy. Immediate reaction was expected of all staff to all allegations or questions of ANE by residents, family members, employees or guests. Staff were to immediately protect the resident and report to the person in charge or up the chain of command. The facility failed to ensure staff immediately identified and reported allegations of abuse, neglect, exploitation or mistreatment immediately to the administrator of the facility as per facility policy and regulatory requirements for Resident (R) 9.

The facility reported a census of 37 residents with 13 included in the sample. Based on observation, interview, and record review the facility failed to provide the appropriate cleaning for Resident (R) 32's urinary catheter bags to meet professional standards. Findings included: - Review of R32's physician's orders [REDACTED]. due to some type of obstruction causing urine to flow backward into the kidneys). Review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The resident required extensive assistance of two staff for toilet use, limited assistance of one staff for personal hygiene, and had an indwelling catheter. Review of the annual MDS dated [DATE] revealed a BIMS score of 15, indicating intact cognition. The resident required extensive assistance of two staff for toilet use, required one staff assistance for personal hygiene, and had an indwelling catheter. Review of the Care Area Assessment (CAA) dated 07/01/19 revealed the resident suffered from [MEDICAL CONDITIONS], presented with impaired mobility, and required a urinary catheter. Review of Care Plan dated 04/13/19, revised 07/05/19, revealed the resident had a catheter with potential for infection related to [MEDICAL CONDITION] and a [DIAGNOSES REDACTED]. The care plan revealed the resident used a leg bag when out of bed, and staff were to replace with a urinary bag when R32 was in bed. The staff were to cleanse the tip of the bag when switching from the bed bag to the leg bag and clean the bag with soap and water before reconnecting. The staff were to encourage fluids and document input and output. The staff were to complete catheter care with soap and water every shift, observe the resident's skin for signs and symptoms of infection, check the catheter bag every 2 hours, and empty as needed. Observation of R32 on 07/31/19 at 08:27 AM revealed Certified Medication Aide (CMA) O applied gloves and cleaned the catheter ends with alcohol swabs then changed R32's bed bag to a leg bag. CMA O drained the bed bag straw yellow urine. CMA O then cleansed the bed catheter bag with hot water, drained, and placed the bed catheter bag in a bag hung in R32's bathroom. Per interview at the same time with CMA O, staff reused the catheter bag and leg bag for a month before it was changed. CMA O stated the staff washed the leg bag the same way staff washed the catheter bag. Observation of the central supply and the nurse's station on 08/01/19 at 06:28 PM revealed no vinegar located in either locked area. When asked about the lack of vinegar, Administrative Staff A and Administrative Nurse D said they did not know why there was not any vinegar and added the facility did fire the stock employee recently. Interview with R32 on 08/01/19 at 04:47 PM revealed he had a history of [REDACTED]. R32 reported he had never physically watched the CNA's clean his catheter bags and said the staff cleaned them in the bathroom. Interview with CMA O on 07/31/19 at 08:31 AM revealed the staff used to wash the catheter bags with a water/vinegar mix but the staff now just used hot water and staff ensured to clean the attachment with the alcohol swabs before connecting the tubes. CMA O stated the vinegar mixture was one-part vinegar and three-parts water, and CMA O did not understand why the facility wanted the care staff to stop cleaning the catheter bags in that manner. CMA O stated the direct care staff did not have access to the vinegar. Interview with CNA N on 08/01/19 at 05:51 PM revealed staff received training videos and in-services with hands-on training (on cleaning catheters). CNA N said she honestly thought all staff needed a refresher though, because one CNA would say one thing and the other CNA would say something else in regard to how staff were supposed to clean catheter bags. CNA N said supposedly staff were only supposed to use water to rinse the catheter bags. CNA N said if a resident displayed symptoms of a UTI she would notify the nurse. Interview with CNA M on 08/01/19 at 05:46 PM revealed the staff training on catheter bag cleaning used to be with vinegar, but now staff completed catheter bag cleaning with soap and water to clean them out. CNA M said the administrative staff took all the vinegar away from direct care staff and she did not know if the facility even had vinegar currently. Interview with Licensed Nurse (LN) G on 07/31/19 at 08:39 AM revealed R32 did have a current UTI, but she was not sure if that was a chronic condition for R32. LN G said when R32 got up in the morning, staff switched him from the bed bag to the leg bag, and the staff rinsed the (urinary catheter) bags with hot water and re-used those bags for a month until a new one was placed. LN G said the staff used to wash the catheter bags with water and vinegar, but said maybe the policy had changed. Interview with Administrative Nurse D on 07/31/19 at 08:54 AM revealed R32's care plan should not instruct the staff to clean the catheter bags with soap and water, and said it should instruct the staff to clean the (urinary catheter) bags with the vinegar/water mixture. Administrative Nurse D stated the vinegar (used to clean the catheter bags) was in central supply and the CNA's needed to ask for it. Administrative Nurse D said she did not feel the way the staff cleaned the catheter bags had caused any infection and stated the UTI's had gone down in the last few months. Interview with Administrative Staff A on 07/31/19 at 08:50 AM revealed she expected the staff to clean the catheter bags with the vinegar/water mixture. Administrative Staff A said this was something staff were still working on with the CNAs and it did not surprise her the staff were unsure of the policy. Administrative Staff A said the policy for changing the (catheter) bags had not been updated since she took over her position and was one of the things the facility was still working on to roll out the new procedures for cleaning catheter bags. Review of catheter leg bag care policy dated 2/2016 revealed the catheter leg bag .would be cleaned daily. The solution to be used would be comprised of water and vinegar in the ratio of one-part vinegar to one-part water. The policy additionally instructed staff allow the liquid to stay in the bag for 30 minutes. The facility failed to provide the appropriate cleaning for R32's urinary catheter bags to meet professional standards.

