**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 41 residents. The sample included 12 residents of which five were reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported the lack of the required stop date for Resident (R) 30's as-needed (PRN) lorazepam (antianxiety-class of medications that calm and relax people). This placed the resident at risk of receiving unnecessary psychotropic (alters mood or thoughts) medications. Findings included: - R30's Electronic Medical Record (EMR) listed diagnoses of generalized anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), hypertension (high blood pressure), and dementia (progressive mental disorder characterized by failing memory, and confusion). R30's Quarterly Minimum Data Set (MDS) dated [DATE] documented R30 had a Brief interview for Mental Status score of four which indicated severe cognitive impairment. The MDS documented R30 had no behaviors. R30 received antianxiety medications, antidepressant (medication used to treat mood disorders), opioids (narcotic medication used to treat pain), and antiplatelet (medication to inhibit blood clotting) medication during the observation period. R30's Care Plan dated 07/20/23 documented R30 was at risk for adverse side effects due to medications with Black Box Warnings (BBW- highest safety-related warning that medications can have assigned by the Food and Drug Administration). R30's Care Plan documented R30 had impaired cognitive function related to her dementia (08/04/23). The plan directed staff to provide approaches that maximized R30's involvement in daily decision making such as limiting choices, using cueing, task segmentation, written lists, and instructions. R30's EMR documented a Physician's Order dated 11/23/23 for lorazepam oral tablet, 0.5 milligrams (mg) by mouth every afternoon for anxiety. R30's EMR documented a Physician's Order dated 12/30/23 for lorazepam oral tablet, 0.5 mg by mouth every six hours as needed for tremors (uncontrolled shaking or trembling). The order lacked a stop date. A Behavior Note dated 12/30/23 at 10:16 AM recorded refused her medications and reported she did not want to take the medication because they were the wrong medications. Staff attempted redirection but it was ineffective. R30 tossed the pills in the trash and reported These pills make me shake. Staff notified R30's representative who attempted to calm the resident. At the time of the note, R30 sat in her recliner with her call light within reach. Staff provided R30 personal space for her to recollect herself, and noted if that was ineffective staff would administer PRN Ativan (lorazepam). A review of R30's Medication Administration Record/Treatment Administration Record (MAR/TAR) revealed R30 received the PRN lorazepam twice on 12/30/23, on 10 occasions in January 2023, and twice in February 2024 thus far. R30's EMR lacked a 14-day stop order or specified duration with a physician-documented rationale for the extended use of R30's PRN lorazepam. The facility was unable to provide this documentation as requested on 02/20/24. The CP's Monthly Medication Review for February 2024 documented no irregularities were noted and lacked evidence the CP identified the lack of a stop date for R30's PRN lorazepam. On 02/21/24 at 07:21 AM Certified Medication Aid (CMA) S prepared R30's morning medications. R30 sat at the medication cart. CMA S asked R30 if she would like to have her medication in her room or at the medication cart. R30 took her medication without behaviors or concerns. R30's PRN Ativan was not administered during this medication pass due to no anxiety or behaviors displayed. On 02/20/24 at 09:20 AM Licensed Nurse (LN) G stated PRN Ativan medication should include a 14-day stop date unless the medical provider reorders the medications. She stated the medical provider would document the continued use duration on a progress note or order. She stated the pharmacist completed monthly reviews of the medication and reported to Administrative Nurse D. On 02/20/24 at 09:35 AM Administrative Nurse D stated R30's PRN Ativan medication had been ordered for the intended use but was unable to provide a specified duration for the medications PRN use. She stated the pharmacy should have identified the lack of duration on the monthly reviews and reported the concern. The Consultant Pharmacist (CP) was not available for interview on 02//20/24 and 02/21/24. The facility's Pharmacy Review policy revised 11/2017 noted the CP will review all residents' records monthly and provide recommendations for clinical guidelines. The policy indicated the medical provider and Director of Nursing would be provided input on recommendations made. The facility failed to ensure the CP identified and reported the lack of the required stop date for R30's PRN lorazepam. This placed the resident at risk of receiving unnecessary psychotropic medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 41 residents. The sample included 12 residents of which five were reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 30 had a stop date for the use of as-needed (PRN) lorazepam (an antianxiety medication that calms and relaxes people). This placed the resident at risk of receiving unnecessary psychotropic (alters mood or thoughts) medications. Findings included: - R30's Electronic Medical Record (EMR) listed diagnoses of generalized anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), hypertension (high blood pressure), and dementia (progressive mental disorder characterized by failing memory, and confusion). R30's Quarterly Minimum Data Set (MDS) dated [DATE] documented R30 had a Brief interview for Mental Status score of four which indicated severe cognitive impairment. The MDS documented R30 had no behaviors. R30 received antianxiety medications, antidepressant (medication used to treat mood disorders), opioids (narcotic medication used to treat pain), and antiplatelet (medication to inhibit blood clotting) medication during the observation period. R30's Care Plan dated 07/20/23 documented R30 was at risk for adverse side effects due to medications with Black Box Warnings (BBW- highest safety-related warning that medications can have assigned by the Food and Drug Administration). R30's Care Plan documented R30 had impaired cognitive function related to her dementia (08/04/23). The plan directed staff to provide approaches that maximized R30's involvement in daily decision making such as limiting choices, using cueing, task segmentation, written lists, and instructions. R30's EMR documented a Physician's Order dated 11/23/23 for lorazepam oral tablet, 0.5 milligrams (mg) by mouth every afternoon for anxiety. R30's EMR documented a Physician's Order dated 12/30/23 for lorazepam oral tablet, 0.5 mg by mouth every six hours as needed for tremors (uncontrolled shaking or trembling). The order lacked a stop date. A Behavior Note dated 12/30/23 at 10:16 AM recorded refused her medications and reported she did not want to take the medication because they were the wrong medications. Staff attempted redirection but it was ineffective. R30 tossed the pills in the trash and reported These pills make me shake. Staff notified R30's representative who attempted to calm the resident. At the time of the note, R30 sat in her recliner with her call light within reach. Staff provided R30 personal space for her to recollect herself, and noted if that was ineffective staff would administer PRN Ativan (lorazepam). A review of R30's Medication Administration Record/Treatment Administration Record (MAR/TAR) revealed R30 received the PRN lorazepam twice on 12/30/23, on 10 occasions in January 2023, and twice in February 2024 thus far. R30's EMR lacked a 14-day stop order or specified duration with a physician-documented rationale for the extended use of R30's PRN lorazepam. On 02/21/24 at 07:21 AM Certified Medication Aid (CMA) S prepared R30's morning medications. R30 sat at the medication cart. CMA S asked R30 if she would like to have her medication in her room or at the medication cart. R30 took her medication without behaviors or concerns. R30's PRN Ativan was not administered during this medication pass due to no anxiety or behaviors displayed. On 02/20/24 at 09:20 AM Licensed Nurse (LN) G stated PRN Ativan medication should include a 14-day stop date unless the medical provider reorders the medications. She stated the medical provider would document the continued use duration on a progress note or order. She stated the pharmacist completed monthly reviews of the medication and reported to Administrative Nurse D. On 02/20/24 at 09:35 AM Administrative Nurse D stated R30's PRN Ativan medication had been ordered for the intended use but was unable to provide a specified duration for the medications PRN use. She stated the pharmacy should have identified the lack of duration on the monthly reviews and reported the concern. A review of the facility's Psychotropic Medication Use policy revised 11/2017 indicated the facility will provide ongoing psychotropic (alters mood or thoughts) medication monitoring and ensure correct indication of use and appropriate duration. The facility failed to ensure R30 had a stop date for the use of PRN lorazepam. This placed the resident at risk of receiving unnecessary psychotropic (alters mood or thoughts) medications.

