Every finding on record at Benefis Senior Services - Eastview

Based on observation, interview, and record review, the facility failed to ensure there was an adequate number of staff available to provide resident care needs promptly when residents requested assistance using their call lights or when they needed help with ADL care, for 4 (#s 3, 20, 34, and 59) of 23 sampled and supplemental residents. The failure resulted in the residents being frustrated and going without care for extended periods of time. Findings include:During an interview on 7/13/26 at 2:42 p.m., resident #59 stated, It depends on how busy they (the staff) are, and what time of day it is, regarding how long he waits for help with his activities of daily living. Certain times of the day were not as good as others for availability of staff.During an interview and observation on 7/14/26 at 8:26 a.m., resident #3 stated, I was still waiting to get up for breakfast and called for help just before 7:00 a.m. Resident #3 pushed his call light again at 8:50 a.m. Per resident #3, he received no assistance from 7:00 a.m. to 8:50 a.m.During an observation and interview on 7/14/26 at 8:54 a.m., staff member J entered resident #3's room and stated, I was in the resident's room earlier this morning but had forgotten the Sara lift, and when I returned to [Resident #3's] room, the resident had fallen asleep. Staff member J stated he did not want to wake the resident and left the resident sleeping to shower another resident. During an observation and interview on 7/14/26 at 10:10 a.m., resident #3 received his breakfast meal three hours after his initial request to get up for breakfast. Resident #3 ate in the dining room by himself. Resident #3 stated he was frustrated by their lack of response.Review of the facility's document titled, Call History, received on 7/16/26, showed the following call light response times for resident #3 on 7/14/26, which started at 7:01 a.m. when resident #3 called for assistance to get up for the day. - Call time 7:01 a.m., cancel time 7:02 a.m., wait time 24 seconds. Per the previous resident interview, resident #3 did not receive care while staff were in the room and shut the call light off. - Call time 8:03 a.m., cancel time 8:25 a.m., wait time 22 minutes. Per the previous resident interview, resident #3 did not receive care during the delayed time period. - Call time 8:50 a.m., cancel time 9:19 a.m., wait time 28 minutes. During an interview on 7/14/26 at 11:12 a.m., resident #34 stated the staff was usually helping others with showers, and she could not get the help she needed. Resident #34 stated it took two to three hours in the morning, on day shift, to receive any help. Resident #34 stated she had the night staff wake her at 5:30 a.m. to get her dressed. Resident #34 stated the night staff got her up early, dressed her, and got her in her wheelchair where she would sleep until 7:00 a.m. Resident #34 stated they (the day shift) are so short-staffed. She would like to sleep in her recliner until 7:00 a.m. but did not trust them (the day staff) to come assist her for her ADL care. During an interview on 7/15/26 at 11:17 a.m., staff member L stated every unit should have three CNAs to provide morning cares; however, the morning shower schedule was heavy on some days. Staff member L stated in the morning, one to two CNAs were pulled from the floor to serve meals and give showers. Staff member L stated, It has delayed patient care and can be challenging (getting residents up and out to breakfast).During an interview on 7/15/26 at 1:24 p.m., staff member M stated, Sometimes we are short-staffed; mornings are hit and miss. On the missed days, morning cares (getting residents up and out for breakfast) are delayed, especially for the early risers (6:00 a.m. to 7:00 a.m.). Staff member M stated they would answer the call light, tell the resident there was a wait time, and turn off the call light before exiting the resident's room.During an interview on 7/16/26 at 9:37 a.m., staff member B stated that the facility liked to have one CNA to eight residents; staff call-offs can affect the ratio. Staff member B stated, We do have a lot of call-offs. Staff member B stated that when call-offs happened, staff member B would try to get overflow from the hospital to fill in; staff member B would provide resident care at times as well if needed.