The facility reported a census of 37 residents with 13 residents included in the sample. Based on observation, interview and record review the facility failed to ensure the completion of the monthly pharmacist Medication Regimen Review (MRR) to include the physician responses for Resident (R) 26, R5, and R21. Findings included: - Review of R26's pharmacy Medication Regimen Review (MRR) revealed the following: 1. Missing MRR's noted for 07/2018, 08/2018, 09/2018, and 11/2018. 2. No physician responses recorded for the MRR on 12/2018 and 06/2019. Review of R5's pharmacy MRR revealed the following: 1. Missing MRR's noted for 07/2018 and 11/2018. 2. No physician responses recorded for the MRR on 09/2018, 10/2018, and 12/2018. Review of R21's pharmacy MRR revealed the following: 1. No physician responses recorded for the MRR on 05/2019 and 06/2019. Interview with Administrative Staff A on 08/01/19 at 05:17 PM revealed the pharmacist completed the MRR monthly and submitted them to the physician. Administrative Staff A said the director of nursing (DON) followed up on the MRR's. Interview with Administrative staff A on 08/05/19 at 02:52 PM revealed the prior DON had old pharmacy reviews in her office that were not completed. Review of medication regimen review policy dated 11/2017 revealed upon completion of the MRR the facility designee and/or attending physician would respond to the recommendations in a timely manner. If no response was received from the attending physician within twenty-one business days of the initial requested review, the DON would contact the facilities medical director or designee agent for requested responses/recommendations and the staff would doucment the attempted contact in the residents file. Any written and/or electronic communications provided to the facility would be filed and any attachments in electronic medical records under specific resident information. The facility failed to ensure the completion of the pharmacist Medication Regimen Reviews (MRR) to include the physician responses for Resident (R) 26, R5, and R21.

The facility totaled 83 residents with 3 residents included in the sample for elopement (an incident in which a cognitively impaired resident with poor or impaired decision-making ability/safety awareness leaves the facility without the knowledge of staff). Based on observation, interview, and record review, the facility failed to identify resident #1 as an elopement risk and place interventions to prevent him/her from eloping from the facility. The resident the eloped from the facility for approximately 19 minutes and traveled approximately 667 feet prior to being found by a passing motorist and returned to the facility. The facility failed to perform elopement risk assessments on residents #1,2, and 3 upon admission and quarterly. Findings included: - Resident #1 [DIAGNOSES REDACTED]. Review of the resident's baseline care plan, initiated 8/23/18, advised staff he/she required assistance of 1-2 staff members, a gait belt, and a front wheeled walker (FWW) for transfers due to weakness to the left lower extremity. The resident also required toileting every 2 hours. On 8/27/18, a WanderGuard (bracelet that sets off an alarm when residents wearing one attempt to exit the building without an escort) was placed on the resident's left ankle. Review of a nurses note, dated 8/23/18, revealed the resident was admitted to the facility at 4 PM and had an unsteady gait with walking with the FWW. He/she did not know what year or his/her location. Nurses note dated 8/24/18 revealed the resident had been up and down several times with an unsteady gait and would forget his/her FWW. Review of a nurses note dated 8/24/18, revealed the resident was compulsive, but easy to redirect. The resident required assist of 1 staff and FWW if he/she was not already up. On the fall risk assessment of factors contributing to fall risk dated 8/24/18, revealed the resident had tripped getting out of the car several days prior. Behavior pattern that made the resident unsafe had been identified as being anxious at times, poor safety awareness, and he/she did not call for assistance appropriately. The resident's gait pattern changed while walking and he/she had jerking movements and instability. The resident had an inability to understand and/or follow directions with impaired judgement and/or decision-making ability. An 8/25/18 nurses note revealed the resident did not wander during that shift. Review of a nurses note, dated 8/26/18, revealed the resident was anxious and wandering at the start of the licensed nurse shift. He/she had been transferring his/herself out of the room and walking without assistance. The resident had a fall alarm (at this facility, a pad that was placed under the resident which would detect when the resident's bodyweight had been removed and send a signal to the direct care staff's pagers) and was frequently visualized by staff. An 8/27/18 nurses note revealed that the direct care staff had notified the nurse the resident's fall alarm had been activated and he/she was not in his/her room. The facility staff had begun searching the facility and contacted the on-site security. The resident had been located at the front of the independent living facility with no injuries. The licensed nursing staff applied a WanderGuard to the resident. The point of care charting revealed between 8/23/18-8/29/18, the resident had 6 instances of documented wandering. review of the resident's medical record revealed [REDACTED]. Review of a facility obtained notarized witness statement from Good Samaritan J over the phone with administrative nursing staff F on 8/29/18 revealed the good Samaritan J had been driving near the facility and seen a person that appeared unstable. He/she then called his/her family member, who was employed by the facility. The good Samaritan stopped and asked the person if help was needed and that person replied they did. By that time the family member, direct care staff C had arrived at the location and they asked the person if he/she lived at the facility. The person said he/she did so they drove him/her to the entry of the independent living facility. At that time, the person they had located stated they were now visiting a client at the facility and could not locate his/her car. While attempting to describe the car, good Samaritan stated they could see his/her confusion. Direct care staff C went to the front desk to see if the person was a resident at that facility and right at that moment two