Juniper Village at Louisville

“Based on observation, interview, and record review the residence failed to detail in each resident's care plan the individualized approach necessary to address fall risk, affecting two of three sample residents (#20 and #21). Chapter 7 regulations governing assisted living residences, requires in part 12.15 that "The assisted living residence shall develop policies and procedures to establish a fall management program. The program shall include the following: B) Detailing in each resident ' s care plan the individualized approach necessary to address fall risk related to deficits in strength, balance, and eyesight, or effects of medication as identified during the comprehensive resident assessment ..." Specifically, from 8/25/24 through 8/30/24, Resident #21 experienced five falls in six days in which the residence failed to update the care plan for Resident #21 to include individualized approaches necessary to address fall risks. On 8/26/24 Resident #21 had a fall which resulted in a skin tear to the left elbow. On 8/30/24 Resident #21 had a fall which resulted in a closed fracture of multiple ribs on the left side and fracture of the right ulna.Specifically, from 8/30/24 through 9/4/24, Resident #20 experienced four falls in which the residence failed to update the care plan for Resident #20 to include individualized approaches necessary to address fall risks. Additionally, on 9/1/24 Resident #20 fell and had an abrasion on the back of his head which resulted in a visit to the emergency department. Findings include:1. Residence PolicyThe residence's Wellness Services Manual: Care Planning Assessment policy, undated, read in part: "When a resident has a change in behavior, cognition, discharge status, communication, ancillary service, need, etc. The Social Service Representative is responsible to change the care plan to match the current functioning and plan for the resident."2. Observations On 9/4/24 at 9:11 a.m., Resident #21 was seated in the residence's common area. The resident was in his walker chair hunched over with dried blood on his lip and a cast on his right arm. The resident was not able to answer questions due to cognitive impairment. 3. Record ReviewResident #21 was admitted to the residence on 6/17/24 with a diagnosis of severe unspecified dementia. The care plan for Resident #21, dated 6/13/24, read in part: The resident requires two person transfer assistance and an escort to/from meals/activities. However, the residence failed to update the care plan after his falls on 8/25, 8/26, 8/29, and 8/30/24, to detail individualized approaches necessary to address fall risks.A progress note, dated 8/25/24, read in part: Resident #21 was found sitting on his left side/hip in the grass. His wheeled walker was standing nearby. His shoes were off and nearby. A visitor wasstanding nearby him. He reported to the staff that he lost his balance and fell.A progress note, dated 8/26/24, read in part: residence staff observed Resident #21 on the floor for an unknown amount of time. The residence noted a skin tear to the left elbow.A fall assessment, dated 8/28/24, read in part: Resident #21 had balance problems while standing/walking and required the use of assistive devices.A progress note, dated 8/29/24, read in part: Residence staff observed Resident #21 on the floor next to his bed, and notified the nurse.A progress note, dated 8/30/24 at 9:47 a.m., read in part: residence staff observed Resident #21 kneeling on the floor next to his bed. Resident #21 had a swollen painful right elbow and a one centimeter skin laceration on his left elbow.A progress note, dated 8/30/24 at 10:57 a.m., read in part: residence staff observed Resident #21 in the common area lose balance, without his walker, and fall on his right side. Resident #21 was taken to the emergency department and returned with a diagnosis of a closed fracture of multiple ribs on the left side and fracture of the right ulna.Emergency department discharge paperwork, dated 8/30/24, read in part for Resident #21: There was a comminuted fracture of the olecranon with seven millimeters of proximal retraction of the proximal fragments. Moderate associated dorsal soft tissue swelling/hematoma.External hospice orders, dated 8/30/24, read in part for Resident #21: Diagnoses were dementia, frequent falls, failure to thrive, and a right elbow fracture.A fall assessment, dated 9/1/24, read in part: Resident #21 had balance problems while standing/walking and required the use of assistive devices.A fall assessment, dated 9/2/24, read in part: Resident #21 had balance problems while standing/walking and required the use of assistive devices.4. InterviewsOn 9/4/24 at 11:50 a.m., Staff #13 stated that to prevent falls for Resident #21, they kept him busy during the day, and provided the walker when they saw him without it. However, Staff #13 stated Resident #21 was not able to use his walker successfully anymore. The staff member confirmed that staff reviewed care plans for updates to individualized approaches necessary to address fall risk. On 9/4/24 at 11:55 a.m., Staff #11 stated to prevent falls for Resident #21, they reminded Resident #21 to use his walker. Additionally, Staff #11 stated the resident required frequent checks at night about every 10-20 minutes.On 9/4/24 at 12:27 p.m., Staff #12 stated when Resident #21 tried to walk without staff assistance, staff did their best to direct him to sit in the nearest chair to prevent falling. Staff #12 confirmed that staff reviewed the resident's electronic record and the book (a staff binder with check in times for residents marked off by staff initials which included times for specific tasks but did not include names or room numbers of the residents) for updates to individualized approaches necessary to address fall risk. 5. There was similar deficient practice for Resident #20 in which the resident fell and was injured.”