The facility had a census of 41 residents. The sample included 12 residents and five Certified Nurse Aides (CNA) reviewed for performance evaluations and required in-service training. Based on record review and interview, the facility failed to ensure five of the five CNA staff reviewed had the required yearly performance evaluations completed. This placed the residents at risk for inadequate care. Findings included: - CNA N, hired 09/30/22, no yearly performance evaluations were provided upon request. CNA O, hired 08/21/22, no yearly performance evaluations were provided upon request. CNA P, hired 04/16/22, no yearly performance evaluations were provided upon request. CNA Q, hired 11/18/21, no yearly performance evaluations were provided upon request. CNA MM, hired 02/15/21, no yearly performance evaluations were provided upon request. On 02/20/24 at 09:57 AM Administrative Nurse D stated the facility did not complete yearly performance evaluations for their staff. Administrative Nurse D stated she relied on other nursing staff to provide education to their peers on the spot when issues would arise. Administrative Nurse D further stated if an issue required more intervention, the nurses would have notified her, and further intervention or education would have been provided at that time. Administrative Nurse D stated that issues would have been addressed when they arose instead of waiting until a yearly evaluation was done. The facility policy Required Training, Performance Evaluation and In-Service of Staff documented performance is evaluated each day through communication with staff leaders and leadership team members. Any performance issues are addressed with staff members and followed up by any additional training needed. The facility failed to ensure five of the five CNA staff reviewed had the required yearly performance evaluations completed. This placed the residents at risk for inadequate care.

The facility identified a census of 41 residents. Based on observation, record review, and interviews, the facility failed to ensure proper infection control standards were followed related to the implementation of procedures to monitor and prevent Legionella disease (Legionella is a bacterium that can cause pneumonia in vulnerable populations) or other opportunistic waterborne pathogens. These deficient practices placed the residents at risk for complications related to infectious diseases. Findings Included: - A review of the information provided by the facility on the facility's Water Management program revealed the program lacked text and diagrams specific to the building's water flow system. The program did not identify building-specific areas at risk for Legionella or identify specific points within the system checked by the water management program team. On 02/20/24 at 10:23 AM Administrative Staff A stated he was unable to locate the facility's water flow system diagram but would contact the maintenance director. On 02/20/24 at 10:35 Maintenance Staff U stated the facility did not have a diagramed flow chart of the facility water system. He stated the team does monitor high-risk areas and ensures areas of standing water are flushed out frequently. A review of the facility's Water Management policy (undated) indicated the facility would provide the appropriate precautions for the control of legionella including identifying areas of growth, completing risk assessments, and implementing precautions to provide regular inspections. The policy indicated microbial monitoring, temperature checks, and system flushing. The facility to ensure proper infection control standards were followed related to implementation of procedures to monitor and prevent Legionella disease or other opportunistic waterborne pathogens. This deficient practice placed the residents at risk for complications related to infectious diseases.

The facility had a census of 41 residents. The sample included 12 residents and five Certified Nurse Aides (CNA) reviewed for in-service training. Based on record review and interview, the facility failed to ensure five of the five CNA staff reviewed had the required 12 hours of in-service education including the required topics per year. This placed the residents at risk for inadequate care. Findings included: - A review of the facility's in-service records revealed the following: CNA N hired 09/30/22: The documentation provided lacked evidence that CNA N completed 12 hours of in-service/education hours in the past 12 months. CNA O hired 08/21/22: The documentation provided lacked evidence that CNA O had completed 12 hours of in-service/education hours in the past 12 months. CNA P hired 04/16/22: The documentation provided lacked evidence that CNA P had completed 12 hours of in-service/education hours in the past 12 months. CNA Q hired 11/18/21: The documentation provided lacked evidence that CNA Q had completed 12 hours of in-service/education hours in the past 12 months. CNA MM hired 02/15/21: The documentation provided lacked evidence that CNA MM had completed 12 hours of in-service/education hours in the past 12 months. On 02/20/24 at 09:12 AM Administrative Nurse D stated the facility provided education for staff; however, the facility did not have a way to track the hours of education provided for the year. Administrative Nurse D further stated Administrative Staff B assisted her in tracking post-tests for the education that was provided for staff; however, Administrative Nurse D stated she was typically the one responsible for ensuring staff met education requirements. The updated facility policy Required Training, Performance Evaluation and In-Service of Staff documented all direct care staff are required to attend 12 hours of continuing education and demonstrate competency annually. The facility failed to ensure five of the five CNA staff reviewed had the required 12 hours of in-service education including the required topics per year. This placed the residents at risk for inadequate care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** -The Medical Diagnosis section withing R28's Electronic Medical Record (EMR) included diagnoses of major depressive disorder (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness), retention of urine, hypertension (elevated blood pressure), dementia (progressive mental disorder characterized by failing memory, confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear (disorder, heart failure and chronic obstructive pulmonary disease (COPD - progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R28 had intact cognition, had verbal and other behavioral symptoms not directed toward other one to three days of the look back period, required extensive assistance of one staff for activities of daily living, and frequently incontinent of urine and bowel. The MDS further documented R28 received an antianxiety medication on a routine basis. The Care Plan, dated 06/28/22, documented R28 was at risk for adverse side effects related to psychotropic medication. The care plan directed staff to give medications ordered by physician, document side effects and effectiveness, to provide education about risks and benefits and the side effect of lorazepam (Ativan). The care plan further documented a Registered Pharmacist to review drug regimen monthly. The Physician Order, dated 10/28/19, directed staff to administer lorazepam 0.5 milligrams (mg) by mouth every 24 hours as needed for anxiety. The ordered did not have a stop date. Record review revealed R28 received PRN lorazepam on May 1, 5, 11, 12, 16, 24, and 30 2022. June 3, 6, 13, 26, and 28 2022, and July 1, 8, 26, 2022. On 08/02/22 at 09:03 AM, Administrative Nurse D verified the PRN lorazepam did not have a stop date and would have expected the pharmacist to have reviewed the order and brought it to the attention of the facility and physician. On 08/03/22 at 10:29 AM, Consultant GG stated during the pharmacy monthly review the as needed psychotropic medications are reviewed and would notify the facility and physician to obtain a stop date. Consultant GG reported the resident had been hospitalized in January 2022 and had returned with the as needed lorazepam which she had not realized and had not sent a request to the facility and physician for a stop date. The facility's Consultant Pharmacist Services Provider Requirements, dated 09/18/17, documented review the medication regimen(drug regimen review of each resident in health center at least monthly incorporating federally mandated standards of care in addition to other applicable professional standards and documenting the review of findings in the resident's clinical record. Communicating to the responsible physician and the facility Director of Nursing potential or actual problems detected and other findings related to medication therapy orders. Communicating recommendations for changes in medication therapy and monitoring of medication therapy. The facility failed to ensure the CP identified and reported the lack of a stop date on R28's as needed lorazepam. This placed the resident at risk for adverse side effects related to psychotropic medication. The facility had a census of 43 residents. The sample included 12 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility's Consultant Pharmacist (CP) failed to identify and report no blood sugar parameters for Resident (R) 25, who received insulin (hormone used to control blood sugar levels). The facilty further failed to ensure the CP identified and reported the lack of a stop date for Resident (R) 28's as needed (PRN) Ativan (a sedative used to treat anxiety). This placed R25 at risk for hyperglycemic (high blood sugar) or hypoglycemic (low blood sugar) episodes and R28 at risk for side effects from psychotropic (alters mood or thought) medication. Findings included: - The Electronic Medical Record (EMR) for R25 documented diagnoses of diabetes mellitus type 2 (DM-when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin), dementia (progressive mental disorder characterized by failing memory and confusion), hypotension (low blood pressure), major depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness), and chronic diastolic heart failure (when the left heart ventricle has decreased blood flow). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R25 had intact cognition and required supervision and one staff assistance with bed mobility, transfers, toileting and personal hygiene. The MDS documented the resident received insulin (a hormone produced in the pancreas by the cells in the pancreas), an antidepressant (a class of medication that used to treat mood disorders and relieve symptoms of depression), and a diuretic (medication to help the body get rid of extra fluids) during the look back period. The Diabetes Mellitus Care Plan, dated 03/18/22, documented staff obtain accu-checks (a system which measures blood glucose in the body) before meals, at bedtime, and at 03:00 AM. It directed staff to observe for signs and symptoms of hypoglycemia and hyperglycemia. The Physician's Order, dated 07/26/21, directed staff to obtain accu-checks before meals and at bedtime. The order lacked blood sugar parameters for the resident. The Physician's Order, dated 12/31/21, directed staff to obtain accu-checks at 03:00AM. The order lacked blood sugar parameters for the resident. A Physician's Order dated 7/13/22 directed Toujeo (long acting insulin) solostar pen inject 28 units twice daily for type 2 DM. A Physician's Order dated 7/13/22 directed Novolog (fast acting insulin) flex pen inject 16 units three times daily for type 2 DM. The Medication Regimen Review, dated 04/06/22, 05/05/22, 06/13/22, and 07/07/22 lacked documentation the CP identified and reported R25 lacked blood sugar parameters. On 08/01/22 at 12:20 PM, observation revealed R25, in her room, asleep in her chair. On 07/28/22 at 01:20 PM, Licensed Nurse (LN) G stated they did not have any blood sugar parameters from the physician. LN G stated she used her nursing judgement to determine when to call the physician. On 08/02/22 at 12:38 PM, Administrative Nurse D stated the resident should have blood sugar parameters and the pharmacist should have recognized this. On 08/03/22 at 10:38 AM, Consultant Pharmacist GG stated that although she looked at the resident's blood sugars, she did not look to see if the resident had blood sugar parameters. The facility's Consultant Pharmacist policy, undated, documented the pharmacist consultant reviewed the drug regimen review of each resident in the health center at least monthly incorporating federally mandated standards of care in addition to other applicable professional standards and documenting the review and findings in the resident's clinical record. The pharmacist would communicate potential or actual problems detected related medication therapy orders to the responsible physician and the Director of Nursing. The facility's Consultant Pharmacist failed to identify and report to the Director of Nursing, physician, and medical director R25 lacked blood sugar parameter's, placing the resident at risk for hyperglycemic or hypoglycemic episodes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 43 residents. The sample included 12 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to obtain, from the physician, blood sugar parameters for Resident (R) 25, who received insulin (hormone used to control blood sugar levels) and had her blood sugar taken five times per day. This placed the resident at risk for hyperglycemic (high blood sugar) or hypoglycemic (low blood sugar) episodes. Findings included: - The Electronic Medical Record (EMR) for R25 documented diagnoses of diabetes mellitus type 2 (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin), dementia (progressive mental disorder characterized by failing memory and confusion), hypotension (low blood pressure), major depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness), and chronic diastolic heart failure (when the left heart ventricle has decreased blood flow). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R25 had intact cognition and required supervision and one staff assistance with bed mobility, transfers, toileting and personal hygiene. The MDS documented the resident received insulin (a hormone produced in the pancreas by the cells in the pancreas), an antidepressant (a class of medication that used to treat mood disorders and relieve symptoms of depression), and a diuretic (medication to help the body get rid of extra fluids) during the look back period. The Diabetes Mellitus Care Plan, dated 03/18/22, documented staff obtain accu-checks (a system which measures blood glucose in the body) before meals, at bedtime, and at 03:00 AM. It directed staff to observe for signs and symptoms of hypoglycemia and hyperglycemia. The Physician's Order,dated 07/26/21, directed staff to obtain accu-checks (point of care test to measure blood sugar levels) before meals and at bedtime. The order lacked blood sugar parameters for the resident. The Physician's Order, dated 12/31/21, directed staff to obtain accu-checks at 03:00AM. The order lacked blood sugar parameters for the resident. A Physician's Order dated 7/13/22 directed Toujeo (long acting insulin) solostar pen inject 28 units twice daily for type 2 DM. A Physician's Order dated 7/13/22 directed Novolog (fast acting insulin) flex pen inject 16 units three times daily for type 2 DM. On 08/01/22 at 12:20 PM, observation revealed R25, in her room, asleep in her chair. On 07/28/22 at 01:20 PM, Licensed Nurse (LN) G stated they did not have any blood sugar parameters from the physician. LN G stated she used her nursing judgement to determine when to call the physician. On 08/02/22 at 12:38 PM, Administrative Nurse D stated the resident should have blood sugar parameters. The facility's Blood Sugar Parameter policy, undated, documented the facility had the responsibility to care for the resident who received accu-check test and medication either oral or insulin for hypoglycemia and hyperglycemia and unless specific parameters are ordered by the physician, the standing orders would be used. The facility failed to obtain, from the physician, blood sugar parameters for R25 who had accu-checks five times per day. This placed the resident at risk for hyperglycemic or hypoglycemic episodes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 43 residents. The sample included 12 residents with five reviewed for unnecessary medications. Based on observation, record review and interview, the facility failed to ensure Resident (R) 28's as needed lorazepam (an antianxiety medication) had a stop date as required, placing the resident at risk for adverse side effects related to psychotropic (altering mood or mind) medication use. Findings included: -The Medical Diagnosis section withing R28's Electronic Medical Record (EMR) included diagnoses of major depressive disorder (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness), retention of urine, hypertension (elevated blood pressure), dementia (progressive mental disorder characterized by failing memory, confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear (disorder, heart failure and chronic obstructive pulmonary disease (COPD - progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R28 had intact cognition, had verbal and other behavioral symptoms not directed toward other one to three days of the look back period, required extensive assistance of one staff for activities of daily living, and frequently incontinent of urine and bowel. The MDS further documented R28 received an antianxiety medication on a routine basis. The Care Plan, dated 06/28/22, documented R28 was at risk for adverse side effects related to psychotropic medication. The care plan directed staff to give medications ordered by physician, document side effects and effectiveness, to provide education about risks and benefits and the side effect of lorazepam. The care plan further documented a Registered Pharmacist to review drug regimen monthly. The Physician Order, dated 10/28/19, directed staff to administer lorazepam 0.5 milligrams (mg) by mouth every 24 hours as needed for anxiety. The ordered did not have a stop date. Record review revealed R28 received as needed lorazepam on May 1, 5, 11, 12, 16, 24, and 30 2022. June 3, 6, 13, 26, and 28 2022, and July 1, 8, 26, 2022. Observation on 08/01/22 at 09:16 AM R28 sat in the dining room with supplemental oxygen supplied by tank attached to her wheelchair. On 08/02/22 at 09:03 AM, Administrative Nurse D verified the as needed lorazepam did not have a stop date as required. The facility's Consultant Pharmacist Services Provider Requirements, dated 09/18/17, documented review the medication regimen (drug regimen review of each resident in health center at least monthly incorporating federally mandated standards of care in addition to other applicable professional standards and documenting the review of findings in the resident's clinical record. Communicating to the responsible physician and the facility Director of Nursing potential or actual problems detected and other findings related to medication therapy orders. Communicating recommendations for changes in medication therapy and monitoring of medication therapy. The facility failed to ensure R28 as needed lorazepam had a stop date as required, placing the resident at risk for adverse side effects related to psychotropic medication.