other staff members arrived and reported the person in their care was resident #1. They allowed a staff member in the back of the car and were instructed on where to take the resident and met at the door by the other employee with a wheelchair. Review of notarized witness statement from direct care staff A revealed he/she had been providing care to another resident and then heard a door alarm sounding. He/she then went to the enunciator display in the commons area and noted it was sounding for the service doors. Staff A went to the services doors, entered the code to turn the alarm off and then looked in the hallway behind the doors. He/she believed that a fell ow staff member had forgot to deactivate the alarm prior to entering/exiting. Facility obtained notarized witness statement from direct care staff H revealed he/she had been providing care to another resident and had been notified that resident #1's fall monitor had been activated. He/she completed providing care to the resident and then went to provide care for resident #1. He/she reported the resident was not located in his/her room, so staff H went with another staff member to check another hallway in the facility. They notified other direct care staff the resident was not located and asked for assistance locating him/her. While searching for the resident, they notified a licensed nurse the resident was missing and proceeded to search other hallways to search for the resident. About the time direct care staff completed a search of a different hallway, other direct care staff were bringing the resident back to his/her room in a wheelchair. Facility obtained notarized witness statement from direct care staff K revealed at approximately 8:40-8:45 PM several other direct care staff reported being unable to locate a resident. We were advised of name and physical description and set off to locate the resident. While approaching the front entrance to the independent living facility, an off-duty staff member was noted to be at the entry way with the resident in his/her family members car. Direct care staff K climbed into the back seat of the car and directed the driver to the long-term care facility house entrance. Another staff member met them at the entrance with a wheelchair and they proceeded to return the resident to his/her room. Notarized witness statement from direct care staff B revealed that staff from the hall the resident resided on advised him/her they were looking for the resident. Staff B then proceeded to search the activities room, kitchen, and 300 hallway for the resident. While he/she was on the 300 hallway, direct care staff A recalled deactivating the door alarm for the service hall door just not to long before. Direct care staff B went out the service door's and then the exterior doors and searched the parking lot, but he/she did not see resident #1. He/she went back inside and begin to walk the hallways to the entrance of the independent living. Upon arriving at the entrance, there was an off duty staff member and his/her family member with the resident in their car. Fearful of him/her being tired and weak, they were asked to drive the resident to the entrance of the long term care house the resident was residing and staff B met them at the entrance with a wheelchair. He/she recalled that after getting the resident back to his/her room and returning to his/her assigned hall, it was 9:11 PM. Facility obtained notarized witness statement from direct care staff C revealed he/she received a phone call at 9:02 PM from his/her family member who stated they had seen and older person struggling to walk and did not appear to be in good shape. He/she asked what they should do and wondered if they could be a resident of the facility. The family member stopped and asked the person if they needed help and they said they did, so the family member got them into their car and waited for staff C to arrive, which was less than 5 minutes. The person advised they lived at the facility, so they drove to the front of the facility and at that time 2 direct care staff members were arriving saying that a resident was missing. Staff C told them he/she believed they had the resident in his/her car and they confirmed it after looking in the car. After that, the resident changed his/her story and advised he/she was visiting a client at the facility and could not find his/her car. They drove him/her back to the entry of the long term care house he/she resided in and the other direct care staff met us out front with a wheelchair. During an interview with direct care staff H on 8/29/18 at 5:28 PM revealed he/she had been providing care to the resident the night he/she eloped. He/she had been providing care to another resident when resident #1's silent alarm went off. He/she finished providing care to the resident he/she was with and less than 5 minutes was in resident #1's room to check on him/her. He/she stated they had seen the resident approximately 5-10 minutes prior to the alarm being activated sitting in his/her recliner in his/her room. Upon his/her arrival into the resident's room, the resident was not present. The resident was new to the facility and this was his/her first night of providing care to that resident, so he/she did not know if the resident wandered prior. He/she stated the only other item they could think of different from the notarized witness statement was that staff did not deactivate the silent alarm until the resident was back in the recliner. Interview with direct care staff C on 8/29/18 at 2:09 PM revealed he/she had no changes from his/her above notarized witness statement and he/she had never provided care to the resident. Interview with direct care staff B on 8/29/18 at 1:36 PM revealed he/she had forgotten to place in his/her witness statement that the resident had been too weak to get out of the car at the main entry way and they was why he/she asked for him to be driven around to the entry of the long term care house and why he/she had brought out the wheelchair. Interview with direct care staff A on 8/30/18 at 9:43 AM revealed after deactivating the alarm on the service door, he/she had checked the hallway behind the service door and then proceeded to some glass doors approximately 50 feet to the right of the other exterior doors and peered outside. He/she did not see anyone or anything in the parking lot and then proceeded on with his/her duties. Less than 5 minutes after deactivating the alarm was when he/she was advised of the missing resident. He/she