Every finding on record at Wichita County Health Center Ltcu

The facility had a census of 10 residents. Based on observation, interview, and record review, the facility failed to employ a full-time Certified Dietary Manager for the 10 residents who received their meals from the facility kitchen. This deficient practice placed the residents at risk of not receiving adequate nutrition. Findings included: - On 06/01/25 at 08:55 AM, observation in the facility's kitchen revealed three dietary staff working. On 06/02/25 at 09:10 AM, Dietary Staff BB verified she did not have certification as a Dietary Manager. She stated she had taken the coursework but not a test to become certified. On 06/03/25 at 08:00 AM, Administrative Nurse D verified the dietary manager was not certified. Administrative Nurse D was aware that the facility should have a Certified Dietary Manager. The facility's Dietary Manager policy, dated 10/26/22, stated the Dietary Manager would supervise food preparation and service, dietary supplies, conduct training for the dietary department, and maintain certified dietary manager credentials. The Dietary Manager would communicate with nursing and the registered dietician any nutritional concerns, assessments, recommendations, and care plan reviews.

The facility had a census of 10 residents. Based on observation, interview, and record review, the facility failed to store, prepare, and serve food in a sanitary condition for 10 residents who reside in the facility and received meals from the facility's kitchen, placing them at risk for foodborne illness. Findings included: - On 06/01/25 at 08:55 AM, the facility kitchen had three dietary staff cleaning and preparing food. The walk-in refrigerator had opened but undated containers of macaroni salad, black olives, cottage cheese, and one eight-pound box of Deli salad. On 06/01/25 at 09:00, Dietary Staff (DS) CC verified the opened, undated foods. On 06/02/25 at 09:10 AM, DS BB verified staff were to date packages of food when they opened them. The facility's Food Storage policy, dated 10/05/23, stated leftover food would be stored in covered containers or wrapped carefully and securely and clearly labeled and dated before being refrigerated.

The facility had a census of 10 residents. Based on observation, interview, and record review, the facility failed to provide a Bed Hold Notice to Resident (R) 2 or her representative, upon transfer and admission to a hospital. This deficient practice placed R2 at risk of not being permitted to return and resume residence in the nursing facility. Findings included: - R2's Electronic Medical Record documented diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), hypertension (elevated blood pressure), diabetes mellitus (DM - when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), and heart disease. R2's admission Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. The MDS documented R2 had re-entered the facility from a skilled nursing facility and required staff assistance with most activities of daily living. R2's Care Plan, dated 04/22/25, directed staff to report signs of medication reactions, take vital signs as ordered, and report abnormal values to the provider. The Progress Note dated 11/23/24 stated R2 was admitted to the hospital for respiratory failure and heart issues. The facility could not provide documentation they provided R2 with a Bed Hold Notice upon discharge to a hospital on [DATE]. On 06/01/25 at 12:55 PM, R2 sat in a recliner in her room. She wore oxygen per nasal cannula and stated she had been hospitalized for open heart surgery. On 06/03/25 at 08:45 AM, Administrative Nurse E verified the facility had not provided a Bed Hold notice to the resident or her representative upon discharge to the hospital on [DATE]. The facility's Bed Hold policy, dated 04/13/11, revised 06/03/25, stated before a nursing facility transfers a resident to a hospital the facility must provide written information to the resident or their representative concerning the bed hold policy.

The facility had a census of 10 residents. The sample included eight residents. Based on observation, record review, and interview, the facility failed to date insulin (a hormone that lowers the level of glucose in the blood) subcutaneous (beneath the skin) injectable pens with an open date and expiration date for Resident (R) 2 and R6. This deficient practice placed the residents at risk of receiving outdated medication that may cause adverse consequences. Findings included: - On [DATE] at 09:04 AM, during an initial tour of the medication room R2's Basaglar (long-acting insulin) and R10's Lantus (long-acting insulin) pens stored in the medication room refrigerator lacked open and expired dates. Licensed Nurse (LN) H verified the in-use pens stored in the medication room refrigerator lacked open and expired dates. On [DATE] at 09:01 AM, Administrative Nurse D verified the insulin pens in use should be labeled with open and expiration dates. The facility's Medication Administration Subcutaneous Injection policy, dated [DATE], documented that Licensed Nurses were allowed to administer patients and residents subcutaneous injections. The policy documented if using a multi-dose vial: date, time, and initial when it was opened.

The facility had a census of 10 residents. Based on observation, record review, and interview, the facility failed to display accurate nursing personnel hours for staff responsible for providing direct care accessible to residents and visitors. Findings included: - During the survey period of 06/01/25 to 06/03/25 the facility posted nursing staff by name and shift but lacked the facility's census and direct care nursing staff hours of nursing. On 06/03/25 at 08:00 AM, Administrative Nurse D reported using a different scheduling system and believed the posting was accurate, related to who and when direct care staff worked but lacked totaled hours. The facility's Posting Daily Nurse Staffing Form policy, dated 06/03/25, documented the Director of Nursing or designee would ensure that the number of registered nurses, licensed practical nurses and certified nurse aides (Direct Care Partners) scheduled for each day, the name of the facility, census of the facility, and total number of hours of each position listed in posted at the entrance to the health center and would be kept current during each day by revising the form as staffing and census change. Daily forms would be kept no less than eighteen (18) months.

The facility had a census of 10 residents. Based on record review and interviews, the facility failed to submit complete and accurate staff information through the Payroll-Based Journal (PBJ) as required. Findings included: - The PBJ report provided by the Centers for Medicare &Medicaid Services (CMS) for Fiscal Year (YR) 2024 Quarter (Q) 2 and Q3, indicated excessively low weekend staffing. The PBJ further indicated that Q4 lacked licensed nurse coverage for 24 hours, seven days in August, and one day in September 2024. A review of the facility's weekend and licensed nurse hours on the dates listed on the PBJ revealed appropriate weekend and licensed nurse coverage. On 06/02/25 at 08:00 AM, Administrative Nurse D reported that the discrepancy may be related to the vendor the facility used to submit PBJ information to CMS had not been accurate. The facility's undated Mandatory Submission of Uniform Format Staffing Information (PBJ) documented the facility will electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contracted staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by the Centers for Medicare and Medicaid Services (CMS). The facility would submit to CMS complete and accurate direct care staffing data, including the category of work for each person on direct care staff, including but not limited to if the individual was a registered nurse (RN), licensed practical nurse (LPN), licensed vocational nurse (LNV), certified nursing assistant (CNA), therapist, or other type of medical personnel as specified by CMS. Resident census data. Information on direct care staff turnover and tenure and the hours of care provided by each category of staff per resident day, including but not limited to, start date, end date, and hours worked for each individual. The facility would distinguish employees from agency and contracted workers. The facility would report information about direct care staff, the facility must specify if the individual was an employee of the facility or was engaged by the facility under contract or through an agency. The facility would submit as directed by CMS to CMS during the established staffing reporting periods but no less frequently than quarterly.