The facility had a census of 43 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed ensure the resident council was able to meet regularly, which placed the residents at risk for unmet concerns related to life in the facility. Findings included: - Record review of the Resident Council Meeting revealed the facility had no minutes or meetings for the months of August 2021, September 2021, January 2022, and April 2022. On 08/01/22 at 01:03 PM Social Services X reported the meetings were scheduled monthly. Social Services X stated she could not remember why no meeting was conducted in August 2021. The September meeting had been canceled due to staffing issues. The January 2022 meeting was canceled due to a Covid (highly contagious, potentially life-threatening respiratory infection) outbreak in the assisted living building. The April 2022 meeting was canceled due to staffing issues. Social Services X verified she had not rescheduled the meeting during the previously noted months. On 08/02/22 at 11:53 AM, Administrative Staff A verified the resident council meetings should be allowed to meet at least monthly monthly and should have been rescheduled to facilitate the meetings. The facility's undated Resident and Family Group policy documented the facility is committed to consideration of views of the resident group and will act promptly upon grievances and recommendation of the group concerns issues of resident care and life in the facility, and meeting will be included on the monthly activity calendar. The facility failed to ensure the resident council was able to meet at least monthly placing the residents at risk for unmet concerns.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 43 residents. The sample included 12 residents of which six where reviewed for accidents and/or hazards. Based on observation, record review, and interview, the facility failed to update interventions on the care plans to prevent falls and hot beverage spill for Resident (R) 6, R34, R14, and 32. This deficient practice placed the residents at risk for injuries and accidents due to uncommunicated care needs. Findings included: - The Medical Diagnosis section within R6's Electronic Medical Record (EMR) included diagnoses of unspecified fall, hypertension (elevated blood pressure), traumatic subdural hemorrhage (collection of blood on the surface of the brain ) without loss of consciousness, and dementia (progressive mental disorder characterized by failing memory, confusion). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R6 had moderately impaired cognition, required supervision to limited assistance with activities of daily living, was not steady, but was able to stabilize without staff assistance with moving from a seated to standing position, moving on and off the toilet, and surface to surface transfers. R6 was not steady and only able to stabilize with staff assistance with turning around and facing the opposite direction when walking. The MDS further documented R6 had no trial of a toileting program, was frequently incontinent of urine and bowel, and had two or more falls with no injury and one fall with injury since last assessment. The Fall Care Area Assessment (CAA), dated 01/18/22, documented R6 had been admitted following hospitalization after a fall in which had resulted in subdural hematoma. The Fall Care Plan, revised on 02/07/22, documented R6 was at risk for falls related to impaired balance, gait, and poor safety awareness. The care plan directed staff to ensure R6 wore appropriate footwear when ambulating, transferring or mobilizing in her wheelchair. Staff were to anticipate R6's needs, check frequently, ensure touch call light pad within reach with encouragement and remind R6 to use it for assistance, and to respond for requested assistance. The care plan further directed staff to keep floor free from spills and clutter, use of glare free light, bed in low position at night, handrails on walls in the bathroom, and keep personal items within reach. The Fall Care Plan, revised on 04/21/22, directed staff to toilet R6 between 02:00 AM to 03:00 AM and ensure a nightlight was kept on in the bathroom to reduce chance of early morning falls. The care plan lacked intervention related to falls on 02/02/22, 02/16/22, 02/27/22, 03/04/22, 03/25/22, 05/31/22, 06/08/22, 06/26/22, 06/30/22, 07/16/22, and 07/26/22. The Physician Order, dated 01/10/22, documented the admission of R6 to the facility due to a fall resulting in a hematoma (collection of blood trapped in the tissues of the skin or in an organ, resulting from trauma) to back of head. The facility's Fall Risk Assessment dated 01/11/22, documented R6 was at moderate risk for falls. The facility's Fall Risk Assessment, dated 04/14/22 and 07/14/22 documented R6 scored at high risk for falls. The Progress Notes recorded the following falls: 02/02/22 at 02:47 PM, fell in bathroom reaching for incontinent pad and received a skin tear to right hand. 02/16/22 at 05:10 AM, found on floor by her recliner, incontinent of urine, and had cut to right eyebrow, bruise to right cheek bone, and hematoma to back of right hand. 02/27/22 at 12:52 AM, resident on floor of room. R6 reported she fell in the bathroom changing her incontinent product. 03/04/22 at 03:00 AM, resident on floor of her bathroom, incontinent of urine; she reported she hit her head on the wall. 03/25/22 at 08:52 AM, found lying on her back next to her bed, holding transfer bar, had golf ball size hematoma to left side frontal lobe (forehead) with three skin tears to left hand. R6 reported she had backed up to the chair and fell to the side. 04/18/22 at 03:00 AM, found on floor of bathroom, incontinent of urine, reported reaching for incontinent product and slid to floor. Skin tear to right elbow. 05/31/22 at 10:57 AM, fell while making her way to the bathroom, holding lip stick in one hand and reaching for the doorknob with the other hand. 06/08/22 at 01:53 AM, found on floor of bathroom, reported trying to sit on toilet and lost balance, hitting back of her head. 06/26/22 at 05:47 AM, found on floor, reported she tried to pick up her shoe and landed on her face. She had some signs of bruising and small skin tear. 06/30/22 at 01:15 PM, R6 pulled out a chair in the dining room and lost her balance. 07/16/22 at 01:00 PM, R6 returned from outing with a family member, her walker caught on carpet in the entry way. Family member tried to catch her, and the resident fell onto the family member. 07/26/22 at 02:45 AM, found sitting on bathroom floor, incontinent of urine. On 08/01/22 at 09:30 AM, observation revealed R6 sat in her room in her recliner with her eyes closed. She was dressed for the day and wore tennis shoes. R6 reported her call light was on her bed and she should use it when going to the bathroom. On 08/01/22 at 08:57 AM, Certified Medication Aide (CMA) R reported if a resident fell, staff were to immediately notify the charge nurse, to assess the resident. The staff were alerted the resident had fallen in the communication system of the electronic record. On 08/01/22 at 10:00 AM, Licensed Nurse (LN) H reported when a resident fell, the staff alert the charge nurse to assess the resident; a neurological exam and 15-minute checks were initiated. LN H stated a new intervention should be placed at the time of the fall, and the care plan should be updated with the intervention. On 08/02/22 at 08:41 AM, Administrative Nurse D verified R6's care plan had not been updated with interventions to prevent falls. She stated it was her responsibility to investigate falls and update the care plans. The facility's undated Care Plan Revision/Updates policy documented each resident will have a care plan developed to meet their individual needs and cares. All resident care plans are reviewed quarterly, annually, and with any significant change in status. The facility failed to identify and implement interventions to the care plan to prevent falls for R6 who had multiple falls. This deficient practice placed R6 at increased risk for further falls and injury. - R34's Medical Diagnosis section within the Electronic Medical Record (EMR) included diagnosis of age-related physical debility, difficulty in walking, hypertension (elevated blood pressure), major depressive (major mood disorder ) disorder recurrent, severe with psychotic (any major mental disorder characterized by a gross impairment in reality testing) symptoms, spinal stenosis (degenerative condition of the spine that could cause weakness and loss of use of extremities), atrial fibrillation (rapid, irregular heart beat), anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), muscle weakness, right shoulder pain, anterograde amnesia (a type of memory loss that occurs when person cannot form new memories), and alcoholic cirrhosis (chronic degenerative disease of the liver) of liver with ascites (the accumulation of fluid in the abdominal cavity, causing swelling). The Quarterly Minimum Data Set (MDS), date 07/01/22, documented R34 had intact cognition, required supervision to limited assistance of one staff for activities of daily living. R34 was not steady but able to stabilize without staff assistance with moving from a seated to standing position, moving on and off the toilet and surface to surface transfer, walking, and turning around and face the opposite direction while walking. The MDS further documented R34 had no trial of toileting program, was frequently incontinent of urine, always continent of bowel, and had pain. R34 had two or more falls with injury. The Fall Care Plan, revised on 02/18/22, documented R34 at risk for falls related to impaired balance, strength, and safety awareness. The care plan further documented to encourage and remind R34 to use the call light, encourage participation in activities that promote exercise, physical activity for strengthening and improved mobility. The care plan directed staff to ensure R34's wheelchair was next to the bed and the brakes were locked, to wear appropriate footwear, keep safe environment free from spills and clutter, use glare free lights, reachable call light, bed in low position at night, handrails in bathroom and keep personal items within reach. The care plan further documented R34 attempted to get up unassisted and needed frequent checks to anticipate needs. The care plan lacked intervention for falls on 06/11/22 and 06/25/22. The Progress Note, dated 06/11/22 at 06:30 PM, R34 was found sitting upright on the floor, incontinent of urine and reported she was looking for her TV remote. The Progress Note, dated 06/25/22, documented around 11:40 PM the resident was found on the floor by the wall. R34 stated she was going to the bathroom, lost her balance, and fell hitting her right shoulder against the wall. The Physician Order dated 06/26/22 directed staff to obtain two view x-ray of the right shoulder following a fall for swelling, bruising, and pain with movement. On 07/28/22 at 12:26 PM observation revealed R34 left the dining room independently with her walker. On 08/01/22 at 12:18 PM, Certified Medication Aide (CMA) R reported