agreed with his/her notarized witness statement. Interview with licensed nursing staff I on 8/29/18 at 2:35 PM revealed he/she was the nurse providing care for the resident the evening he/she eloped. The resident had multiple family members visiting that evening and staff I had been advised by one of them that the resident believed he/she was going home with them. Staff I then proceeded to walk with the resident to the front door of the house to say goodbye to his/her family members and then walked back to the recliner in his/her room with no concerns noted. Staff I did report the resident had wandered in the facility before but was usually related to him/her looking for a bathroom. After the resident returned to the facility from being out, staff I performed a head to toe assessment and did not see any indications of the resident having fallen which had been a primary concern since he/she had left the facility without his/her FWW. During an interview with administrative staff G and administrative nursing staff F on 8/29/18 at 10:55 AM revealed the resident was discovered while still on the facility campus (per Google maps estimate the resident had traveled approximately 667 feet from potential exit point) and had been located by a family member of an off-duty staff member. The family and staff member had brought the resident to the front door of the facility and right at that time, several of the direct care who had been searching for the resident arrived and they were able to identify the resident. Staff had reported that a door alarm had gone off and after looking at the enunciator panel, it had been found to be the service door. The staff peered out and reported they had not seen any residents. Then the silent alarm had been triggered and after pulling the records, the alarm had been triggered at 8:47 PM and staff reported they had not reset the alarm until the resident was back in his/her room and the alarm was deactivated at 9:06 PM (total of 19 minutes). Administrative staff had determined the causal factor was that an elopement assessment had not been completed upon the resident's admission. During an interview with administrative staff G on 8/30/18 at 4:10 PM revealed he/she had found that elopement risk assessments had not been completed on the residents per the policy when they started to perform the investigation into how resident #1 had eloped. Review of the policy entitled Elopement Risk Prevention or Response, last revised 6/17, revealed that all resident were screened for elopement risk upon the first day of admission, quarterly, change of condition, or after attempted elopement and utilized in the care planning process. The facility failed to develop interventions for resident #1 to ensure he/she did not elope from the facility after demonstrating signs of wandering prior to his/her elopement. The facility also failed to ensure residents #1,2,and 3 were screened for elopement risk quarterly and upon admission in an effort to prevent elopement from occurring.

The facility reported a census of 78 residents. Based on observation, interview and record review, the facility failed to maintain a sanitary kitchen environment in 2 of the 7 kitchenettes serving food to the residents, and failed to maintain adequate hand hygiene practices in the main kitchen, to ensure sanitary food preparation, distribution and service of foods in accordance of professional standards for food service safety, for the residents of the facility. Findings included: - On 06/11/18 at 8:33 AM, during initial tour of the main kitchen food areas, with dietary staff D, revealed multiple dietary staff worked during breakfast preparing multiple different food/serving items, in multiple different areas. The large kitchen area contained a center walk-through area from one dining room and out through a back service door. The center area held the kitchen handwashing sink for the main entrance of the kitchen. However, upon attempt to complete handwashing prior to inspection in the kitchen areas, revealed the handwashing sink lacked any paper towels and instead had a hand blow dryer on the wall. Therefore, after cleaning your hands, a staff would be unable to turn the water off (from the soiled faucet handles) without recontaminating his/her hands. Dietary staff D verified the failure to turn off the water in the sink and ability to keep his/her hands clean, prior to going into the food areas of the kitchen. On 6/13/18 from 10:40 AM through 12:00 PM, observations of the main kitchen dietary staff A, revealed the staff pulled steam pans of food items from various ovens, checked the temperatures of the foods, and placed them into warmed carts for each of the 2 nursing units. This observation time in the facility's main kitchen, revealed multiple staff members in and out of the main kitchen food areas without washing hands prior to entering or exiting. One observed staff member attempted to wash his/her hands and then realized no way to turn off the water with the soiled faucet handles after blow drying his/her hands. The staff attempted to turn off the faucet using his/her elbow. Other observations during this time, included the following staff failing to wash his/her hands prior to contact with the resident's foods or food utensil items. 1.) At 11:05 AM, dietary staff B, entered the main kitchen, did not attempt to wash his/her hands and reported coming to the kitchen for sloppy joes. Another staff informed staff B it was in the oven. Staff B used an oven mitt and removed a steam pan with sloppy joes, placing it on a preparation counter. Staff B opened the end of the foil and obtained a temperature reading of the food. Staff B closed the foil, picked up a marker and wrote the temperature of the food on the foil top. Staff B picked up the steam pan and exited the main kitchen to go back to his/her satellite kitchen for food serving. 2.) At 11:20 AM, another dietary staff C entered the main kitchen and did not attempt to wash his/her hands. Staff C reported coming to the main kitchen for pickles. Staff C went to the reach-in refrigerator and took out a large jar of pickles, putting it on the food preparation counter, went to the back dishwasher section, opened a drawer and pulled out tongs, then took a plastic container off of a drying rack, returned to the other preparation counter, and used the tongs to obtain pickles. Staff C replaced the jar of pickles into the reach-in refrigerator, used a marker to write out a label and placed it on the plastic wrap top of the container. Staff C then returned to another satellite kitchenette to serve food items to the residents. 