The facility had a census of eight residents. The sample included eight residents. Based on record review and interview, the facility failed to ensure licensed nursing staff had appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This placed all residents at risk for decreased quality of care. Findings included: - The facility Facility Assessment, dated 04/25/2019, documented nursing of personal care, enteral feedings (provision of nutrients through the gastrointestinal tract when the resident cannot ingest, chew or swallow food), wound and skin integrity, pain management, fall reduction program, diabetes (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin) management, orthopedic (pertaining to bones) management, palliative (treatment designed to relieve or reduce intensity of uncomfortable symptoms)/hospice care (end of life care), cardiovascular (pertaining to the heart and blood vessels) and cerebral vascular accident (stoke) management, activities of daily living, RAI (resident assessment instrument) process, diagnostic services/lab/radiology, respiratory care, infection control, medication management, bowel/bladder/GU(pertaining to genital and urinary system) management, care of mental illness, dementia(progressive mental disorder characterized by failing memory, confusion) care, care of dialysis (procedure where impurities or wastes were removed from the blood) residents, clinical records, vital signs including pain, blood glucose (sugar) monitoring, ostomy (a surgical procedure that creates an opening in the abdominal wall) services, respite care (short term health services to the dependent adult), and isolation procedures. The facility was unable to provide any evidence of staff competencies for the licensed nursing staff. On 09/19/23 at 04:34 PM, Administrative Nurse D reported the licensed nurse staff for the long-term care residents consisted of all agency nursing staff, which the facility did not assess competencies or provide performance evaluations for. Administrative Nurse D said the facility's nursing management staff which consisyted of the director of nursing, assistant director of nursing, Resident Assessment Instrument (RAI) nurse, and clinical care nurse were employees of the facility but also had no competency skill reviews. Upon request the facility failed to provide a policy for nursing staff competencies. The facility failed to ensure licensed staff had appropriate competencies and skill sets to provide nursing related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This placed all residents at risk for decreased quality of care.

The facility had a census of eight residents. The sample included eight residents. Based on observation, interview, and record review the facility failed to employ a full time certified dietary manager for the eight residents who resided in the facility and received meals from the facility kitchen. This deficient practice placed the eight residents at risk for receiving inadequate nutrition. Findings included: - On 09/18/23 at 08:20 AM, observation revealed six dietary staff preparing and serving meals in the facility's temporary kitchen. The facility kitchen was under construction and currently empty. Staff were using two dorm size refrigerators and the walk-in refrigerator and freezer. Staff served meals on disposable plates with regular cups and silverware. On 09/18/23 at 08:20 AM, Dietary Staff BB stated she was not certified in dietary management and had been taking those classes since January 2023. On 09/20/23 at 12:00 PM, Administrative Staff A stated the facility was aware the dietary manager needed to be certified. She stated the current dietary manager had been enrolled and taking classes since January 2023. The facilities Dietary Policy, dated 03/09/2012, stated the dietary manager was responsible for dietary assessment and progress notes, menu changes and options, and to inform the nursing supervisor and physician of dietician recommendations. The facility failed to employ a full time certified dietary manager for the eight residents who resided in the facility and received meals from the facility kitchen, placing the eight residents at risk for receiving inadequate nutrition.

The facility had a census of eight residents. The sample included eight residents. Based on observation, interview, and record review the facility failed to monitor refrigerator temperatures, sanitation during dishwashing, and failed to ensure thorough coverage of hair when serving meals. This deficient practice placed the eight residents of the facility at risk for food borne illness. Findings included: - On 09/18/23 at 08:20 AM, observation revealed six dietary staff preparing meals in the facility's temporary kitchen. The facility kitchen was under construction and currently empty. Staff were using two dorm size refrigerators and the walk-in refrigerator and freezer. Staff served meals on disposable plates with regular cups and silverware. On 09/18/23 at 11:45 AM, observation revealed one of six dietary staff with a moderate amount of hair outside of the back of the hairnet. On 09/19/23 at 07:45 AM, observation revealed Dietary Staff (DS) BB plated breakfast items from the steam table for residents with many long hairs dangling out of her hairnet. The Temperature Log for equipment temperatures had a line drawn through 09/15/23 and no refrigerator or freezer temperatures documented. On 09/16/23 through 09/18/23, the log lacked evidence the staff assessed and recorded refrigerator temperatures for the mini refrigerators used for food preparation during construction. On 09/19/23 at 08:41 AM, DS BB stated staff washed dishes using three dish tubs, Dawn dish detergent, quaternary sanitizer, and a rinse. DS BB verified staff had not tested the sanitizer in the dishwashing tubs for the past five days. DS BB verified staff were to ensure all hair was contained in a hair net when cooking or serving food. The Dietary Department Monitoring of Refrigerator/Freezer Temperatures policy, dated 07/06/2012, stated one time each shift staff would record the temperature of the reach in refrigerator, walk-in refrigerator, and walk-in freezer on the appropriate form. The Monitoring of Dish Machine Temperature/Sanitation policy, dated 06/28/12, stated staff would record the temperature and sanitation readings. Inadequate temperature or sanitation readings would be reported to the Dietary Manager as soon as possible. The Dietary Dress Code policy, dated 07/22/23, stated employees who work in food service must secure their hair and wear hairnets over hair in accordance with established health standards. The facility failed to monitor refrigerator temperatures and sanitation during dishwashing, and failed to ensure thorough coverage of hair when serving meals, placing the eight residents of the facility at risk for food borne illness.

The facility had a census of eight residents. Based on interview, and record review the facility failed to submit complete and accurate staffing information through Payroll Based Journaling (PBJ) when the facility failed to submit staffing hour data for all direct care personnel as required. Findings included: - The PBJ report provided by the Centers for Medicare & Medicaid Services (CMS) for Fiscal year (FY) 2022 Quarter 4 and FY 2023 Quarters 1 through 3 indicated data was suppressed though the facility did not meet the reasons for suppressed data other than inaccurate data or failure to report. On 09/20/23 at 10:36 AM, Administrative Nurse D reported he was now submitting the staffing information to CMS, and the staff who did it prior must have submitted the incomplete nursing coverage. Upon request the facility did not provide PBJ submission policy. The facility failed to submit accurate information to CMS PBJ as required.

The facility had a census of eight residents. The sample included eight residents. Based on observation, record review and interview, the facility failed to ensure Resident (R) 8 had a physician's order and was assessed for the ability to safely self- administer topical (on the surface of the body) medication, which placed R8 at risk of improper use of medication and related side effects. Findings included: - R8's Electronic Medical Record (EMR) recorded diagnoses of Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness), frequent falls, hypertension (elevated blood pressure), and urinary retention (lack of ability to urinate and empty the bladder). The Admission Minimum Data Set (MDS), dated [DATE], documented R8 had severe cognitive impairment, exhibited no behaviors, required limited assistance of one staff with transfers, walking, toilet use and personal hygiene. R8 was not steady and only able to stabilize with staff assistance; R8 had functional range of motion impairment to one side of upper and lower extremities and used a walker and wheelchair for mobility. The MDS further documented R8 was frequently incontinent of urine. R8 had falls prior to admission and had two or more non-injury falls and two or more falls with injury after admission. The Pain Management Care Plan, dated 07/26/23, documented R8 was able to voice increased pain, and took medication for neuropathy (weakness, numbness and pain from nerve damage, usually in the hands and feet). The plan further documented R8 had diclofenac gel (Voltaren-topical pain medication) as ordered as needed. The plan had un undated, handwritten intervention which stated R8 may keep Aspercreme (topical pain medication) at bedside and self- administer. The Physician Order, dated 06/06/23, stated staff may administer diclofenac two gram (gm) topically four times a day as needed. The Physician Order, dated 06/27/23, stated staff may administer Aspercreme twice a day as needed. The Physician Orders lacked direction R8 could self-administer any medications or keep at bedside. R8's clinical record lacked evidence the facility assessed R8's ability to safely and effectively self-administer topical medications. On 09/19/23 at 09:21 AM, observation revealed R8's bedside table had Aspercreme and diclofenac gel containers in the basket. On 09/19/23 at 10:04 AM, Administrative Nurse E verified the facility did not have an assessment tool to verify R8 had the cognitive ability to self-administer medications safely. On 09/20/23 at 08:55 AM, Administrative Nurse E verified the physician orders did not indicate the Aspercreme or diclofenac gel may be self-administered. The facility's Medication Self Administration policy, dated 04/02/08, documented some patients or residents desire to the ability to self-administer their medications without supervision or medical staff. A resident must be alert, oriented and able to self-administer the physician ordered medication properly. A physician or midlevel practitioner may write or verbally order permission for a resident to self-administer their medication. The physician or midlevel will determine if the resident is competent to administer the drug without supervision. The resident must demonstrate an understanding of the indication of the medication, dose, frequency of use and proper administration technique to the physician or licensed nurse. The facility failed to ensure R8 had a physician order and the ability to safely self- administer topical medication which placed the resident at risk improper use of medication and related side effects.