R34 was a standby for assistance with toileting as an intervention to prevent falls. On 08/01/22 at 10:00 AM, Licensed Nurse (LN) H reported when a resident fell, the staff alert the charge nurse to assess the resident, a neurological exam and 15-minute checks were initiated. LN H stated a new intervention should be placed at time of fall, and the care plan should be updated with intervention. On 08/02/22 at 08:41 AM, Administrative Nurse D verified R34's care plan had not been updated with interventions to prevent falls. She stated it was her responsibility to investigate falls and update the care plans. The facility's undated Care Plan Revision/Updates policy documented each resident will have a care plan developed to meet their individual needs and cares. All resident care plans are reviewed quarterly, annually, and with any significant change in status. The facility failed to identify and update interventions on the care plan to prevent falls placing R34 at risk for further falls and injury. - The Electronic Medical Record (EMR) for R14 documented diagnoses of hypertension (high blood pressure), dementia without behavioral disturbance (progressive mental disorder characterized by failing memory and confusion), and diabetes mellitus type 2 (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R14 had severely impaired cognition and had only transferred with one staff two or fewer times, did not ambulate, had unsteady balance, and had no functional impairment. The MDS further documented R14 had two or more non injury falls since prior assessment. The Fall Risk Assessment, dated 05/03/22, documented the resident a high risk for falls. The Care Plan, dated 05/09/22, initiated on 11/14/21, directed staff to use two staff to assist with transfers on and off of the shower chair, and provide and serve her diet as ordered. The care plan documented R14 was able to feed herself but occasionally required reminders and cuing during meals. The care plan lacked documentation R14 required lids on her hot and cold drinks. The Nurse's Note, dated 04/13/22 at 09:04 AM, documented R14 spilled hot coffee down the left side of her chest and abdomen, had slight redness, no blisters or burns present, and improved after five minutes. The Nurse's Note, dated 06/26/22 at 03:45 PM, documented R14 spilled warm coffee on her left abdomen and upper thigh earlier that morning. The note documented R14 was sleepy upon rising from bed at 07:00 AM, had no redness or injury. The Investigation Report, dated 07/09/22, documented R14 spilled her hot coffee onto her chest after a dietary aide had given it to her without a lid. The report further documented R14's had scattered redness to the front of her lower chest, lower abdomen and very slightly to the front of her thighs. The area of redness to the left chest measured 9 centimeters (cm) x 4 cm, redness to abdomen measured 5 cm x 1.7 cm x 0.7 cm in three different spots. The coffee had a temperature of 161.8 and directed dietary staff to ensure the temperature of hot beverages were within acceptable range when serving. The report documented R14 was on a list to have cooled coffee with a cup and lid and staff would receive further training regarding hot liquids. The Physician's Order, dated 07/09/22, directed staff to apply silvadene cream 1% (an antibiotic cream used to treat burns) apply to left chest, abdomen, and thighs topically, twice a day for seven days. The Nurse's Note, dated 07/10/22, documented no redness or blistering noted in relation to R14's coffee spill. The Weekly Skin Assessment, dated 07/14/22, documented R14 had faint red markings on the center of her abdomen. The Investigation Report, dated 07/14/22, documented a Certified Nurse Aide (CNA) had to bear hug a resident to hold her up in the shower so another CNA could provide pericare after R14 had a bowel movement (bm). The report documented R14's feet slid due to the floor was wet and the CNA had to lower the resident onto the floor. The resident was assessed without injury and due to the resident unable to bear weight, staff used the hoyer (mechanical lift) to assist the resident off of the floor and into her wheelchair. The report further documented R14 should have been properly positioned in the shower chair and should have been transferred with two staff. On 08/01/22 at 10:47 AM, observation revealed CNA M placed a gait belt around R14's waist, had her lean forward, count to three, and CNA M and Licensed Nurse (LN) I tried to stand the resident up straight. Further observation revealed R14 sat back down and CNA M counted to three again, and the resident was able to partially stand up and pivot to the wheelchair. R14 sat crooked in her wheelchair and CNA M took the back of her pants and pulled up to reposition the resident into the wheelchair. CNA M pushed R14 into the dining room, without foot pedals, into the dining room. On 07/28/22 at 08:47 AM, CNA M stated she did not know if R14 had any falls and would need to ask her nurse. CNA M further stated R14 required cups with lids so she did not spill on herself. On 08/02/22 at 10:05 AM, LN I stated R14 was a two- person transfer and had a recent fall in the shower room. R14 stated staff should use foot pedals on the wheelchairs when transporting residents. On 08/02/22 at 08:30 AM, Administrative Nurse D stated R14 was on a list for resident's who required lids on their cups and that was not communicated to the dietary staff member. Administrative Nurse D stated the resident required two staff to transfers and should not have been transferred by one staff in the shower room. Administrative Nurse D stated she was responsible to update the care plan after a fall or incident and verified she had not done so. The facility's Care Plan Revision/Updates policy, undated, documented each resident would have a care plan developed to meet their individual needs and cares and would be reviewed and changed with each significant change of status. The facility failed to revise R14's care plan with interventions to prevent further falls and accident hazards, placing the resident at risk for further falls and injury. - The Electronic Medical Record (EMR), documented for R32 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), Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), and osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R32 had moderately impaired cognition and required extensive assistance of one staff for bed mobility and supervision and one staff for transfers. The MDS further documented R32 had unsteady balance, no functional impairment, and no falls. The Fall Risk Assessments, dated 09/23/21 and 12/24/21 documented R32 a high risk for falls and 06/28/22 a moderate risk for falls. The Care Plan, dated 07/07/22, initiated on 10/08/21, directed staff to ensure the call light was within reach and remind the resident to use it, ensure resident wore appropriate footwear when ambulating or transferring, and required one person assist for safe transfers. The care plan lacked interventions to prevent further falls. The Fall Investigation, dated 12/07/21 at 02:29 PM, documented R32 fell while straightening the sheet on her bed, had soreness to bilateral knees, and denied hitting her head. The investigation further documented R32 reported she was messing with the edge of her sheet before getting into bed for a nap, slipped and fell to her knees. The clinical record lacked evidence a resident centered intervention was put into place to prevent further falls. The Fall Investigation, dated 07/05/22 at 03:29 PM, documented at approximately 11:15 AM, R32 was observed on the floor in her room and the resident was seated in the upright position facing the hallway with her back against her nightstand. The resident stated she lost her balance while she tried to make her bed. R32 stated she did not hit her head and denied pain. The investigation documented R32 had poor safety awareness and would continue to monitor the resident. The clinical record lacked evidence a resident centered intervention was put into place to prevent further falls. The Fall Investigation, dated 07/07/22 at 09:45 PM, documented R32 was observed lying on her right side, on the floor, in her room with her legs stretched out in front of her. The investigation documented R32 had reached over her head to pick up colored pencils she had dropped on the floor and fell. The investigation further documented R32 did not sustain any injuries and was shown her call light and educated to push the red button for assistance. The clinical record lacked evidence a resident centered intervention was put into place to prevent further falls. On 08/01/22 at 11:20 AM, observation revealed Certified Nurse Aide (CNA) M place a gait belt around R32's waist, had the resident reach with her right hand to the right armrest of her wheelchair, stand, and then sit down into her wheelchair. On 08/01/22 at 11:20 AM, CNA M stated R32 required reminders to use her call light because she was forgetful. CNA M was unsure of any recent falls for R32. On 08/02/22 at 09:56 AM, Licensed Nurse (LN) I stated R32 often tried to get up unassisted and they reeducate her to use her call light. LN I further stated staff keep R32's bed in the lowest position and make sure the resident used her wheelchair because she had poor balance. On 08/02/22 at 12:38 PM, Administrative Nurse D verified the care plan lacked interventions for the falls and stated R32's cognition changed daily and staff should assist the resident to make her bed or let the resident assist the staff so she did not feel she needed to do it by herself. The facility's Care Plan Revision/Updates policy, undated, documented each resident would have a care plan developed to meet their individual needs and cares and would be reviewed and changed with each significant change of status. The facility failed to revise R32's care plan with meaningful, resident centered interventions for cognitively impaired R32, who had falls, placing the resident at risk for further falls.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 43 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to identify and/or implement interventions to prevent falls for Resident (R)6, R34, R14, R32 and R38. which placed the residents at increased risk for ongoing falls and injuries. Findings included: -The Medical Diagnosis section within R6's Electronic Medical Record (EMR) included diagnoses of unspecified fall, hypertension (elevated blood pressure), traumatic subdural hemorrhage (collection of blood on the surface of the brain ) without loss of consciousness, and dementia (progressive mental disorder characterized by failing memory, confusion). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R6 had moderately impaired cognition, required supervision to limited assistance with activities of daily living, was not steady, but was able to stabilize without staff assistance with moving from a seated to standing position, moving on and off the toilet, and surface to surface transfers. R6 was not steady and only able to stabilize with staff assistance with turning around and facing the opposite direction when walking. The MDS further documented R6 had no trial of a toileting program, was frequently incontinent of urine and bowel, and had two or more falls with no injury and one fall with injury since last assessment. The Fall Care Area Assessment (CAA), dated 01/18/22, documented R6 had been admitted following hospitalization after a fall in which had resulted in subdural hematoma. The Fall Care Plan, revised on 02/07/22, documented R6 at risk for falls related to impaired balance, gait, and poor safety awareness. The care plan directed staff to ensure R6 wore appropriate footwear when ambulating, transferring or mobilizing in her wheelchair. Staff were to anticipate R6's needs, check frequently, ensure touch call light pad within reach with encouragement and remind R6 to use it for assistance, and to respond for requested assistance. The care plan further directed staff to keep floor free from spills and clutter, use of glare free light, bed in low position at night, handrails on walls in the bathroom, and keep personal items within reach. The Fall Care Plan, revised on 04/21/22, documented staff to toilet R6 between 02:00 AM to 03:00 AM and ensure a nightlight was kept on in the bathroom, to reduce chance of early morning falls. The Physician Order, dated 01/10/22, documented the admission of R6 to the facility due to a fall resulting in a hematoma (collection of blood trapped in the tissues of the skin or in an organ, resulting from trauma) to back of head. The facility's Fall Risk Assessment dated 01/11/22, documented R6 was at moderate risk for falls. The facility's Fall Risk Assessment, dated 04/14/22 and 07/14/22 documented R6 scored at high risk for falls. The facility's Bowel and Bladder Program Screener, dated 01/11/22, 04/14/22, and 07/14/22, scored R6 a good candidate for retraining. The Progress Notes recorded the following falls: 02/02/22 at 02:47 PM, fell in bathroom reaching for incontinent pad and received a skin tear to right hand. 02/16/22 at 05:10 AM, found on floor by her recliner, incontinent of urine, and had cut to right eyebrow, bruise to right cheek bone, and hematoma to back of right hand. 02/27/22 at 12:52 AM, resident on floor of room. R6 reported she fell in the bathroom changing her incontinent product. 03/04/22 at 03:00 AM, resident on floor of her bathroom, incontinent of urine; she reported she hit her head on the wall. 03/25/22 at 08:52 AM, found lying on her back next to her bed, holding transfer bar, had golf ball size hematoma to left side frontal lobe (forehead) with three skin tears to left hand. R6 reported she had backed up to the chair and fell to the side. 04/18/22 at 03:00 AM, found on floor of bathroom, incontinent of urine, reported reaching for incontinent product and slid to floor. Skin tear to right elbow. 05/31/22 at 10:57 AM, fell while making her way to the bathroom, holding lip stick in one hand and reaching for the doorknob with the other hand. 06/08/22 at 01:53 AM, found on floor of bathroom, reported trying to sit on toilet and lost balance, hitting back of her head. 06/26/22 at 05:47 AM, found on floor, reported she tried to pick up her shoe and landed on her face. She had some signs of bruising and small skin tear. 06/30/22 at 01:15 PM, R6 pulled out a chair in the dining room and lost her balance. 07/16/22 at 01:00 PM, R6 returned from outing with a family member, her walker caught on carpet in the entry way. Family member tried to catch her, and the resident fell onto the family member. 07/26/22 at 02:45 AM, found sitting on bathroom floor, incontinent of urine. On 08/01/22 at 08:57 AM, Certified Medication Aide (CMA) R reported if a resident fell, staff were to immediately notify the charge nurse, to assess the resident. The staff was alerted that the resident had fallen in the communication system of the electronic record. On 08/01/22 at 10:00 AM, Licensed Nurse (LN) H reported when a resident fell, the staff alert the charge nurse to assess the resident; a neurological exam and 15-minute checks were initiated. LN H stated a new intervention should be placed at the time of the fall, and the care plan should be updated with the intervention. On 08/02/22 at 08:41 AM, Administrative Nurse D verified no new interventions had been developed and implemented for R6 to prevent falls. She stated it was her responsibility to investigate falls and update the care plans. The facility's undated Fall Prevention Protocol, documented the effectiveness of fall reduction activities, including assessment, causal factors, interventions, and education will be evaluated by the Interdisciplinary Care Plan team at time of each comprehensive assessment. The effectiveness of the facility fall reduction activities will be evaluated on a monthly basis by Quality Assurance Performance Improvement (QAPI) committee. Outcome indicators include the number f falls, and the severity of fall-related injuries, and effectiveness of implemented care plan interventions. The facility failed to identify and implement interventions to prevent falls for R6 who had multiple falls. This deficient practice placed R6 at increased risk for further falls and injury. - R34's Medical Diagnosis section within the Electronic Medical Record (EMR) included diagnosis of age-related physical debility, difficulty in walking, hypertension (elevated blood pressure), major depressive (major mood disorder ) disorder recurrent, severe with psychotic (any major mental disorder characterized by a gross impairment in reality testing)symptoms, spinal stenosis (degenerative condition of the spine that could cause weakness and loss of use of extremities), atrial fibrillation (rapid, irregular heart beat), anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), muscle weakness, right shoulder pain, anterograde amnesia (a type of memory loss that occurs when person cannot form new memories), and alcoholic cirrhosis (chronic degenerative disease of the liver) of liver with ascites (the accumulation of fluid in the abdominal cavity, causing swelling). The Quarterly Minimum Data Set (MDS), date 07/01/22, documented R34 had intact cognition, required supervision to limited assistance of one staff for activities of daily living. R34 was not steady but able to stabilize without staff assistance with moving from a seated to standing position, moving on and off the toilet and surface to surface transfer, walking, and turning around and face the opposite direction while walking. The MDS further documented R34 had no trial of toileting program, was frequently incontinent of urine and always continent of bowel, had pain. R34 had two or more falls with injury. The Fall Care Plan, revised on 02/18/22, documented R34 at risk for falls related to impaired balance, strength, and safety awareness. The care plan further documented to encourage and remind R34 to use the call light, encourage participation in activities that promote exercise, physical activity for strengthening and improved mobility. The care plan directed staff to ensure R34's wheelchair was next to the bed and the brakes were locked, to wear appropriate footwear, keep safe environment free from spills and clutter, use glare free lights, reachable call light, bed in low position at night, handrails in bathroom and keep personal items within reach. The care plan further documented R 34 attempted to get up unassisted and needed frequent checks to anticipate needs. The Progress Note, dated 06/11/22 at 06:30 PM, R34 was found sitting upright on the floor, incontinent of urine and reported she was looking for her TV remote. The Progress Note, dated 06/25/22, documented around 11:40 PM the resident was found on the floor by the wall. R34 stated she was going to the bathroom, lost her balance, and fell hitting her right shoulder against the wall. On 07/28/22 at 12:26 PM observation revealed R34 left the dining room independently with her walker. On 08/01/22 at 12:18 PM, Certified Medication Aide (CMA) R reported R34 was a standby for assistance with toileting as an intervention to prevent falls. On 08/01/22 at 10:00 AM, Licensed Nurse (LN) H reported when a resident fell, the staff alert the charge nurse to assess the resident, a neurological exam and 15-minute checks were initiated. LN H stated a new intervention should be placed at time of fall, and the care plan should be updated with intervention. On 08/02/22 at 08:41 AM, Administrative Nurse D verified new interventions had not developened or implemented for R34 to prevent falls. She stated it was her responsibility to investigate falls and update the care plans. The facility's undated Fall Prevention Protocol, documented the effectiveness of fall reduction activities, including assessment, causal factors, interventions, and education will be evaluated by the Interdisciplinary Care Plan team at time of each comprehensive assessment. The effectiveness of the facility fall reduction activities will be evaluated on a monthly basis by Quality Assurance Performance Improvement (QAPI) committee. Outcome indicators include the number of falls, and the severity of fall-related injuries, and effectiveness of implemented care plan interventions. The facility failed to identify and implement interventions to prevent falls placing R34 at risk for further falls and injury. - The Electronic Medical Record (EMR) for R14 documented diagnoses of hypertension (high blood pressure), dementia without behavioral disturbance (progressive mental disorder characterized by failing memory and confusion), and diabetes mellitus type 2 (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R14 had severely impaired cognition and had only transferred with one staff two or fewer times, did not ambulate, had unsteady balance, and had no functional impairment. The MDS further documented R14 had two or more non injury falls since prior assessment. The Fall Risk Assessment, dated 05/03/22, documented the resident a high risk for falls. The Care Plan, dated 05/09/22, initiated on 11/14/21, directed staff to use two staff to assist with transfers on and off of the shower chair, provide and serve her diet as ordered. The care plan documented R14 was able to feed herself but occasionally required reminders and cuing during meals. The care plan lacked documentation R14 required lids on her hot and cold drinks. The Nurse's Note, dated 04/13/22 at 09:04 AM, documented R14 spilled hot coffee down the left side of her chest and abdomen, had slight redness, no blisters or burns present, and improved after five minutes. The Nurse's Note, dated 06/26/22 at 03:45 PM, documented R14 spilled warm coffee on her left abdomen and upper thigh earlier that morning. The note documented R14 was sleepy upon rising from bed at 07:00 AM, had no redness or injury. The Investigation Report, dated 07/09/22, documented R14 spilled her hot coffee onto her chest after a dietary aide had given it to her without a lid. The report further documented R14's had scattered redness to the front of her lower chest, lower abdomen and very slightly to the front of her thighs. The area of