Based on observation, interview, and record review, the facility failed to follow training during resident care and use proper hand hygiene, to include when gloves were used, between dirty and clean procedures for 2 (#3 and #4) out of 2 residents observed for peri-care and wound care; and failed to ensure staff used proper hand hygiene during the medication pass for 4 (#s 2, 4, 56, and 73) out of 6 residents sampled for medication administration. This deficient practice increased the risk of the spread of infection. Findings include:1. Peri-care resident #3During an observation and interview on 7/14/26 at 8:54 a.m., Staff member J entered resident #3's room and did not perform hand hygiene before they donned gloves and a gown. Staff member J grabbed a clean brief and two wet washcloths. Staff member J reached under his gown with his gloved hand to answer a status check using the facility's internal communication system. Staff member J failed to uphold proper infection control for hand hygiene and when reaching under his gown.-Staff member J approached the resident and placed both wet washcloths on the footboard of the resident's bed. Staff member J opened the resident's brief, tucked the front half of the brief between the resident's legs, and used the soapy washcloth to wipe the resident's penis and scrotal area with the washcloths that were on the footboard.-At 9:16 a.m., staff member K entered resident #3's room and stated to staff member J that the call light was still on. Staff member J placed the soiled washcloth on the resident's footboard and, with soiled gloves, pushed the call button on the wall to turn the light off. -Staff member K returned with a gown and gloves on. Staff member J, without removing their soiled gloves, used the bed remote to adjust the bed height. Staff member K removed the resident's soiled brief and retrieved one package of disposable wipes and two blue chuck pads. Staff member K used the disposable wipes to clean the stool from the resident's buttock area. Staff member K, without removing their soiled gloves, grabbed the two clean blue chuck pads, the clean brief, and placed them part-way under the resident's buttocks and lower back.-Staff member J entered the resident's bathroom wearing the same soiled gloves; returned to the bedside and handed staff member K a tube of barrier cream. Staff member K applied the barrier cream to the resident's buttocks area.-Staff member J used the disposable wipes to clean stool from the resident's buttock area. Staff member J, without removing their soiled gloves, pulled the clean chuck pads and clean brief into place. Both staff members J and K adjusted the resident's position in bed with their soiled gloves on.-Staff member K used the disposable wipes to wipe the resident's penis and scrotal area. While still wearing the soiled gloves, staff member J picked up resident #3's bedside water cup and offered the resident a drink. Staff member K stated to staff member J, Not while lying down. Staff member J returned the water cup to the bedside table.-Both staff members J and K closed the resident's brief while still wearing the same soiled gloves. Staff member K used their removed gown to cover and scoop the soiled brief and chuck pads off the resident's bed before they discarded them in the trash.-Staff member J, wearing the same soiled gloves, pulled the resident's clean pants up to the resident's mid-buttocks, used the bed remote to raise the head of the resident's bed, picked up the resident's hearing aid from the bed, picked up the bedside water cup, and offered the resident a drink. Staff member J held the water cup for the resident to drink. Staff member J placed the water cup back on the bedside table and placed the hearing aid in the resident's left ear and then touched the resident's right ear and hearing aid, all with the same soiled gloves. Staff member J then placed the resident's clean shirt on the resident and reached under his gown a 2nd time and touched the facility's internal communication device to speak to another staff member.Once the resident was dressed, staff member J performed the following tasks with soiled gloves: -Placed the Sara lift sling on the resident and used the Sara lift controls to raise the resident.-Removed a pillow from the resident's wheelchair and placed it on the floor; then placed a pair of sandals (which were under the pillow) on top of the pillow previously placed on the floor. -Staff member J took the catheter drainage bag from the resident's lap and placed the drainage bag directly on the floor, and took their phone out of their pocket and set it on the resident's floor. Staff member J removed the soiled gloves for the first time since the care session started, without performing hand hygiene. The staff member then donned new gloves.-After the drainage bag was drained, staff member J entered the resident's bathroom, placed the UDMC on the counter next to the sink, and then discarded the urine in the toilet. Without cleaning the UDMC, staff member J set it on the back of the resident's toilet.-While wearing soiled gloves, staff member J knelt in front of resident #3 and placed the resident's sandals on the resident's feet. Staff member J attempted to finish buttoning the resident's shirt while using their soiled gloves, but stated they were having difficulty and removed gloves without performing hand hygiene, then buttoned the remaining buttons on the resident's shirt. Staff member J then picked up the pillow from the floor and placed it on the right side of the resident (between the resident and the wheelchair).-Staff member J picked the O2 tubing and nasal cannula off the floor and placed the now soiled nasal cannula in the resident's nose. Staff member J picked up a pillow from the floor (that had previously fallen off the resident's bed) and placed it on the resident's bed. -Staff member J used the Sara lift and sling, without cleaning it, and pulled the resident's pants up. Staff member J reached under his gown and again touched the facility's internal communication device to speak to another staff member, without sanitizing his hands. During an interview on 7/14/26 at 10:12 a.m., staff member J stated, when asked about hand hygiene during care sessions, Gel in, and gel out while entering a room, before and after peri care brief changes. I suppose I didn't do that. I should have changed gloves after his bottom was done.2. Peri-care and wound care resident #4During an observation on 7/15/26 at 1:01 p.m., staff members L and M, while wearing gowns and gloves, removed the resident's soiled brief and cleaned the stool from the resident's buttocks and peri area. After the resident was cleaned, staff member L discarded the soiled brief, performed hand hygiene, and left the room.