Based on observation, record review, and interview, the facility failed to implement a fall prevention per the resident's care plan for one (#13) of three sampled residents reviewed for falls. The administrator reported 44 residents resided in the facility. A Falls - Clinical Protocol policy, dated March 2018, read in part, If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions, based on assessment of the nature or category of falling .The staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling. Resident #13 had diagnoses which included Alzheimer's disease, congestive heart failure, chronic pain, and a history of falls. An MDS assessment, dated 11/25/24, documented Resident #13 had severely impaired cognition. The assessment documented the resident had no falls since admission. A fall risk assessment for Resident #13, dated 11/26/24, documented the resident had a high risk for falls. An incident report, dated 12/02/24, documented Resident #13 was found on the floor. The report documented an intervention was a fall mat to be placed beside the bed and staff would monitor the intervention. A care plan for Resident #13, dated 12/03/24, documented the resident was at risk for falls due to psychotropic medication use and impaired balance. The care plan documented a fall mat would be placed beside the bed. On 12/11/24 at 3:03 p.m., Resident #13 was observed lying in bed asleep. There was no fall mat observed on the floor. On 12/11/24 at 3:07 p.m., CMA #1 checked Resident #13's room and reported there was no fall mat in the room. The CMA reported they were not aware a fall mat was supposed to be in use. On 12/11/24 at 3:27 p.m., the DON reported there should be a fall mat in place for Resident #13. They reported the updated care plan included the fall mat as an intervention to prevent falls.

Based on observation, record review, and interview, the facility failed to remove a medication patch as ordered for one (#16) of 10 sampled residents observed during a medication pass. The administrator reported 44 residents resided in the facility. Findings: An Administering Medications policy, dated April 2019, documented medications were to be administered in accordance to prescriber orders, including any required time frame. Resident #16 had diagnoses which included Alzheimer's dementia, hypertension, diabetes, and pain. An MDS assessment for Resident #16, dated 09/13/24, documented the resident was severely impaired with cognition. A care plan for Resident #16, dated 09/16/24, documented the resident had pain and medications would be administered as ordered. A physician's order for Resident #16, dated 10/12/24, documented Lidoderm (lidocaine) adhesive medicated patch 5%, 1 topical, apply to lower back every day at 9:00 a.m., then remove patch every evening at 9:00 p.m. On 12/10/24 at 10:00 a.m., CMA #2 was observed to remove a patch from Resident #16 and observed to apply a new lidocaine patch. CMA #2 reported the patch they removed should have been removed on 12/09/24 at 9:00 p.m. The CMA reported the lidocaine patch was to be applied in the morning, left in place for 12 hours, then removed in the evening. On 12/11/24 at 9:18 a.m., the DON reported CMA #2 had reported the lidocaine patch was not removed as ordered. The DON provided a copy of a medication error report completed on 12/10/24 and reported the physician order was not followed.