3.) Multiple observations, from 10:40 AM through 12 noon, revealed administrative assistant staff E, came in and out of the main kitchen food areas on multiple occasions, without any attempts to wash his/her hands. Staff E was preparing food/drink/utensil items for a group in an adjacent dining area. Staff E did wear a hair net but did not attempt to wash his/her hands. This staff member answered the telephone, on the wall, across from the hand washing sink, at least twice, put glasses on carts to take to the other room. Staff C touched drinking glasses, cups, utensils, trays, both in and out of the food preparation and serving areas. Staff E went in and out of the walk-in refrigerator, and brought out a bag of various prepared mixed fruit and put it on the preparation table, then grabbed a plastic container from the drying area to put the fruit in. At that point, staff E, did stop and attempted to wash his/her hands, but without any paper towels, he/she had to touch the soiled faucet handles to turn off the water. The Facility's 12/16, policy for hand hygiene, instructed staff involved in handling food would perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents and visitors. The procedure instructed steps for hand hygiene, which included, . e.) Dry thoroughly with a single-use towel. F.) Use towel to turn off the faucet . The hand hygiene table included conditions for hand hygiene as before preparing or handling medications or food items. The facility failed to maintain adequate hand hygiene practices in the main kitchen, to ensure sanitary food preparation, distribution and service of foods in accordance of professional standards for food service safety, for the residents of the facility. - Observation, on 6-11-18 at 10:30 am, revealed a kitchenette on Hester hall, revealed 4 drawers in the kitchenette cabinetry, containing food items and utensils, had spillage stains and crumbs in the front interior of the drawers. Another kitchenette cabinetry contained exterior cupboard doors, that contained dried food and liquid drippings. Interview, on 6-14-18 at 1:30 pm, with dietary administrative staff E revealed the floors and fronts of the cabinets were the responsibility of the housekeeping staff to clean and the inside of the cabinets/drawers/counter tops, were the responsibility of the dietary aide assigned to the kitchenette. The undated facility policy for kitchen cleaning, did not address the cleaning responsibilities of the kitchenettes. The facility failed to ensure the drawers of the 2 kitchenette were maintained in a sanitary manner to prevent the spread of food borne infections for the residents.

The facility reported a census of 78 residents. Based on observation and interview, the facility failed to maintain an effective infection control program when the housekeeping services failed to properly sanitize a resident with infection's room, to prevent the spread of infection to the other residents of the facility. Findings included: - Observation, on 6-13-18 at 10:00 am, revealed housekeeping staff G provided housekeeping services/sanitation to a residents' isolation room. Staff G, wore personal protective equipment of footwear, gown, gloves and mask. He/she gathered cleaning supplies and sprayed the toilet and sink areas with Virucept (a disinfectant). Staff G stated that the wet time required to adequately disinfect the surfaces was 10 minutes. On 6-13-18 at 10:03 AM, after 3 minutes of wet time, staff G wiped down the sink and door knobs. On 6-13-18 at 10:05 AM, after 5 minutes of wet time, staff G cleaned the inside of the toilet and sprayed it with toilet bowel cleaner. He/she confirmed that there had not been a 10 minutes since he/she sprayed the Virucept. On 6-13-18 at 11:15 AM, administrative staff F, confirmed the expectation was that the wet time for Virucept be left on for 10 minutes as recommended on the bottle. The facility failed to maintain an effective infection control program related to sanitizing a resident's isolation room, with failure to ensure adequate wet time of the sanitizer, to prevent the spread of infections for the residents of the facility.

The facility census totaled 104 residents with 3 sampled for accidents. Based on observation, interview and record review, the facility failed to ensure staff stayed with the resident while on the toilet as care planned for 1 of 3 residents, who had repeated (6 total falls in a 3 month time period, 3 of which were from the toilet) which resulted in 3 abrasions, a laceration to the forehead which a physician closed with sutures and a fractured scapula (shoulder blade). (#1) Finding included: - Review of resident #1's admission orders [REDACTED]. The significant change MDS (minimum data set) dated 7/26/16 included a BIMS (brief interview for mental status) score of 15, indicating cognition intact with no rejection of cares. The resident required extensive assistance of two or more staff for bed mobility, transfers, and toilet use. The resident received scheduled and PRN (as needed) pain medications in last 5 days of the observation period and the resident reported pain almost constantly which affected his/her sleep. The resident fell prior to admission but had not since admission or prior assessment dated [DATE]. Review of the ADL (activities of daily living) CAA (care area assessment) dated 8/1/16 revealed the resident showed limited range of motion to the right ankle (from foot drop) and both shoulders (from rotator cuff (shoulder) injury). These were not new concerns but did limit his/her ADL abilities. He/she showed signs of weakness and had difficulty standing for extended periods. The resident received physical and occupational therapy prior to hospitalization and felt he/she functioned at the same level as before hospitalization . He/she required 1 staff member assist with ADLs. Staff provided physical assistance with transfers, dressing and toileting as he/she lost his/her balance when attempting to transfer independently. The fall CAA dated 8/1/16 identified the resident at increased risk for falls related to previous admission factors listed: weakness and unsteadiness at times, limited weight bearing on right leg from chronic foot drop. The resident reported declining strength over past year with a history of multiple falls. Risk factors included the following medications with possible side effects that increased fall risk: tramadol (an