The facility had a census of eight residents. The sample included eight residents. Based on observation, interview, and record review the facility failed to notify the state Long Term Care Ombudsan (LTCO) of Resident (R)3's discharge to a hospital in July 2023. This deficient practice placed R3 at risk for impaired rights due to decreased oversight of transfers. Findings included: - R3's Electronic Medical Record documented diagnoses of anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), diabetes (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), and dementia (progressive mental disorder characterized by failing memory, confusion). The Annual Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS documented R3 was independent with all activities of daily living (ADL). R3's Care Plan dated 07/07/23 directed R3 was independent with all personal cares and ADLs. The Progress Note, dated 07/18/23 at 08:00 PM, documented R3 was admitted to the hospital for cough and hypoxia (inadequate supply of oxygen). The Progress Note, dated 07/20/23 at 11:10 AM, documented R3 was transferred back to the facility from the hospital. The facility was unable to provide evidence the LTCO was notified t=of the facility initiated transfer. On 09/19/23 at 09:05 AM, observation revealed Licensed Nurse (LN) G administered medications to R3 who took the pills whole with water. On 09/19/23 at 12:34 PM, Administrative Nurse E verified R3 was discharged to the hospital 07/18/23 and the facility did not send discharge notices to the LTCO. Upon request the facility did not provide a policy for notifying the ombudsman of discharges. The facility failed to notify the state LTCO of R3's facility-initiated discharge to a hospital in July 2023, placing R3 at risk for impaired rights due to decreased oversight of transfers.

The facility had a census of eight residents. The sample included eight residents. Based on observation, interview, and record review the facility failed to provide a copy of the Bed Hold notice to Resident (R)3, or her representative, upon discharge to a hospital in July 2023. This deficient practice place R3 at risk to not be allowed to return to their same room upon discharge from the hospital. Findings included: - R3's Electronic Medical Record documented diagnoses of anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), diabetes (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), and dementia (progressive mental disorder characterized by failing memory, confusion). The Annual Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS documented R3 was independent with all activities of daily living (ADL). R3's Care Plan dated 07/07/23 directed R3 was independent with all personal cares and ADL. The Progress Note, dated 07/18/23 at 08:00 PM, documented R3 was admitted to the hospital for cough and hypoxia (inadequate supply of oxygen). The Progress Note, dated 07/20/23 at 11:10 AM, documented R3 was transferred back to the facility from the hospital. R3's clinical record lacked evidence the resident or representative was provided a Bed Hold notice. On 09/19/23 at 09:05 AM, observation revealed Licensed Nurse (LN) G administered medications to R3 who took the pills whole with water. On 09/19/23 at 12:34 PM, Administrative Nurse E verified R3 was discharged to the hospital 07/18/23 and the facility did not provide R3 with a bed hold notice. The facilities Bed Hold policy, dated 11/15/17, stated information regarding the bed hold policy would be provided to the resident or their representative prior to transfer of the resident for hospitalization or therapeutic leave by the charge nurse or the Social Service staff. The facility failed to provide a copy of the Bed Hold notice to R3, or her representative, upon discharge to a hospital, placing R3 at risk to not be allowed to return to their same room upon discharge from the hospital.

The facility had a census of eight resident. The sample included eight residents. Based on observation, record review, and interview, the facility failed to revise the care plan with effective interventions for Resident (R) 8 who had over 60 falls in four months. This placed R8 at risk for ongoing falls and injury due to uncommunicated care needs. Findings included: - R8's Electronic Medical Record (EMR) diagnoses of Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness), frequent falls, hypertension (elevated blood pressure), and urinary retention (lack of ability to urinate and empty the bladder). The Admission Minimum Data Set (MDS), dated [DATE], documented R8 had severe cognitive impairment, exhibited no behaviors, required limited assistance of one staff with transfers, transfers, walking, toilet use and personal hygiene. R8 was not steady and only able to stabilize with staff assistance; R8 had functional range of motion impairment to one side of upper and lower extremities and used a walker and wheelchair for mobility. The MDS further documented R8 was frequently incontinent of urine. R8 had falls prior to admission and had two or more non-injury falls and two or more falls with injury after admission. The Comprehensive Care Plan, dated 06/22/23, documented R8 was a high fall risk, had unsteady balance and forgot her limitations. The plan documented she fell frequently, required a gait belt, walker and one staff assist with ambulation and to the bathroom. The care plan also documented R8 had nonslip tape in front of her bed and recliner to reduce her falls. R8's medical record recorded falls for the month of June 2023 on 06/06, 06/07, 06/08, 06/10, 06/11, 06/12 (twice), 06/13, 06/17, 06/19 (twice), 06/21, 06/24, 06/27 (five times), and 06/29. R8 was sent to the emergency roiagnom on [DATE] for a contusion (bruise) on the left side of her head, and on 08/17/23 due to small to her left eyebrow. The June 2023 Fall Risk Care Plan interventions included the use non-skid socks once, one person assistance twice, two person assistance three times, gait belt with transfers four times, use of assistive device four times, bed alarm once, 15 minute checks (unspecific length time frame) four times, 30 minute (unspecific length of time frame) six times, cueing and reminding 14 times, bold Bathroom sign three times, personal items next to bed, once and slipper socks on at bedtime once. R8's medical record recorded falls for the month of July 2023 on 07/02, 07/05, 07/06, 07/08, 07/09, 07/10 (four times), 07/12, 07/13, 07/14, 07/15, 07/16, 07/18, 07/19 (twice), 07/20, 07/21 (twice), 07/23, 07/27, 07/29 (twice), and 07/31. The July 2023 Fall Risk Care Plan interventions included the use of non-skid socks five times, one person assist five times, use of gait bet with transfers three times, 30 minute checks (unspecific length time frame) three times, toileting program (unspecified to type) four times, cueing and reminding 24 times, bathroom sign in room four times, personal items next to bed three times, and place trash can closer four times. R8's medical record recorded falls for the month of August 2023 on 08/02, 08/04, 08/05 (twice), 08/08, 08/09, 08/12, 08/16, 08/20 (twice), 08/24, and 08/30. The August 2023 Fall Risk Care Plan interventions included cueing and reminding 14 times and 30-minute checks (unspecific length of time frame) twice. R8's medical record recorded falls for the month of September 2023 on 09/02, 09/06, 09/10, 09/13 (twice), 09/18 (twice), 09/19 (twice), and 09/20. The September 2023 Fall Risk Care Plan interventions included cueing and reminding three times. On 09/19/23 at 08:19 AM, observation revealed R8 tried to leave the dining room in her wheelchair. R8 had some difficultly crossing the threshold of carpet and linoleum floor so dietary staff assisted her. R8 leaned to the left in her wheelchair and her left arm hung over the side of the chair. Further observation R8 had difficulty navigating brick pillars and corners on her left side as she went to the commons area near the nurse's station. R8 was pleasant to staff and other residents. On 09/19/23 at 08:43 AM Certified Nurse Aide (CNA) N reported the staff try to check on R8 every 15 minutes; R8 had a motion sensor in her room. CNA N reported staff had to remind R8 to sit up straight in the wheelchair and said R8 fell frequently. On 09/19/23 at 09:21 AM Licensed Nurse (LN) H stated R8 had a motion sensor in her room and staff checked on her frequently. LN H said staff offered to take R8 to the bathroom. On 09/19/23 at 09:40 AM, R8 reported the small dressing to her right elbow was due to falling twice the day before. R8 said she had rug burn. On 09/19/23 at 10:04 AM, Administrative Nurse D verified R8 was checked frequently, and reported distraction for R8 helped. Administrative D stated at monthly fall meetings, the facility's interdisciplinary team reviewed falls and the appropriateness of interventions but they met more often for R8. Administrative Nurse D verified the care plan had repeated interventions and R8 continued to have falls . Upon request the facility failed to provide a policy related to the revision of care plans. The facility failed to revise the care plan with person centered interventions to prevent R8 from falling which placed R8 at risk of ongoing falls and injury related to uncommunicated care needs.