-Staff member I entered resident #4's room in a gown and gloves to assess the wound located on the tip of the resident's penis. Staff member I assessed and cleaned the resident's wound. While wearing soiled gloves, staff member I reached under their gown and removed the Rover device from their pocket. Staff member I used their Rover device to take pictures of the wound and then set the Rover device on the resident's bedside table. Staff member I then entered the resident's bathroom, exited with a medicated ointment, and applied it to the wound while wearing the soiled gloves. -Both staff members I and M, using soiled gloves, placed a clean brief on the resident. Staff member M adjusted the resident's pillows, and then both placed a blanket on resident #4 without removing their soiled gloves. -Staff member I took off their protective gown and gloves, and without performing hand hygiene, picked up their Rover device from the resident's bedside table and placed it in their pocket. Staff member M removed the gown and gloves, and without performing hand hygiene, picked up the Hoyer sling and shorts from the foot of the bed, then hung the Hoyer sling in the resident's bathroom. During an interview on 7/16/26 at 9:37 a.m., staff member B stated the following should happen regarding hand hygiene during cares: Gel into the room, glove up, brief change, remove gown and gloves, gel again, new gowns and gloves., then continue patient (resident) cares.3. Medication PassDuring an observation on 7/14/26 at 12:43 p.m., staff member H carried out the following steps for a medication administration task:- The staff member logged on to the computer/EMAR (electronic medication administration record), then grabbed the bar code scanner, located keys from their pocket, unlocked the half door, and exited the kitchen serving area. Staff member H approached resident #4 in the dining area and scanned the barcode attached to the resident's chair. Staff member H then walked back to the kitchen serving area, used the keys from their pocket, unlocked the half door, unlocked the medication cart, and pulled the resident's information up on the computer/EMAR.-Staff member H, without performing hand hygiene, pulled a bottle from the medication cart and used the bar-code scanner to scan the medication. Staff member H placed the medication in a plastic medication cup, poured the medication in a crush bag, crushed the medication, and poured the crushed medication back into the medication cup. Staff member H used a clean plastic spoon and scooped pudding into the medication cup. Staff member H left the spoon in the medication cup. Once the medication was prepped, staff member H put away the medication bottle, closed and locked the medication cart, locked the computer screen, picked up the medication cup with the medication pudding mixture and spoon, unlocked the half door with the keys from their pocket, and approached resident #4. During an observation on 7/14/26 at 12:49 p.m., staff member H performed hand hygiene using an alcohol-based sanitizer. Staff member H then picked up their Rover device, retrieved the keys from their pocket, unlocked the half door, and approached resident #56 in the dining area. Staff member H used their Rover device to scan the barcode attached to the resident's chair.-Staff member H then walked back to the kitchen serving area, and using the keys, unlocked the half door and medication cart, then started to pull the medication cards for resident #56. Staff member H pushed the medication card bubble with one hand, allowing the medications to fall onto their other hand above the medication cup. Staff member H spread their two fingers, allowing the medications to drop into the medication cup. Staff member H put away all medication cards, closed and locked the medication cart, picked up the medication cup, unlocked the half door with the keys from their pocket, and approached resident #56. Staff member H administered the medications to the resident. Staff member H failed to maintain proper medication transfer procedures and failed to properly perform hand hygiene before and after medication preparation.During an observation on 7/15/26 at 7:51 a.m., staff member I was standing at the medication cart in the dining area. Staff member I locked the medication cart, picked up their Rover device, and approached resident #2 in the dining area. Staff member I used their Rover device to scan the barcode on the back of the resident's chair. Staff member I returned to the medication cart, used keys from their pocket to unlock the medication cart, and started to pull and scan (with their Rover device) all medication cards for resident #2. Staff member I placed all medication(s) into a medication cup, put all medication cards back into the medication cart, locked the medication cart, and grabbed a clean plastic spoon. Staff member I approached resident #2 and administered the medications. The staff member did not sanitize their hands.During an observation and interview on 7/15/26 at 8:01 a.m., staff member I performed hand hygiene with an alcohol-based hand sanitizer before picking up their Rover device. Staff member I approached resident #56 in the dining area and used their Rover device to scan the barcode on the back of the resident's chair. Staff member I walked back to the medication cart and unlocked it, then started to pull and scan all medication cards for resident #56. Staff member I placed all medications into a medication cup and put all medication cards back into the medication cart. Staff member I stated they liked to wait until the resident has food in front of them before giving them their medications. Staff