Based on record review and interview, the facility failed to update and implement comprehensive person-centered care plans to include relevant interventions for two (#35 and #188) of four residents sampled for falls. The administrator reported 37 residents resided in the facility. Findings: The Using the Care Plan policy, dated August 2006, read in part, .Changes in the resident's condition must be reported to the MDS Assessment Coordinator so that a review of the resident's assessment and care plan can be made . 1. A care plan for Resident #35, dated 08/16/23, read in part, .Approach: 05/17/23: Resident to use call light for assist; 07/11/23: Resident to use call light for assist; 07/29/23: Educated resident on the importance of locking wheelchair before trying to transfer; 08/07/23: Fall no injury-encourage resident to utilize call system when needing transfer assist; 08/24/23: Allow staff to assist with her needs. Created: 09/17/23. The interventions dated on 08/16/23 consisted of the following: Assessment and treatment for postural/orthostatic hypotension, evaluate need for bed/chair alarms, evaluate need for hip protectors, implement exercise program that targets strength, gait, and balance, increased staff supervision with intensity based on resident need. Obtain order for Vitamin D supplements of at least 800 units daily, order comprehensive medication review by pharmacist, assess for polypharmacy and medications that increase the fall risk . The fall interventions dated on 08/16/23 were listed on the plan of care; however, they were not implemented. An event report, dated 08/24/23, documented the resident had an unwitnessed fall in the bathroom which resulted in a hematoma. The report documented new intervention to prevent reoccurrence: Needs to call for help. Staff to ask Q2 hour if required toileting and assist as needed. The intervention was not added to the care plan. An event report, dated 08/27/23, documented the resident had a fall which resulted in a skin tear and bruise. The report documented new intervention implemented to prevent reoccurrence: Resident instructed to ask for assist with needs. Staff to ensure that table, drinks, and call light to remain within reach at all times. The care plan was not updated. An event report, dated 08/29/23, documented the resident had an unwitnessed fall in their room with no apparent injury. The report documented new intervention implemented to prevent reoccurrence: Exchanged w/c for larger w/c. The care plan was not updated. On 10/13/23 at 8:15 a.m., the RN/MDS coordinator reported the interventions listed on the care plan, dated 08/16/23, had not been implemented for the resident. The RN/MDS coordinator reported those interventions were added from a computer program template, but not implemented. On 10/13/23 at 08:35 a.m., the DON reported fall interventions listed on the care plan without a date came from a computer program template and had not been implemented. The DON reported they had informed the RN/MDS coordinator to delete the interventions on the care plan that came from the template. 2. A quarterly MDS assessment, dated 08/14/23, documented Resident #188 was admitted to the facility with diagnoses which included anemia, UTI, and Alzheimer's. The assessment documented the resident was severely cognitively impaired. The assessment documented a history of falls. A care plan for Resident #188, dated 08/24/23, documented the resident was at risk for falls. The plan of care documented repeated interventions to monitor the resident closely after each of the following falls that occurred on 06/23/23, 07/12/23, 07/22/23, and 08/16/23. The care plan included numerous fall interventions which included an evaluation for hip protectors, implement exercise program that targets strength gait and balance, increase staff supervision with intensity based on resident need, order comprehensive medication review by pharmacist, assess for polypharmacy and medications that increase the fall risk, and provide individualized toileting interventions based on needs/patterns. The fall interventions were listed on the resident's individualized plan of care; however, the interventions were not implemented and did not correspond to falls. On 10/13/23 at 8:00 a.m., the RN/MDS coordinator reported they used the event reports to create the plan of care. The RN/MDS coordinator reported the events dated 06/23/23, 07/12/23, 07/22/23, and 08/16/23 had the same interventions to monitor Resident #188 closely. The RN/MDS coordinator reported the other interventions listed with the date of 08/24/23 were not implemented, but added to the care plan through a computer template. On 10/13/23 at 8:35 a.m., the DON reported the fall interventions for Resident #188's care plan, which did not have a date, had not been implemented. The DON reported they had informed the RN/MDS coordinator to delete the interventions from the care plan if they were generated from the computer program template and not implemented for the individual resident.

Based on record review and interview, the facility failed to implement the facility fall policy to ensure repeated falls were assessed to determine a pattern, and fall interventions were re-evaluated, for one (#188) of four residents sampled for falls. The administrator reported 37 residents resided in the facility. Findings: The Falls-Clinical Protocol, dated March 2018, read in part, .After a fall, the physician should review the resident's gait, balance, and current medications that may be associated with dizziness or falling .If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions, based on assessment of the nature or category of falling, until falling reduces or stops or until a reason is identified for its continuation (for example, if the individual continues to try to get up and walk without waiting for assistance) .If the individual continues to fall, the staff and physician will re-evaluate the situation and reconsider possible reasons for the resident's falling (instead of, or in addition to those that have already identified) and also reconsider the current interventions . A quarterly MDS assessment for Resident #188, dated 08/14/23, documented the resident was severely cognitively impaired. The assessment documented a history of falls. A care plan for Resident #188, dated 08/24/23, documented the resident was at risk for falls. The plan of care documented the same intervention to monitor the resident closely following falls which occurred on: 06/23/23, 07/12/23, 07/22/23, and 08/16/23. The care plan included numerous fall interventions which included the evaluation for hip protectors, implement exercise program that targets strength gait and balance, increase staff supervision with intensity based on resident need, order comprehensive medication review by pharmacist, assess for polypharmacy and medications that increase the fall risk, and provide individualized toileting interventions based on needs/patterns. These fall interventions were listed on the resident's individualized plan of care but had not been implemented and did not correspond to specific falls. On 10/13/23 at 8:00 a.m., RN/MDS coordinator reported they used the event reports to create the plan of care for Resident #188. The RN/MDS coordinator reported the events dated 06/23/23, 07/12/23, 07/22/23, and 08/16/23 had the same intervention to monitor the resident closely. The RN/MDS coordinator reported other interventions listed, with the same date of 08/24/23, had not been implemented and were added to the care plan through a computer program template. On 10/13/23 at 8:35 a.m., the DON was asked about the fall interventions listed on resident #188's care plan. The DON reported the fall interventions without a corresponding fall date were not implemented. The DON stated they had informed the RN/MDS coordinator to delete the interventions on the care plan that were entered from the computer program template but not implemented for the resident.

Based on record review, observation, and interview, the facility failed to ensure the ice machine was clean and sanitary. The dietary manager reported 34 residents received daily ice from the machine. Findings: A maintenance log record documented monthly cleaning of the ice machine. The record documented 5/20/22 as the last date the ice machine had been cleaned and checked. On 06/07/22 at 10:08 a.m., the ice machine was observed to have a slimy film, with brown and black residue, on the ice guard plate inside the machine. At 10:21 a.m. the dietary manager was shown the residue and agreed it was not clean and sanitary for resident use.