The facility had a census of eight residents. The sample included eight residents. Based on observation, interview, and record review the facility failed to document and assess a skin injury of unknown origin to Resident (R) 1 which required treatment. This deficient practice placed R1 at risk for impaired skin care and treatment for her injury and risk for further injuries. Findings included: - R1's Electronic Medical Record documented diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), dementia (progressive mental disorder characterized by failing memory, confusion), and macular degeneration (progressive deterioration of the retina). The Annual Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of one, indicating severely impaired cognition. The MDS documented R1 required total staff assistance with all activities of daily living, had impaired range of motion (ROM) in both lower extremities and used a wheelchair. The Skin Care Plan, dated 07/07/23, directed the aide or nurse to cut the resident's toenails, perform a weekly skin assessment, and explain all cares. The Mobility/Safety Care Plan, dated 07/07/23, directed staff to use a full lift and two staff with all transfers. The Skin Assessment, dated 06/13/23, documented an old bruise to R1's right forearm. The Progress Note, dated 06/17/23, documented the resident removed the steri-strips (wound closure adhesive strips) to an old skin tear on her left forearm. The nurse cleansed the wound and applied three new steri-strips. The progress notes and skin assessments lacked further documentation regarding the injury to R1's left forearm. On 09/18/23 at 03:15 PM, observation revealed R1 sat in a wheelchair in the living room in front of the TV while other residents and staff played a card game in the room. She was alert, non-verbal, and did not respond to voice. She moved her hands lightly over her knees. On 09/20/23 at 09:00 AM, Certified Nurse Aide (CNA) M stated R1 moved around in bed when she needed to toilet. She stated R1 got skin tears mostly on her legs, so staff were to remove the wheelchair foot pedals during transfers. CNA M stated R1 received a skin tear on her hand during a lift transfer at beginning of August. CNA M stated staff were to report any incidents or injuries to the nurse immediately. On 09/20/23 at 10:25 AM, Administrative Nurse F stated nurse aides were to inform nurses of new bruising or skin tears and the unit manager, assistant director of nursing, or the risk manager should investigate. On 09/20/23 at 10:51 AM, Administrative Nurse B verified the lack of documentation for the 06/17/23 injury and stated staff had not notified the risk manager to investigate the injury. Administrative Nurse B verified staff were to document an assessment when finding a skin tear, place treatment orders on the Treatment Administration Record (TAR), and send the form for skin tears to the risk manager who would investigate. The facilities Abuse, Neglect or Exploitation policy, dated 11/28/27, stated incident reports and documentation would be reviewed to identify events such as suspicious bruising to determine if an investigation was warranted. All incidences need to be reported to the immediate supervisor and investigation procedures initiated upon any incident of unknown origin. Skin tears of unknown origin were to be documented and investigated. Investigation forms would be completed and turned into the risk manager. The facility failed to document and assess a skin injury to R 1 requiring treatment when she had an injury of unknown origin and date, placing R1 at risk for impaired skin care and treatment for her injury.