redness to the left chest measured 9 centimeters (cm) x 4 cm, redness to abdomen measured 5 cm x 1.7 cm x 0.7 cm in three different spots. The coffee had a temperature of 161.8 and directed dietary staff to ensure the temperature of hot beverages were within acceptable range when serving. The report documented R14 was on a list to have cooled coffee with a cup and lid and staff would receive further training regarding hot liquids. The Physician's Order, dated 07/09/22, directed staff to apply silvadene cream 1% (an antibiotic cream used to treat burns) apply to left chest, abdomen, and thighs topically, twice a day for seven days. The Nurse's Note, dated 07/10/22, documented no redness or blistering noted in relation to R14's coffee spill. The Weekly Skin Assessment, dated 07/14/22, documented R14 had faint red markings on the center of her abdomen. The Investigation Report, dated 07/14/22, documented a Certified Nurse Aide (CNA) had to bear hug a resident to hold her up in the shower so another CNA could provide pericare after R14 had a bowel movement (bm). The report documented R14's feet slid due to the floor was wet and the CNA had to lower the resident onto the floor. The resident was assessed without injury and due to the resident unable to bear weight, staff used the hoyer (mechanical lift) to assist the resident off of the floor and into her wheelchair. The report further documented R14 should have been properly positioned in the shower chair and should have been transferred with two staff. On 08/01/22 at 10:47 AM, observation revealed CNA M placed a gait belt around R14's waist, had her lean forward, count to three, and CNA M and Licensed Nurse (LN) I tried to stand the resident up straight. Further observation revealed R14 sat back down and CNA M counted to three again, and the resident was able to partially stand up and pivot to the wheelchair. R14 sat crooked in her wheelchair and CNA M took the back of her pants and pulled up to reposition the resident into the wheelchair. CNA M pushed R14 into the dining room, without foot pedals, into the dining room. On 07/28/22 at 08:47 AM, CNA M stated she did not know if R14 had any falls and would need to ask her nurse. CNA M further stated R14 required cups with lids so she did not spill on herself. On 08/02/22 at 10:05 AM, LN I stated R14 was a two- person transfer and had a recent fall in the shower room. R14 stated staff should use foot pedals on the wheelchairs when transporting residents. On 08/02/22 at 08:30 AM, Administrative Nurse D stated R14 was on a list for resident's who required lids on their cups and that was not communicated to the dietary staff member. Administrative Nurse D stated the resident required two staff to transfers and should not have been transferred by one staff in the shower room. Administrative Nurse D stated she was responsible to update the care plan after a fall and verified she had not done so. The facility's Fall Prevention Protocol, policy, undated, documented each senior who resided at the facility would be provided services and care that ensured an environment to prevent accidents. The policy documented all staff members would be educated on the fall reduction program annually through the mandated safety inservice and more often based on needed. The facility's Accident Prevention/Hazards policy, undated, documented all staff members of the facility would ensure that each senior's environment remained as free from accident hazards as possible. Each senior was assisted with activities of daily living, based on his/her needs including bathing, dressing, eating, oral hygiene, ambulation, and toileting activities. Clinical staff would ensure each senior was as safe from accidents as he/she received restorative services as possible. The facility failed to prevent coffee spills for cognitively impaired R14, which resulted in a mild burn, and failed to follow R14's care plan which resulted in a fall in the shower. These deficient practices placed the resident at increased risk for further injury. - The Electronic Medical Record (EMR), documented for R32 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), Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), and osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R32 had moderately impaired cognition and required extensive assistance of one staff for bed mobility and supervision and one staff for transfers. The MDS further documented R32 had unsteady balance, no functional impairment, and no falls. The Fall Risk Assessments, dated 09/23/21 and 12/24/21 documented R32 a high risk for falls and 06/28/22 a moderate risk for falls. The Care Plan, dated 07/07/22, initiated on 10/08/21, directed staff to ensure the call light was within reach and remind the resident to use it, ensure resident wore appropriate footwear when ambulating or transferring, and required one person assist for safe transfers. The care plan lacked interventions to prevent further falls. The Fall Investigation, dated 12/07/21 at 02:29 PM, documented R32 fell while straightening the sheet on her bed, had soreness to bilateral knees, and denied hitting her head. The investigation further documented R32 reported she was messing with the edge of her sheet before getting into bed for a nap, slipped and fell to her knees. The clinical record lacked evidence a resident centered intervention was put into place to prevent further falls. The Fall Investigation, dated 07/05/22 at 03:29 PM, documented at approximately 11:15 AM, R32 was observed on the floor in her room and the resident was seated in the upright position facing the hallway with her back against her nightstand. The resident stated she lost her balance while she tried to make her bed. R32 stated she did not hit her head and denied pain. The investigation documented R32 had poor safety awareness and would continue to monitor the resident. The clinical record lacked evidence f a resident centered intervention was put into place to prevent further falls. The Fall Investigation, dated 07/07/22 at 09:45 PM, documented R14 was observed lying on her right side, on the floor, in her room with her legs stretched out in front of her. The investigation documented R32 had reached over her head to pick up colored pencils she had dropped on the floor and fell. The investigation further documented R32 did not sustain any injuries and was shown her call light and educated to push the red button for assistance. The clinical record lacked evidence a resident centered intervention was put into place to prevent further falls. On 08/01/22 at 11:20 AM, observation revealed Certified Nurse Aide (CNA) M place a gait belt around R32's waist, had the resident reach with her right hand to the right armrest of her wheelchair, stand, and then sit down into her wheelchair. On 08/01/22 at 11:20 AM, CNA M stated R32 required reminders to use her call light because she was forgetful. CNA M said she was unsure of any recent falls R32. On 08/02/22 at 09:56 AM, Licensed Nurse (LN) I stated R32 often tried to get up unassisted and they reeducate her to use her call light. LN I further stated staff keep R32's bed in the lowest position and make sure the resident used her wheelchair because she had poor balance. On 08/02/22 at 12:38 PM, Administrative Nurse D verified the care plan lacked interventions for the falls and stated R32's cognition changed daily and staff should assist the resident to make her bed or let the resident assist the staff so she did not feel she needed to do it by herself. The facility's Fall Prevention Protocol, policy, undated, documented each senior who resided at the facility would be provided services and care that ensured an environment to prevent accidents. The policy documented all staff members would be educated on the fall reduction program annually through the mandated safety in-service and more often based on needed. The facility failed to implement meaningful, resident centered interventions for cognitively impaired R32, who had falls, placing the resident at risk for further falls. - The Electronic Medical Record (EMR) for R38 documented diagnoses of hypertension (high blood pressure), heart failure (a condition when the heart does not pump enough blood for the body's needs), and cerebrovascular accident (sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain). The Significant Change Minimum Data Set (MDS), dated [DATE], documented R38 had severely impaired cognition and required extensive assistance of two staff for bed mobility, transfers, and did not ambulate. The MDS further documented R38 had unsteady balance, no functional impairment, and had a fall with injury. The Fall Risk Assessment, dated 06/21/22 documented R38 was a high risk for falls. The Care Plan, dated 07/29/22, initiated on 08/27/21, directed staff to ensure R38 wore appropriate footwear when in wheelchair, ensure foot pedals were on the wheelchair when pushing him to and from his room; ensure his call light was within reach. The Fall Investigation, dated 06/15/22 at 05:50 PM, documented R38 had a witnessed fall in the dining room. Staff pushed the resident in his wheelchair out of the dining room without feet pedals and the resident's feet went under the wheelchair which caused him to fall forward out of the wheelchair. The investigation documented R38 yelled out in pain and stated his back hurt. Staff contacted the physician and were directed to send the resident to the emergency room (ER) for treatment. The investigation documented the ambulance arrived and R38 denied back pain. The facility contacted R38's family and it was decided not to send the resident to the ER. On 08/01/22 at 11:45 AM, observation revealed Certified Nurse Aide (CNA) M and CNA N assisted R38 from his bed and into his Broda chair (repositioning chair) . With the sling for the lift (mechanical lift) already underneath the resident, CNA M attached the sling to the lift, raised R38 up and lowered him into the chair. On 08/01/22 at 11:45 AM, CNA N stated she did not think R38 had any recent falls and stated he used to be in a regular wheelchair but he was recently placed on hospice and the Broda chair was better for him. On 08/02/22 at 10:11 AM, Licensed Nurse I stated R38 fell in the dining room and should have had the foot pedals on the wheelchair before he was pushed anywhere. On 08/02/22 at 12:54 PN, Administrative Nurse D stated R38 had been in a regular wheelchair and should have had wheelchair pedals on before he was ever pushed into the dining room. Administrative Nurse D verified the care plan was not followed. The facility's Fall Prevention Protocol, policy, undated, documented each senior who resided at the facility would be provided services and care that ensured an environment to prevent accidents. The policy documented all staff members would be educated on the fall reduction program annually through the mandated safety in-service and more often based on needed. The facility failed to follow R38's care plan to make sure he had wheelchair pedals on his wheelchair before he was pushed to and from his room which resulted in a fall.