anti- inflammatory), bumex (diuretic), baclofen (antispasmodic), gabapentin (nerve pain medication), duloxetine (nerve pain medication), Benadryl (antihistamine), topiramate (nerve pain medication) and bystolic (to lower blood pressure). The resident also had an implanted morphine pain pump which had the potential to alter his/her alertness/cognitive ability but he/she denied any difficulties or concerns with feeling dizzy or lightheaded. On 6/16/16 staff noted the resident as a very high risk for falls. The resident reported several falls over the past several months with one resulting in an unspecified head injury. He/she could not walk and needed assistance of 1 staff for pivot transfers to the wheelchair. As of 8/1/16 there were no acute changes as noted to above assessment. The resident continued to require staff assistance for mobility and remained alert and oriented. He/she continued on the same medications which increased his/her fall risk. The significant change MDS dated [DATE] included the same information on cognition, no rejection of cares and ADLs. The resident had 2 non-injury falls, 1 minor injury fall and 1 major injury fall since the last assessment. The ADL care plan with a revision dated of 8/1/16 included a problem of self-care deficit. The plan directed staff to provide the resident assistance by 1 staff to stand, pivot and transfer to the wheelchair with a gait belt and walker. The resident required 1 staff assist with toileting for transfers and wore a splint to the right lower leg. The care plan dated 8/1/16 included a problem of falls which identified the resident at increased risk for falls related to increased weakness and instability. The resident had decreased range of motion and functioning of the right lower extremity from foot drop with limited weight bearing and a history of multiple falls at home. The resident had adverse reaction to electric stimulation therapy which resulted in dead right leg and inability to ambulate. The resident received physical and occupational therapy but was hesitant to try and felt it was pointless. He/she expressed fear of falling. The 8/1/16 care plan directed staff to: Transfer the resident as described in ADL care plan. Keep the call light within the resident's reach and encourage him/her to use it. Assist the resident with transfers using a walker for help with stability. Monitor the resident for changes in alertness and orientation which may be affected by medication changes or acute medical changes. The resident wore a splint to the right foot, used a wheelchair for mobility which staff propelled, and needed to have the bed in the low position when in bed and a mat at bedside. Review of the facility's fall investigations for the resident revealed the following: On 6/11/16 at 8:20 PM the resident fell from the bed trying to reach the call light for assistance. The resident stated he/she was used to having a larger bed at home. The facility identified the root cause as a new place, new bed which was narrower. Interventions included lower bed to floor, place a fall mat on floor, apply a quarter side rail for turning and move the cabinet to other side of bed. The resident declined a concave mattress as well as body pillow for positioning. The care plan lacked the interventions from the fall investigation of adding quarter side rail and moving a cabinet. On 7/29/16 at 10:33 PM the resident was filling out paper on the bedside table which moved and the resident slid to the floor. The facility identified root cause of bedside table with wheels moved while the resident wrote on it to complete the menu. As an intervention, staff would help him/her fill out the menu, monitor for drowsiness and encourage him/her to lie back in bed if noted being tired. On 8/3/16 at 9:30 AM staff found the resident on the bathroom floor. The resident sat beside the toilet with blood on his/her forehead and floor from a laceration and a small skin tear to the right knee. The facility identified the root cause as the resident got dizzy or fell asleep on the toilet; lost balance and fell on forehead. Interventions to prevent future falls included frequent visual checks while the resident used the restroom and staff were to stay with the resident. The facility planned to research equipment to use for positioning if he/she needed to rest leaning forward when on the toilet. The nurses' notes dated 8/3/16 at 1:53 PM indicated the resident received a couple of stitches to close the laceration. As an intervention, staff were to remain in the room while the resident used the restroom. On 8/17/16 at 7:15 AM staff found the resident sitting on floor on top of blankets and pillows next to the bed. The resident said he/she slipped out of bed because of the blankets and pillows when he/she moved. The facility identified the root cause as the resident often sat on the edge of the bed and leaned forward resting on the bed rail. The facility planned to have a table constructed for use when sitting on side of bed or when in bathroom for extended periods of time. The facility failed to develop an immediate intervention while the staff came up with a table solution. On 8/19/16 at 7:30 PM staff found the resident sitting on the floor next to the bed. The resident said he/she attempted to take his/her shorts off and slid off the toilet. He/she could not reach the bathroom call light and scooted to the bed call light to call for assistance. The resident received 3 superficial abrasions on the right wrist. The facility extended the call cord for the bathroom and the resident agreed not to dress him/herself and call for assistance. The facility failed to develop a new intervention to prevent further falls from the toilet. On 8/23/16 at 12:28 AM staff found the resident on the bathroom floor sitting with his/her back against the toilet and holding his/her forehead which had a small laceration with moderate amount of red drainage. The resident said he/she reached for the wipes and fell to the floor. The resident complained of pain to his/her head and right shoulder. Staff sent the resident by ambulance to the hospital for evaluation. The emergency room reported the resident had a fractured right scapula. The laceration to his/her forehead was approximated and secured with sutures. Review of the X-ray report included in the facility's fall investigation dated 8/23/16 at 1:36 AM of the right shoulder revealed a fracture. The facility identified the root cause as staff assisted the resident to the toilet with the wheelchair