“Based on observation, interview, and record review the residence failed to detail in each resident's care plan the individualized approach necessary to address fall risk, affecting two of three sample residents (#20 and #21). Chapter 7 regulations governing assisted living residences, requires in part 12.15 that "The assisted living residence shall develop policies and procedures to establish a fall management program. The program shall include the following: B) Detailing in each resident ' s care plan the individualized approach necessary to address fall risk related to deficits in strength, balance, and eyesight, or effects of medication as identified during the comprehensive resident assessment ..." Specifically, from 8/25/24 through 8/30/24, Resident #21 experienced five falls in six days in which the residence failed to update the care plan for Resident #21 to include individualized approaches necessary to address fall risks. On 8/26/24 Resident #21 had a fall which resulted in a skin tear to the left elbow. On 8/30/24 Resident #21 had a fall which resulted in a closed fracture of multiple ribs on the left side and fracture of the right ulna.Specifically, from 8/30/24 through 9/4/24, Resident #20 experienced four falls in which the residence failed to update the care plan for Resident #20 to include individualized approaches necessary to address fall risks. Additionally, on 9/1/24 Resident #20 fell and had an abrasion on the back of his head which resulted in a visit to the emergency department. Findings include:1. Residence PolicyThe residence's Wellness Services Manual: Care Planning Assessment policy, undated, read in part: "When a resident has a change in behavior, cognition, discharge status, communication, ancillary service, need, etc. The Social Service Representative is responsible to change the care plan to match the current functioning and plan for the resident."2. Observations On 9/4/24 at 9:11 a.m., Resident #21 was seated in the residence's common area. The resident was in his walker chair hunched over with dried blood on his lip and a cast on his right arm. The resident was not able to answer questions due to cognitive impairment. 3. Record ReviewResident #21 was admitted to the residence on 6/17/24 with a diagnosis of severe unspecified dementia. The care plan for Resident #21, dated 6/13/24, read in part: The resident requires two person transfer assistance and an escort to/from meals/activities. However, the residence failed to update the care plan after his falls on 8/25, 8/26, 8/29, and 8/30/24, to detail individualized approaches necessary to address fall risks.A progress note, dated 8/25/24, read in part: Resident #21 was found sitting on his left side/hip in the grass. His wheeled walker was standing nearby. His shoes were off and nearby. A visitor wasstanding nearby him. He reported to the staff that he lost his balance and fell.A progress note, dated 8/26/24, read in part: residence staff observed Resident #21 on the floor for an unknown amount of time. The residence noted a skin tear to the left elbow.A fall assessment, dated 8/28/24, read in part: Resident #21 had balance problems while standing/walking and required the use of assistive devices.A progress note, dated 8/29/24, read in part: Residence staff observed Resident #21 on the floor next to his bed, and notified the nurse.A progress note, dated 8/30/24 at 9:47 a.m., read in part: residence staff observed Resident #21 kneeling on the floor next to his bed. Resident #21 had a swollen painful right elbow and a one centimeter skin laceration on his left elbow.A progress note, dated 8/30/24 at 10:57 a.m., read in part: residence staff observed Resident #21 in the common area lose balance, without his walker, and fall on his right side. Resident #21 was taken to the emergency department and returned with a diagnosis of a closed fracture of multiple ribs on the left side and fracture of the right ulna.Emergency department discharge paperwork, dated 8/30/24, read in part for Resident #21: There was a comminuted fracture of the olecranon with seven millimeters of proximal retraction of the proximal fragments. Moderate associated dorsal soft tissue swelling/hematoma.External hospice orders, dated 8/30/24, read in part for Resident #21: Diagnoses were dementia, frequent falls, failure to thrive, and a right elbow fracture.A fall assessment, dated 9/1/24, read in part: Resident #21 had balance problems while standing/walking and required the use of assistive devices.A fall assessment, dated 9/2/24, read in part: Resident #21 had balance problems while standing/walking and required the use of assistive devices.4. InterviewsOn 9/4/24 at 11:50 a.m., Staff #13 stated that to prevent falls for Resident #21, they kept him busy during the day, and provided the walker when they saw him without it. However, Staff #13 stated Resident #21 was not able to use his walker successfully anymore. The staff member confirmed that staff reviewed care plans for updates to individualized approaches necessary to address fall risk. On 9/4/24 at 11:55 a.m., Staff #11 stated to prevent falls for Resident #21, they reminded Resident #21 to use his walker. Additionally, Staff #11 stated the resident required frequent checks at night about every 10-20 minutes.On 9/4/24 at 12:27 p.m., Staff #12 stated when Resident #21 tried to walk without staff assistance, staff did their best to direct him to sit in the nearest chair to prevent falling. Staff #12 confirmed that staff reviewed the resident's electronic record and the book (a staff binder with check in times for residents marked off by staff initials which included times for specific tasks but did not include names or room numbers of the residents) for updates to individualized approaches necessary to address fall risk. 5. There was similar deficient practice for Resident #20 in which the resident fell and was injured.”