The facility had a census of 43 residents. The sample included 12 residents. The facility idneitfied two staff members currently positive for COVID-19 (highly contagious, potentially life-threatening respiratory virus). Based on observation, record review, and interview, the facility failed to follow the core principles of infection control for resident surveillance of signs/symptoms of COVID-19 when they failed to complete a respiratory assessment and temperature at least daily for 12 sampled residents, Resident (R) 5, R6, R14, R16, R23, R25, R28, R31, R32, R34, R38, and R142. This deficient practice placed the residents at increased risk for transmission and/or development of COVID-19. Findings included: - The Electronic Medical Record (EMR) for R5 from 02/07/22 - 08/02/22 lacked documentation for monitoring and assessing the resident for COVID-19 symptoms including respiratory status and temperature. The Electronic Medical Record (EMR) for R6 from 02/07/22 - 08/02/22 lacked documentation for monitoring and assessing the resident for COVID-19 symptoms including respiratory status and temperature. The Electronic Medical Record (EMR) for R14 from 02/07/22 - 08/02/22 lacked documentation for monitoring and assessing the resident for COVID-19 symptoms including respiratory status and temperature. The Electronic Medical Record (EMR) for R16 from 02/07/22 - 08/02/22 lacked documentation for monitoring and assessing the resident for COVID-19 symptoms including respiratory status and temperature. The Electronic Medical Record (EMR) for R23 from 02/07/22 - 08/02/22 lacked documentation for monitoring and assessing the resident for COVID-19 symptoms including respiratory status and temperature. The Electronic Medical Record (EMR) for R25 from 03/02/22 - 08/02/22 lacked documentation for monitoring and assessing the resident for COVID-19 symptoms including respiratory status and temperature. The Electronic Medical Record (EMR) for R28 from 02/07/22 - 08/02/22 lacked documentation for monitoring and assessing the resident for COVID-19 symptoms including respiratory status and temperature. The Electronic Medical Record (EMR) for R31 from 06/12/22 - 08/02/22 lacked documentation for monitoring and assessing the resident for COVID-19 symptoms including respiratory status and temperature. The Electronic Medical Record (EMR) for R32 from 02/07/22 - 08/02/22 lacked documentation for monitoring and assessing the resident for COVID-19 symptoms including respiratory status and temperature. The Electronic Medical Record (EMR) for R34 from 02/07/22 - 08/02/22 lacked documentation for monitoring and assessing the resident for COVID-19 symptoms including respiratory status and temperature. The Electronic Medical Record (EMR) for R38 from 02/07/22 - 08/02/22 lacked documentation for monitoring and assessing the resident for COVID-19 symptoms including respiratory status and temperature. The Electronic Medical Record (EMR) for R142 from 02/07/22 - 08/02/22 lacked documentation for monitoring and assessing the resident for COVID-19 symptoms including respiratory status and temperature. On 07/28/22 at 12:26 PM observation revealed R34 left the dining room independently with her walker. Observation on 08/01/22 at 09:16 AM R28 sat in the dining room with supplemental oxygen supplied by tank attached to her wheelchair. On 08/01/22 at 12:20 PM, observation revealed R25, in her room, asleep in her chair. On 07/27/22 at 11:19 AM, Administrative Nurse D stated they had not been screening the residents' respiratory status for a few months because she had talked to her local health department who stated the facility did not need to screen residents daily. Administrative Nurse D further stated her medical director also told them they did not need to. Administrative Nurse D stated they were told to assess the resident if they were exhibiting symptoms. The Centers for Medicare and Medicaid Services (CMS) and Centers for Disease Control and Prevention (CDC) guidance dated 04/02/20 recommended: Long-term care facilities should immediately implement symptom screening for all. In accordance with previous (CMS) guidance, every individual regardless of reason entering a long-term care facility (including residents, staff, visitors, outside healthcare workers, vendors, etc.) should be asked about COVID-19 symptoms and they must also have their temperature checked, Facilities should limit access points and ensure that all accessible entrances have a screening station. In accordance with previous CDC guidance, every resident should be assessed for symptoms and have their temperature checked every day. The facility failed to follow the guidelines set by the CDC and CMS for monitoring and assessing residents' respiratory status and temperatures at least daily, which placed the residents at risk for transmission and/or development of COVID-19.

The facility had a census of 43 residents. The sample included 12 residents. Based on observation, record review, and interviews, the facility failed to store, prepare, and serve food in a sanitary condition for 43 residents who received meals from the kitchen, and ate in the dining room placing them at risk for food borne illness. Findings included: - On 08/01/22 at 11:23 AM during the kitchen inspection, observation revealed the testing sanitizing solution lacked documentation for the month of July 2022. The sanitizing test strips were found without an expiration date, and the ventilation vent cover above the cooking surface in the kitchenette attached to the dining room in the long-term care area, was covered with thick dust like debris. The dining room had numerous chairs found to have dried food particles on the seat, arms, and back of chairs. The chairs also had dark liquid spill stains on the seats. On 08/02/22 at 08:30 AM, Dietary Staff (DS) CC verified the testing strips did not have a expire date on them and no logs for sanitizing solution were found. DS CC verified the vent above the cook stove should be cleaned. On 08/02/22 at 11:25 AM, Administrative Staff A verified the dining room chairs had dried food debris and dark liquid type stains on the seats. He reported it was the responsibility of all staff to maintain a clean environment for the residents. The facility's undated General Cleaning and Maintenance of Resident Environment policy, documented Environmental Service and Custodial staff will keep furnishings and equipment safe and in good repair and will maintain a safe and functional dining environment. The policy further documented the staff will provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, functional and comfortable interior. The facility did not provide a policy for testing and maintaining record of sanitizing solution logs. The facility failed to store, prepare, and serve food in a sanitary condition for 43 resident who resided in the facility and received meals from the kitchen and dining room, placing them at risk for food borne illness.

The facility had a census of 41 residents. Based on observation and interview, the facility failed to store food in a safe and sanitary manner for the 41 residents, that resided in the facility, and received food from the facility kitchen. Findings Included: - On 04/19/21 at 08:30 AM, during initial kitchen tour, observation of the silver double door refrigerator in the kitchen revealed no documentation of daily temperature logs for April 1-19, 2021. Further observation revealed no documentation of daily temperature logs for this refrigerator since April 2020. Observation of the refrigerator revealed storage of condiments, 4 gallons of milk, eggs, yogurt cups, and prepared chili mix to be served on 04/20/21. On 04/19/21 at 08:35 AM, Dietary Staff (DS) BB verified the refrigerator temperature had not been documented, and stated the facility use to have a sheet on the front of the door, but it was currently not there. DS BB verified the lack of temperature log documentation for the last year. On 04/26/21 at 03:15 PM, Administrative Staff A verified staff should document the refrigerator and freezer temperatures twice daily and keep a record of the temperatures for at least three months. Administrative Staff A verified the lack of temperature log documentation for the last year. The undated facility Refrigerator and Freezer Temperature policy, documented dining services would be responsible for taking temperatures on all kitchen and nourishment room refrigerators and freezers, and recording temperatures on temperature report logs daily, during each shift. The facility failed to log daily refrigerator temperatures, and store food in a safe and sanitary manner for the residents that resided in the facility, placing the residents at risk for food borne illness.