placed to the side of the resident, and the resident verbalized he/she wanted to sit on the toilet for a bit. The resident leaned forward for cleansing wipes and fell off the toilet. Interventions included staff were to stay with resident at all times when toileting (an intervention previously put in place after the resident's 8/3/16 fall), and a folded fall mat in front of resident in bathroom if he/she refused to have staff present. Staff were to encourage the resident to call staff for assistance Review of direct care staff B's notarized statement included in the facility's investigation indicated he/she on 8/23/16 assisted the resident to the toilet at about 12:26 AM and when the resident rang at about 12:33 AM staff B entered the room and found the resident on the floor. The facility also sent a fax to the physician on 8/23/16 stating the resident started a new medication Trintellix (an antidepressant) on 8/16/16 and resident had an increase in confusion, tremors with 2 falls since starting new med (8/17/16 and 8/23/16, staff wrote in above this the fall of 8/19/16). The physician ordered to stop Trintellix and start Zoloft (an antidepressant) 25 mg (milligrams) 1 tablet daily. Review of additional fall investigations revealed: On 8/24/16 at 5:20 PM staff found the resident sitting on the floor in front of the recliner resident said he/she just plopped out. The resident reached to put a fork on bedside table and just slid right out of the chair. The resident said he/she put the foot rest down and then went to the floor. The root cause analysis portion of the investigation form remained blank. Staff added an intervention to place Dycem (a non-slip material) in the recliner to prevent sliding out of recliner. On 8/24/16 at 8:30 PM staff found the resident seated on the floor in front of the bed. The facility identified the root cause as the resident stated he/she needed something off the side table. Interventions included reminders to call for assistance for items not in reach and crib mattress on floor in front of bed. Scoop mattress placed on the bed and he/she felt more secure. Staff added interventions to place a mattress (crib mattress as defined in the investigation) next to the bed when he/she lay in bed. Encourage and educate the resident to use the call light when he/she needed something. The care plan lacked the interventions from the fall investigation of scoop mattress. Review of the progress notes from the orthopedic physician assistant dated 8/24/16 revealed the outside X-rays showed a fracture of the shoulder. The resident had severe rotator cuff arthropathy (a disease of the joint with signs of inflammation). The resident was dealing with significant neurological issues that were causing him/her to spasm and fall asleep. Review of the nurse's notes between 8/3/16 and 8/29/16 revealed the following: 8/4/16 at 11:53 AM - continues with fall follow-up. Staff had been staying with the resident while he/she used the restroom for safety. The resident has slept a lot this shift. 8/4/16 at 11:14 PM - staff stayed in room with the resident while he/she used the restroom for safety. 8/6/16 at 9:14 PM - staff stayed with the resident while he/she used the bathroom for safety and the resident denied dizziness when asked. 8/18/16 at 1:05 AM - the resident was in the bathroom sitting on the toilet with eyes closed. The resident awakened to name and was alert to person and place. The resident transferred with assistance of 1 staff with a gait belt, standing and pivoting. 8/18/16 at 12:43 PM- resident was calm and cooperative with staff. He/she sat on the edge of the bed in front of his/her tray table the majority of the shift with reminders to call for assistance to lay in bed if he/she got sleepy to reduce risk of another fall. 8/20/16 at 10:41 AM- resident complained of not feeling right. The resident fell twice this week (8/17/16 & 8/19/16). The resident could not focus or stay upright while sitting. The resident had jerking movement in lower and upper extremities. The resident stated he/she wanted to see the doctor because something was not right. Staff took the resident to the walk-in clinic. Note at 6:55 PM indicated the resident went from the walk-in clinic to the hospital for additional testing and returned to the facility at 5:30 PM with a [DIAGNOSES REDACTED]. CT (computerized imaging by X-ray) of the spine revealed severe degenerative disc disease with space narrowing. Orders for Lidocaine patch (a local anesthetic that stops nerves from transmitting painful impulses to the brain) to back and remove at 5:00 AM tomorrow and follow-up with a specialist. 8/21/16 at 1:52 PM- The resident stated he/she felt more like him/herself today. The small jerky movements continued at times. 8/21/16 at 9:17 PM- resident noted sitting on bed with his/her head down having small jerky movements. When staff asked if he/she felt okay, the resident replied yes. The resident appeared to be weaker than normal and continued to be a high fall risk. 8/22/16 at 2:34 PM- The resident was alert and oriented, and woke when spoken to but quickly returned to sleep. The family member present said he/she had not seen the resident that tired. 8/23/16 at 2:45 AM- staff recorded at 12:28 AM the nurse received notification the resident was on the floor in the bathroom. Staff found the resident sitting on his/her buttocks with legs outward and back against the toilet holding his/her forehead which had a small laceration. The resident verbalized leaning forward to reach the wipes and fell to the floor. The resident complained of pain to his/her head and right shoulder. The resident went by ambulance to the hospital emergency room for evaluation. The above notes reflect the resident having pain, decreased alertness, and sleepiness with jerky movements, appeared weaker and needed to lean on items for comfort when sitting up. No further mention of staff staying with the resident while on the toilet after 8/6/16. On 10/10/16 at 3:39 PM observation revealed the resident lay in bed with a scoop mattress in place with 1 quarter rail on the right upper bed and multiple pillows. The bed was at standard height of about 3-3.5 feet from the floor with no mat on the floor and the over bed table sat to the right of the bed. At 4:38 PM observation revealed the resident remained in same position with pillows and bed same height with no mat on the floor. On 10/11/16 at 8:39 AM observation revealed direct care staff A answered the resident's call light. The resident said