The facility had a census of eight residents. The sample included eight residents. Based on observation, interview and record review, the facility failed to investigate causative factors and implement relevant interventions, including changing interventions which were ineffective, to prevent falls for Resident (R) 8 who had over 60 falls in four months and for R5. The facility further failed to assess R5 for the safe use of an electric recliner. This placed the residents at further risk of injuries from falls and preventable accidents. Findings included: - R8's Electronic Medical Record (EMR) diagnoses of Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness), frequent falls, hypertension (elevated blood pressure), and urinary retention (lack of ability to urinate and empty the bladder). The Admission Minimum Data Set (MDS), dated [DATE], documented R8 had severe cognitive impairment, exhibited no behaviors, required limited assistance of one staff with transfers, transfers, walking, toilet use and personal hygiene. R8 was not steady and only able to stabilize with staff assistance; R8 had functional range of motion impairment to one side of upper and lower extremities and used a walker and wheelchair for mobility. The MDS further documented R8 was frequently incontinent of urine. R8 had falls prior to admission and had two or more non-injury falls and two or more falls with injury after admission. The Comprehensive Care Plan, dated 06/22/23, documented R8 was a high fall risk, had unsteady balance and forgot her limitations. The plan documented she fell frequently, required a gait belt, walker and one staff assist with ambulation and to the bathroom. The care plan also documented R8 had nonslip tape in front of herbed and recliner to reduce her falls. R8's medical record recorded falls for the month of June 2023 on 06/06, 06/07, 06/08, 06/10, 06/11, 06/12 (twice), 06/13, 06/17, 06/19 (twice), 06/21, 06/24, 06/27 (five times), and 06/29. R8 was sent to the emergency roiagnom on [DATE] for a contusion (bruise) on the left side of her head, and on 08/17/23 due to a cut to her left eyebrow . The June 2023 Fall Risk Care Plan interventions included the use non-skid socks once, one person assistance twice, two person assistance three times, gait belt with transfers four times, use of assistive device four times, bed alarm once, 15 minute checks (unspecific length time frame) four times, 30 minute (unspecific length of time frame) six times, cueing and reminding 14 times, bold Bathroom sign three times, personal items next to bed, once and slipper socks on at bedtime once. R8's medical record recorded falls for the month of July 2023 on 07/02, 07/05, 07/06, 07/08, 07/09, 07/10 (four times), 07/12, 07/13, 07/14, 07/15, 07/16, 07/18, 07/19 (twice), 07/20, 07/21 (twice), 07/23, 07/27, 07/29 (twice), and 07/31. The July 2023 Fall Risk Care Plan interventions included the use of non-skid socks five times, one person assist five times, use of gait bet with transfers three times, 30 minute checks (unspecific length time frame) three times, toileting program (unspecified to type) four times, cueing and reminding 24 times, bathroom sign in room four times, personal items next to bed three times, and place trash can closer four times. R8's medical record recorded falls for the month of August 2023 on 08/02, 08/04, 08/05 (twice), 08/08, 08/09, 08/12, 08/16, 08/20 (twice), 08/24, and 08/30. The August 2023 Fall Risk Care Plan interventions included cueing and reminding 14 times and 30-minute checks (unspecific length of time frame) twice. R8's medical record recorded falls for the month of September 2023 on 09/02, 09/06, 09/10, 09/13 (twice), 09/18 (twice), 09/19 (twice), and 09/20. The September 2023 Fall Risk Care Plan interventions included cueing and reminding three times. On 09/19/23 at 08:19 AM, observation revealed R8 trying to leave the dining room in her wheelchair. R8 had some difficultly crossing the threshold of carpet and linoleum floor when dietary staff assisted her. R8 leaned to the left in her wheelchair and her left arm hung over the side of the chair. Further observation R8 had difficulty navigating brick pillars and corners on her left side as she went to the commons area near the nurse's station. R8 pleasant to staff and other residents. On 09/19/23 at 08:19 AM, observation revealed R8 tried to leave the dining room in her wheelchair. R8 had some difficultly crossing the threshold of carpet and linoleum floor so dietary staff assisted her. R8 leaned to the left in her wheelchair and her left arm hung over the side of the chair. Further observation R8 had difficulty navigating brick pillars and corners on her left side as she went to the commons area near the nurse's station. R8 was pleasant to staff and other residents. On 09/19/23 at 08:43 AM Certified Nurse Aide (CNA) N reported the staff try to check on R8 every 15 minutes; R8 had a motion sensor in her room. CNA N reported staff had to remind R8 to sit up straight in the wheelchair and said R8 fell frequently. On 09/19/23 at 09:21 AM Licensed Nurse (LN) H stated R8 had a motion sensor in her room and staff checked on her frequently. LN H said staff offered to take R8 to the bathroom. On 09/19/23 at 09:40 AM, R8 reported the small dressing to her right elbow was due to falling twice the day before. R8 said she had rug burn. On 09/19/23 at 10:04 AM, Administrative Nurse D verified R8 was checked frequently, and reported distraction helped. Administrative D stated at monthly fall meetings, the facility's interdisciplinary team reviewed falls and the appropriateness of interventions but had met more often for R8. Administrative Nurse D verified the care plan had repeated interventions and R8 continued to have falls. The facility's Fall Intervention and Reduction Policy and Procedure for Residents, dated 05/24/23, documented to provide the safest environment to minimize resident falls and accidents. To actively work toward reducing injury and number of falls or accident occurrences on our residents. Fall interventions need to be evaluated, individualized, monitored, and appropriate interventions are to be placed on the resident care plan. The facility staff is expected to provide safe quality care to our residents and anticipate specific needs of our residents and patients to provide that care. Anticipating and minimizing a fall, accidents or near miss is our expectation for the safety of the residents at this facility. The licensed nurses, Certified Nurse's Aides, ancillary staff, the resident coordinator, Risk Manager, and Medical staff will be involved in prevention and minimizing hazards for accidents and falls. Those same staff shall be involved in the investigation and interventions for possible causes. The facility failed to identify causative factors and provide relevant interventions, to include changing or modifying ineffective interventions, to prevent R8 from falling. This placed the R8 at risk for continued falls and injury. 27168 - R5's Electronic Medical Record (EMR) recorded diagnoses of coronary artery disease (CAD - abnormal condition that may affect the flow of oxygen to the heart), atrial fibrillation (rapid, irregular heart beat), hypertension (elevated blood pressure), anemia (inadequate number of healthy red blood cells to carry adequate oxygen to body tissue), heart failure and chronic fatigue. R5's Quarterly Minimum Data Set (MDS), dated [DATE], recorded the resident had a Brief Interview for Mental Status (BIMS) score of 13 which indicated intact cognition. R5 required extensive staff assistance with transfers and limited staff assistance with bed mobility. The Cognitive Loss Care Area Assessment (CAA), and Fall CAA, dated 6/02/23, was triggered but lacked a reason for the triggered area. The Fall/Mobility Care Plan, dated 07/07/23, directed staff to pivot transfer R5 with two person assist, and have a Dycem (non-slip pad used to help stabilize objects and hold things firmly in place, or to provide a better grip) in chair for slippage prevention. The care plan documented R5 would use her wheelchair for mobility throughout the day. The care plan documented R5 would call for assistance to move around the room. The Fall Risk Assessment, dated 05/21/23, documented a score of 70.0 (a score of 45.0 or greater indicated a high risk for falls). R5's clinical record lacked an assessment to determine if the resident was safe to use the electric lift chair. The Nurses Note, dated 05/24/23 at 09:05 PM, recorded R5 had an unwitnessed fall from her recliner and landed on her face and left hand. The resident was alert and mildly confused, and stated she was trying to kill a bug and fell out of the recliner. R5 had a large laceration on her forehead, and staff controlled the bleeding and cleansed the wound. R5 was placed on a cervical spine board and transferred to the hospital on a stretcher. R5's EMR lacked evidence of an through investigation regarding the residents fall, witness statements, or root cause. On 07/18/23 at 08:10 AM, observation revealed R5 sat in the lift recliner in her room, feet elevated, eyes closed and a Dycem on the chair seat. On 09/19/21 at 08:40 AM, Licensed Nurse (LN) H stated the medical records documented the resident had a fall out of the recliner chair 05/24/23. LN H verified the resident was a high fall risk and required two staff assist with transfers. LN H verified the facility did not thoroughly investigate, obtain witness statements, or complete a post fall investigation. LN H verified a Dycem non slip pad was placed in the resident's wheelchair and recliner after the fall to prevent further slippage. The facility's Fall Intervention and Reduction policy, dated 5/24/2017, stated the facility would provide the safest environment possible to minimize resident falls and accidents, maximize residents' strengths and abilities to help minimize falls, and to decrease chance of serious resident injury. The facility staff was expected to provide safe quality care to the residents and anticipated specific needs of the residents when they provide care. The staff would anticipate and minimize fall, accident or near miss and would be involved in preventing and minimizing hazards for accidents and falls. The policy recorded staff would be involved in the investigation and interventions for possible causes, such as interventions to prevent falls/accidents, and nurses would be anticipatory not reactionary. The staff would use the following tips to keep the residents safe, which include; anticipate the resident's needs, placement of bed, position resident for comfort, personal needs, pain, inspect environment, provide a quiet relaxing environment in resting hours to promote sleep. The facility would strive to be restraint free/alarm free facility for the residents, spend quality of time with the resident, engage residents during the day in activity and activities, monitor medication interaction, reaction, and review for unnecessary medications. The facility failed to assess R5 for safe use of an electric recliner and failed to thoroughly investigate causative factors and implement interventions to reduce of prevent falls for R5 after she fell from the recliner, placing the resident at risk for further fall related injuries.

The facility had a census of eight residents. The sample included eight residents, with five reviewed for unnecessary medications. Based on observation, interview and record review, the facility failed to ensure the Consultant Pharmacist identified and reported the lack of an appropriate indication, or the required physician documentation, for Resident (R) 2's use of an antipsychotic medication (class of medications used to treat any major mental disorder characterized by a gross impairment in reality testing and other mental emotional conditions). This placed the resident at risk for inappropriate use of an antipsychotic medication with side effects. Findings include: - R2's Electronic Medical Record (EMR) recorded diagnoses of dementia (progressive mental deterioration characterized by confusion and memory failure) with behavioral disturbance, and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest.) R2's Admission Minimum Data Set (MDS), dated [DATE], recorded R2 had Brief Interview for Mental Status (BIMS) score of three which indicated severe cognition impairment. The MDS recorded R2 was totally dependent and required two staff for most activities of daily living (ADLS.) The MDS recorded R2 received an antipsychotic medication for all seven days of the look back period. The Psychotropic Care Area Assessment (CAA), dated 06/29/23, recorded the area triggered but did not give a description as to why the area triggered. The Medication Care Plan, dated 07/18/23 recorded R2 received Black Box Warning (BBW-highest safety-related warning that medications can have assigned by the Food and Drug Administration,) medication and referenced the Medication Administration Record (MAR) in the EMR. The Physician's Order, dated 08/24/23, directed the staff to administer Seroquel (antipsychotic) 25 milligrams (mg), in the morning and administer Seroquel 50 mg, at bedtime for a diagnosis of behaviors. Review of the Consultant Pharmacist monthly review on 08/29/23, 07/30/23, 6/30/23, 05/30/23, 04/30/23, 03/30/23, 02/28/23, 01/31/23, 12/31/22, 11/29/22, and 10/30/22 lacked a recomendation for the appropriate diagnosis for the Seroquel. R2's EMR lacked a documented physician rationale which included the multiple unsuccessful attempts for nonpharmacological symptom management and risk versus benefits for the continued Seroquel use. On 09/19/23 at 09:00 AM, observation revealed R2 in bed with head of bed elevated approximately 40 degrees, LN I crushed R2's medications and mixed in chocolate pudding, then administered the resident her morning medications which included the Seroquel 25 mg tablet. On 09/21/23 at 09:20 AM, Administrative Nurse F verified the resident received Seroquel, an antipsychotic medication with a diagnosis of dementia with behavior disturbance and said that was an inappropriate diagnosis for the medication. Administrative Nurse F verified the pharmacist had sent monthly reviews to the facility for a gradual dose reduction however failed to request an appropriate diagnosis for the use of the Seroquel. The facility's Pharmacist Consultant policy, dated 02/22/2012 recorded the consultant pharmacist would review the residents charts monthly to monitor for gradual dose reduction (GDR),) proper diagnosis , proper assessment regarding medication therapy and proper diagnosis in the care plan, and assure positive outcome to prescribed therapy. The facility failed to ensure the Consultant Pharmacist reported the inappropriate indication for the continued use of antipsychotic medication. This placed the resident at risk for unecessary antipsychotic medication with side effects.

The facility had a census of eight residents. The sample included eight residents, with five reviewed for unnecessary medications. Based on observations, interview and record review, the facility failed to ensure an appropriate indication, or a documented physician rationale which included the multiple unsuccessful attempts for nonpharmacological symptom management and risk versus benefits for the continued use for Resident (R)2's antipsychotic (a medication used to treat any major mental disorder characterized by a gross impairment testing). This placed R2 at risk for unintended effects related to psychotropic (alters mood or thought) drug medications. Findings include: - R2's Electronic Medical Record (EMR) recorded diagnoses of dementia (progressive mental deterioration characterized by confusion and memory failure) with behavioral disturbance, and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest.) R2's Admission Minimum Data Set (MDS), dated [DATE], recorded R2 had Brief Interview for Mental Status (BIMS) score of three which indicated severe cognition impairment. The MDS recorded R2 was totally dependent and required two staff for most activities of daily living (ADLS.) The MDS recorded R2 received an antipsychotic medication for all seven days of the look back period. The Psychotropic Care Area Assessment (CAA), dated 06/29/23, recorded the area triggered but did not give a description as to why the area triggered. The Medication Care Plan, dated 07/18/23 recorded R2 received Black Box Warning (BBW-highest safety-related warning that medications can have assigned by the Food and Drug Administration,) medication and referenced the Medication Administration Record (MAR) in the EMR. The Physician's Order, dated 08/24/23, directed the staff to administer Seroquel (antipsychotic) 25 milligrams (mg), in the morning and administer Seroquel 50 mg, at bedtime for a diagnosis of behaviors. R2's EMR lacked a documented physician rationale which included the multiple unsuccessful attempts for nonpharmacological symptom management and risk versus benefits for the continued Seroquel use. On 09/19/23 at 09:00 AM, observation revealed R2 in bed with head of bed elevated approximately 40 degrees, LN I crushed R2's medications and mixed in chocolate pudding, then administered the resident her morning medications which included the Seroquel 25 mg tablet. On 09/21/23 at 09:20 AM, Administrative Nurse F verified the resident received Seroquel, an antipsychotic medication with a diagnosis of dementia with behavior disturbance and said that was an inappropriate diagnosis for the medication. The Psychotropic Medication Use and Monitoring policy, dated 05/10/2018 recorded a psychotropic drug is any drug that affects brain activities associated with mental processes and behaviors. Each resident's need for the psychotropic medication would be monitored, as well as when the resident has received optimal benefits from the medication and when the medication dose can be lowered or discontinued. The facility would use and administer psychotropic medications appropriately working with the interdisciplinary team to ensure the appropriate use, evaluation and monitoring. The facility would make every effort to comply with State and Federal regulations related to the use of psychotropic medications in the facility to include regular review for the continued need, appropriate dosage change, side effects, risk and/or benefits. The facility would support the appropriate use of psychotropic medications that are therapeutic and enabling for residents suffering from mental illness while recognizing that the use of psychotropic medications for dementia -related behaviors is inappropriate in most cases but rather the use of non-pharmacological interventions based on individual needs, preferences and routines is the most appropriate and first-line treatment for dementia related behaviors. Efforts to reduce dosage or discontinue psychotropic medications will be on-going, as appropriate, for the clinical situation. Psychotropic medications would never be used for the purpose of discipline or convivence. The facility failed to ensure R2 did not receive antipsychotic medication without an appropriate diagnosis or required documentation for its use, placing R2 at risk for adverse side effects related to the use of Seroquel.

The facility had a census of eight residents. The sample included eight residents. Based on observation, interview, and record review, the facility failed to label Resident(R)3's insulin (hormone which allows cells throughout the body to uptake glucose) flex pen, stored in the medication room, with the date opened. This deficient practice placed the affected resident at risk for ineffective medications. Findings included: - On [DATE] at 08:20 AM, observation of the facility's medication room revealed the following: R3's Levemir (long-acting insulin) flex pen lacked an open date and expiration date. On [DATE] at 08:25 AM, Licensed Nurse (LN) H verified the nurses were to date the flex pens when opened and discard the expired insulin. On [DATE] at 10:00 AM, Administrative Nurse E verified the nurses should label and date the flex pens with the resident's name and discard expired pens. Upon request the facility's lacked a Storage of Medication policy. The facility failed to label, and date the resident's insulin flex pen with the date opened and expiration date placing the resident at risk for ineffective medication.