he/she was not awake yet but needed to use the restroom. Observation revealed the bed a standard height of about 3-3.5 feet from the floor and no fall mat on the floor. Direct care staff A lowered the bed, assisted the resident to sit on the side of the bed, and assisted the resident with hard plastic foot splint and shoes. Staff B applied a gait belt, positioned the wheelchair parallel to the bed and the resident used the side rail for support to stand and pivot to the chair. Once in the bathroom the resident used the grab bars to stand and pivot to the toilet. Staff A positioned a table in front of the resident which had the morning care items on it. Staff A remained in the room for a few minutes putting items away and making bed then reminded the resident to use the call light when he/she was done and staff A left the room. At 8:59 AM the resident rang the call light and direct care staff A assisted the resident to the wheelchair. On 10/11/16 at 10:40 AM the resident said when he/she fell on [DATE] he/she thought the staff was in the room just not in the bathroom because he/she wanted privacy. The resident said he/she reached for the wipes and lost her balance falling off the toilet. He/she said since the staff put the table in front of him/her with all the needed items he/she had not fallen since. On 10/11/16 at 8:43 am direct care staff A said the resident was supposed to have the mat on the floor but he/she did not like it and would tell staff not to put it there. He/she also did not want the bed lowered. On 10/11/16 at 11:55 AM interview with direct care staff B who confirmed he/she was assigned to care for the resident on 8/23/16 when the resident fell from the toilet after he/she left the resident alone on the toilet. He/she reported the resident needed to get up to the bathroom every hour or so and needed to sit for a while usually about 30 minutes. He/she said the resident had trouble with urine retention and it took a while to get it started. Staff B said the resident told him/her to go because he/she needed to sit for a while. Staff B said there was a time when staff had to stay with the resident while he/she was on the toilet but then he/she was directed to leave the resident because the resident used the call light. Direct care staff B stated there was confusion about what the care plan said about staying with the resident. He/she had been told it was ok during the night to leave the resident as staff were trying different things like a wheelchair beside him/her, then a walker and then a table. Staff B reported the resident did his/her own personal hygiene and kept the wipes on the floor beside the toilet. On 10/11/16 at 2:12 PM direct care staff C reported there was a time when staff was to stay with the resident on the toilet due to him/her falling from the toilet. He/she confirmed being on duty when the resident fell from the toilet on 8/19/16. He/she did not remember putting the resident on the toilet and it might have been co-worker. He/she reported being confused about staying with the resident because the resident wanted to sit on the toilet for 30 minutes at a time sometimes and staff were trying different things to keep him/her safe. Staff B said the resident really did not tolerate sitting up and needed to lean to the right side or forward. Staff had added the padding to the right safety rail at the toilet so he/she could lean on it. On 10/11/16 at 2:37 PM licensed nurse D reported he/she did not know staff needed to stay with the resident while on the toilet. He/she felt it was unrealistic on the night shift for staff to stay with the resident. The residents woke up often at night and need assistance. There were usually 4 direct care staff and a nurse to provide care for approximately 50-55 residents. If staff had to stay with one resident for 20 minutes or more that would not be enough staff. He/she did not think the resident was a fall risk once he/she sat on the toilet. Nurse D said the staff did not tell him/her the resident remained alone because the resident asked for privacy on the toilet before the fall on 8/23/16. When asked how he/she documented the time of the fall he/she reported looking at his/her watch to have the time for documentation purposes and confirmed the time as 12:28 AM. On 10/11/16 at 2:42 PM licensed nurse G reported he/she responded to the call light and found the resident on the floor with no staff present. He/she went to the room door and hollered for assistance when other 2 staff responded from another resident's room. He/she was not sure if the staff staying with the resident in the bathroom was started because of this fall on 8/19/16 or before that time. He/she said if staff needed to leave the resident to care for others the staff should have told him/her so he/she could sit with the resident. On 10/11/16 at 1:30 pm interview with administrative nurse F revealed the floor nurses completed the fall report with root cause analysis and developed an initial intervention to prevent future falls. He/she report the administrative team reviewed the fall reports routinely. When asked about the resident's care plan intervention of staff staying with the resident while on the toilet and he/she reported an expectation for staff to stay as close as the resident would allow. He/she said the staff needed to be close enough to hear if the resident moved about so the staff could respond and hopefully prevent a fall. He/she said the resident asked staff not to stay with him/her and staff respected the resident's wishes. He/she voiced an expectation for staff to stay close with the door open at least partially. He/she reported having many conversations with the resident to come up with ways to prevent future falls but did not know if the resident had been involved in the specific decision regarding staff staying with him/her while on the toilet. Review of the facility's policy titled, Fall Management dated April 2015 revealed the interdisciplinary team would develop an individualized plan of care for residents determined to have a potential for falling. All staff who worked directly with the resident was responsible for knowing and following the plan of care. The facility failed to ensure staff stayed with the resident while he/she used the restroom, failed to have bed in lower position and a floor mat on the floor as planned for resident #1 who experienced repeated falls from the toilet which resulted in a fractured scapula and forehead laceration which required a physician to close with sutures.