The facility had a census of eight residents. The sample included eight residents. Based on observation, interview, and record review the facility failed to review resident rights routinely with the eight residents of the facility. Findings included: - Review of the Resident Council minutes for the past 12 months revealed no documentation residents' rights were discussed or reviewed during the meetings. On 09/19/23 at 01:40 PM, during an interview regarding the Resident Council, Resident (R) 5 and R6 stated the staff did not review residents' rights with them. On 09/19/23 at 02:32 PM, Administrative Nurse D verified staff had not documented the resident rights were reviewed routinely during resident council meetings or any other time. The facilities Resident Rights policy stated the facility must establish and maintain policies regarding transfer, discharge, and the provision of services under the state plan for all residents. The facility failed to review resident rights routinely with the eight residents of the facility.

The facility had a census of 12 residents. The sample included 6 residents of which 2 were reviewed for accidents. Based on observation, record review and interview, the facility failed to provide adequate supervision and appropriate interventions to prevent accidents for Resident #12, who had a history of [REDACTED]. Findings included: - The physician order [REDACTED].#12 had [DIAGNOSES REDACTED]. The annual (MDS) Minimum Data Set assessment, dated 4/30/15, revealed the resident had intact cognition, required supervision and setup with transfer, personal hygiene, walking in the room and toilet use. The assessment revealed the resident required limited assistance of 1 staff with walking in the corridor, locomotion on and off the unit, dressing, bathing, had a steady balance at all times, no range of motion impairment, and used a walker. The assessment further revealed the resident was occasionally incontinent of urine and bowel, had 2 non injury falls and received antidepressant and antibiotic medications. The quarterly (MDS) Minimum Data Set assessment, dated 11/4/14, revealed Resident #12 had moderately impaired cognition, independent with all (ADLs) Activities of Daily Living except bathing, had a steady balance at all times, no ROM impairment and used no assistive devices. The assessment revealed the resident received (PRN) as needed pain medications, had 2 non injury falls, 1 minor injury fall, 1 major injury fall, and received antidepressant medications. The 8/13/14 care plan revealed the resident was independent with transfers and ambulation and did not use any assistive devices. The care plan included the following entries: 11/3/14 - directed the staff to perform stand by assist with the resident, cue and remind him/her to call. 11/4/14 - directed the staff to ensure the resident was wearing non skid socks, change to a facility bed and use temporary bed/chair alarms. 11/19/14 - staff did not update the care plan after the fall. 11/22/14 - staff did not update the care plan after the fall. 1/2/15 - staff replaced the resident's slippers and hypertension (high blood pressure) medication was stopped. 1/8/15 - directed the staff to place the resident's alarm behind his/her back and not under the buttocks. 4/12/15 - staff did not update the care plan after the fall. 4/25/15 - staff did not update the care plan after the fall. 5/9/15 - staff did not update the care plan after the fall and encourage the resident to use his/her call pendant. 5/21/15 - directed the staff to do hourly rounds to monitor the resident. 5/23/15 - directed the staff to offer the bathroom every time the resident's bed alarm sounded. 5/26/15 - staff did not update the care plan after the fall. 5/27/15 - physical therapy to evaluate and treat the resident, review the resident's medications, make a referral to a cardiologist, and start a urinary log on 5/28/15. 6/9/15 - staff did not update the care plan after the fall. 6/16/15 - staff did not update the care plan after the fall. 7/1/15 - the staff were to keep the resident's arm in a sling until the next morning and follow up at 7:00 AM with the physician's assistant in the clinic. The resident received pain medication as ordered, and offered non pharmacological pain relief such as an ice pack or warm blanket to his/her left shoulder. The History and Physical, dated 6/10/14, stated the resident's past medical history included near syncopal (fainting) episodes. The Fall Risk Assessments, dated 4/12/15, 4/28/15, and 6/9/15, revealed a score of 65, with a score of 46 or greater being high risk for falling. The 11/1/14 at 9:00 AM, nurse's note indicated the staff found the resident on the floor outside of the bathroom with his/her head propped up against the roommates recliner. The resident stated he/she passed out and complained of low back pain. The resident was later taken for an x-ray which revealed no broken bones. Staff did not address a toileting schedule for the resident. The 11/4/14 at 5:18 AM, nurse's note indicated the resident's roommate called the staff to the resident's room and found the resident on the floor at the side of the bed with bare feet. The resident complained of back pain from the previous fall. The 11/4/14 at 2:05 PM, nurse's note indicated the staff found the resident on the floor next to his/her bed and he/she complained of back pain from the previous fall. The 11/14/14 Physical Therapy Plan of Treatment and Summary of Progress stated the resident was able to transfer from the bed to the chair with stand by assistance, did appear to have decreased safety awareness, and would not be independent with these tasks. The resident had moderate ataxia (poor coordination and unsteadiness) without the walker, was unstable, and a major risk for falls without the use of the walker. The resident did seem to be confused and would forget previous conversations with therapy staff and unsure as to why he/she was in physical therapy room. The 11/19/14 at 8:20 PM nurse's note indicated the staff left the resident standing at the sink, the resident fell and received a 1 (cm) centimeter x 1 cm skin tear to the left elbow. The note indicated the resident requested Lortab (a pain medication) for back pain. The note indicated the resident did not wear non skid footwear. (as care planned) The 11/22/14 at 11:45 AM, nurse's note indicated the staff found the resident on the floor in the doorway of his/her room. The resident stated he/she felt faint, fell and complained of pain to his/her tailbone. (staff did not update the care plan after the fall.) The 11/24/14 Radiology report revealed the resident had an acute compression fracture (collapse of a vertebrae) of T12 vertebrae (the last vertebrae in the thoracic location of the spine, generally defined as middle back). The 12/9/14 updated Physical Therapy Plan of Treatment and Summary of Progress stated the resident was unstable and unsafe without the walker, forgetful and needed a lot of repetition and cues for safety. (staff did not update the care plan after the fall.) The 1/2/15 at 1:30 PM Fall Event Assessment stated the staff found the resident on the floor of his/her room, the resident complained of pain to the back of his/her head and stated he/she hit it on the floor. The resident was assisted to a standing position with assistance of 2 staff, use of a gait belt and had a significant drop in blood pressure. The assessment revealed staff had not rechecked the resident's blood pressure for 2 hours. The 1/8/15 at 2:20 PM Fall Event Assessment stated the staff found the resident on the floor in front of the recliner. The resident could not relate what happened and had no injuries noted. The staff were to place the chair alarm behind the resident's back instead of under his/her buttocks. The 2/10/15 Physical Therapy Plan of Treatment and Summary stated the resident's confusion level had increased, his/her balance was unsafe and he/she does not always remember to call for assistance. Review of the restorative exercises documentation revealed staff initiated an exercise program 3 times a week for the resident on 3/30/15 and the resident refused the exercises 5 of 9 times in April, 9 of 11 times in May, 12 of 15 times in June. The 4/12/15 at 6:45 AM, nurse's notes revealed the resident stated he/she was standing, looking out of the window, lost his/her balance, and fell against the footboard of the bed. (staff did not update the care plan after the fall.) The 4/12/15 at 8:50 PM, nurse's notes revealed the resident did not remember the fall from earlier in the day and stated he/she did not fall. The 4/25/15 at 10:32 AM Fall Event Assessment revealed the resident was found on his/her knees in the bathroom, without the walker, had been incontinent, and the resident could not remember what happened. Staff did not address a toileting schedule for the resident and update the care plan after the fall. The 4/28/15 at 4:30 AM, nurse's notes revealed the resident was found on the floor in the bathroom during rounds, area by the bed was wet with urine and feces, bare footed, a red scrape area on the middle of the back and he/she could not relate what happened when asked and would state I don't know. Staff reminded the resident to use call pendant and importance of wearing non skid footwear. (Although the resident had moderately impaired cognition and increased level of confusion.) Staff did not address a toileting schedule for the resident. The 4/28/15 at 3:55 PM, nurse's notes revealed the resident did not remember falling previously in the day. The 5/9/15 at 9:40 AM Fall Scene Investigation Report revealed the resident fell to the floor in his/her room. The staff were to encourage the resident to use his/her walker with transfers and ambulation. (The care plan update, to encourage the cognitively impaired resident to use his/her call pendant.) The 5/21/15 (unknown time) Fall Scene Investigation Report revealed the staff found the resident on the floor in his/her room with bare feet and slippers in his/her hand. The resident was unable to remember what he/she was doing prior to the fall. The 5/23/15 at 8:10 AM Fall Scene Investigation Report revealed the staff found the resident with bare foot, on the floor in the bathroom, with no walker. The 5/26/15 at 3:30 AM Fall Scene Investigation Report revealed the staff found the resident on the floor in his/her room with non gripper socks. The staff were to remind the resident to use the call light when he/she needed assistance. (staff did not update the care plan after the fall.) The 5/27/15 at 12:40 AM Fall Scene Investigation Report revealed the staff found the resident on the floor with no gripper socks/shoes and he/she did not use the call pendant. The resident could not remember what he/she was doing. The 5/27/15 physician progress notes [REDACTED]. Staff partially completed a voiding diary (a log which is used to evaluate a pattern of toileting) from 5/28 - 5/31 but did not toilet the resident every 2 hours per the directions so no pattern could be identified. The 6/9/15 at 4:30 PM Fall Scene Investigation Report revealed the staff found the resident on the floor in his/her room and the resident could not remember what he/she was doing prior to the fall. The report stated the resident had memory loss and staff were having to remind him/her to use the call pendant. (Staff did not update the care plan after the fall.) The 6/16/15 at 11:20 PM Fall Scene Investigation Report revealed staff found the resident on the floor in the bathroom, the resident stated he/she was on the way out of the bathroom, the resident was confused at times and was not using the walker. The report stated the resident was last toileted at 8:10 AM, many of the resident's falls involved the resident going to the bathroom without the walker or assistance and staff did not update the care plan after the fall. The 6/18/15 cardiology notes directed the staff to check postural blood pressure changes to make sure the resident did not drop his/her blood pressure significantly in the standing position but no documentation this was completed. The 6/30/15 Physical Therapy Progress Note stated the resident discharged from physical therapy and unable to alter his/her safety habits significantly. The note stated after coming to the therapy room multiple times, the resident could not find his/her way back to his/her room without cues. The 7/1/15 at 3:19 AM nurse's note stated the staff found the resident lying on his/her back on the bathroom floor which was wet with urine. The note stated the resident's walker was at the bedside, the resident had a large purple bruise and a 4.5 (cm) centimeter half moon shaped skin tear to his/her left upper arm. The note further stated the resident received an x-ray and no broken bones identified. Staff did not address a toileting schedule for this resident and were to continue the current plan of care. The 7/8/15 Radiology Report revealed the resident had left shoulder pain, decreased range of motion after the fall on 7/1/15, and a full thickness tear of the left rotator cuff. On 7/8/15 at 2:15 PM, observation revealed the resident ambulated down the hallway with a front wheeled walker and a staff member holding onto back of his/her gait belt. Further observation revealed the resident would angle the walker to his/her side but continue to walk straight forward and staff would have to remind him/her to keep the walker in front of him/her. On 7/13/15 at 10:01 AM, observation revealed a staff member assisted the resident from the bed to a chair at the side of the bed so he/she could do exercises. Further observation revealed the resident stopped after a few leg lifts, rubbed his/her eyes and stated Oh I feel dizzy. On 7/9/15 at 3:02 PM, Nurse Aide G stated the resident does get up by himself/herself, does forget to use the call pendant, and knows when he/she has to go to the bathroom. Nurse Aide G stated the resident is incontinent approximately 1/2 of the time when walking from the bed to the bathroom. Nurse Aide G stated approximately 3 times a shift, staff will find the resident up independently in his/her room. Nurse Aide G stated the resident did fall during one of his/her shifts and the resident fell when he/she attempted to go to the bathroom. On 7/13/15 at 10:10 AM, Nurse Aide H stated to prevent falls, the staff are using the gait belt and encouraging the resident to use his/her call pendant which he/she uses approximately 1/4 of the time. On 7/13/15 at 2:49 PM, Nurse J stated the resident is confused and forgets his/her limits, and he/she will stand up and move the walker out of the way and start walking without the walker. Nurse Aide J stated the resident was not on a toileting program and the voiding diary was not completed according to the directions. On 7/13/15 at 3:06 AM, Nurse Aide I stated the resident will sometimes use his/her call pendant, approximately 3-4 times a day staff will find him/her up independently in his/her room without the walker, and he/she is confused a lot. Nurse Aide I stated the resident is not on a toileting program, often toilets himself/herself and did complain about being dizzy when he/she stood up. Nurse Aide I stated the resident did get dizzy while ambulating to the bathroom with him/her and the staff had to hold the resident up. On 7/13/15 at 3:37 PM, Nurse K stated most of the resident's falls are when he/she does not have his/her walker with him/her. The resident occasionally used his/her call pendant and staff constantly remind him/her to use it. Nurse K stated at least once a day staff find the resident ambulating without assistance and observe the resident stand up at the dining room table by himself/herself. Nurse K stated when the resident ambulated, he/she became distracted easily and was unsteady. The resident did not guide his/her walker correctly, became dizzy when he/she stood up and staff have discussed orthostatic blood pressure at medical staff meeting several times. On 7/13/15 at 4:05 PM, Administrative Nurse A stated the resident would push his/her walker out of the way and walk into the bathroom without it. Administrative Nurse A stated the staff complete 30 minute checks on the resident but this is not on the care plan, and restorative should try to work with the resident at least 3 times a week. Administrative Nurse A stated the resident came to the facility with cardiac issues, which could cause dizziness, and staff did not address these issues on the care plan. The facility's Fall Intervention and Reduction Policy and Procedure for Residents, dated 5/1/2015, directed the staff to review the resident's care plan and fall care plan after a fall. The policy further directed the staff to complete the fall care plan with identified interventions each time there is a fall. The facility failed to provide Resident #12 with adequate supervision to prevent falls, and implement appropriate interventions to prevent additional falls, which resulted in 2 major injuries, a compression fracture and torn rotator cuff.