member I used a marker from their pocket to write resident #56's name on the medication cup and then placed the medication cup in the top drawer of the medication cart.During an observation on 7/15/26 at 8:09 a.m., staff member I locked the medication cart and approached resident #73. Staff member I scanned the barcode on the back of the resident's chair before returning to the medication cart. Staff member I unlocked the medication cart and pulled all the medication cards and scanned all medication cards needed for resident #73. Staff member I used a marker from their pocket and wrote the resident's name on the plastic medication cup. Staff member I placed medications in the labeled plastic medication cup. Staff member I touched their internal communication device to speak to another staff member and used their phone to call the pharmacy. Staff member I returned all medication cards to the medication cart, placed the filled medication cup in the top drawer, and locked the medication cart. Staff member I unlocked the medication cart with keys from their pocket and picked up the previously filled medication cup for resident #56. Staff member I failed to properly perform hand hygiene before and after medication preparation. During an interview on 7/16/26 at 9:37 a.m., staff member B stated hand hygiene (either using an alcohol-based sanitizer or washing with soap and water) should be done before and after prepping medications and in-between residents. Staff member B stated it was never acceptable to .pop pills from the med card to hands., they should always be popped from the card to the cup.-Review of the facility's policy, Hand Hygiene, revised June of 2025, showed: . Use an alcohol-based waterless antiseptic agent for routinely decontaminating hands if hands are not visibly soiled in all other clinical situation described below. (D 1 - 7.). D,. 1. Before having direct contact with patients.2. After contact with a patient's intact skin (as in taking a pulse or blood pressure or lifting a patient).3. After removing gloves.4. After contact with body fluids or excretions, mucous membranes, nonintact skin, or wound dressings, as long as hands are not visibly soiled.5. When moving from a contaminated body site to a clean body site during patient care.6. After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient.

Based on interview and record review, the facility failed to report allegations of resident abuse to the State Survey Agency within 24 hours of the incident for 2 (#s 4 and 74) of 23 sampled and supplemental residents. Findings include:Review of the Facility-Reported Incident, dated 4/1/26 at 3:50 p.m., showed staff member F reported an allegation of abuse to staff member B on 4/1/26. Staff member F stated the incident occurred the week prior. Resident #4 was inappropriately touched by another resident. The allegation of resident-to-resident abuse was not reported to the State Survey Agency within 24 hours of the incident.During an interview on 7/16/26 at 9:40 a.m., staff member F stated she reported, on 6/24/26, to the nurse she found resident #74 in resident #4's room. Staff member F stated resident #74 was rubbing the leg of resident #4. Staff member F stated she failed to effectively communicate the incident to the nurse on duty the evening the incident occurred. During an interview on 7/16/26 at 10:40 a.m., staff member B stated the incident involving resident #4 and #74 which occurred on 6/24/26 was not reported to the State Survey Agency within 24 hours because staff member F reported the incident to the nurse in charge and a miscommunication occurred. Staff member B stated the nurse had thought resident #74 was consoling resident #4. Staff member B stated the facility reported the incident on 4/1/26 to the State Survey Agency after receiving an email on 4/1/26 from staff member F who reported the incident to the nurse on 6/24/26.Review of the facility's policy titled, [Facility Name] Resident Abuse/Neglect Allegations [Facility Name], last revision dated November of 2025, showed: Allegations of Abuse, Neglect, and/or Misappropriation of FundsI. All employees who suspect abuse. must report their suspicions to their supervisor, so an investigation can be initiated. All employees adhere to the mandatory reporting law (53-5-511MCA) when suspecting abuse.II. The COO/CDON/ DON or designee initiates an investigation immediately when there is any report of suspected resident abuse. Protocol: . c. Report to the Unit Manger (or their Designee) and follow the direction provided - which may include completion of an initial report to the State Certification Abuse Reporting Hotline.d. Reports of alleged abuse or incidents resulting in serious bodily injury are reported to the Executive Director (or delegate [usually the manager on-call]), the State, and the Ombudsman, no later than 2 hours after the allegation is made.e. Investigation must be started 'immediately' - which is defined by CMS as: 'as soon as possible, but not to exceed 24 hours after the discovery of the incident.' [sic]

Based on interview and record review, the facility failed to protect the resident's right to be free from neglect of care by a staff member for 1 (#65) of 6 residents sampled for neglect of care. The neglect of care placed the resident at an increased the likelihood of adverse events related to incontinence and immobility. Findings include: Review of a Facility-Reported Incident, dated 12/15/25, and submitted to the State Survey Agency on 12/22/25, showed staff member E was alleged to have neglected resident #65 on 12/15/25. The investigative findings showed staff member E had not provided repositioning and incontinence care for resident #65. The investigative file showed staff member E did not accept assistance offered by other staff members and other staff members assigned to the unit did not take the initiative to assist staff member E when they clearly saw resident #65 had not been turned. The resident was receiving end-of-life care and was totally dependent for assistance. Review of the written statement by staff member F, dated 12/15/25, showed staff member F witnessed neglect of care by staff member E. Staff member F wrote, . it was clear that he (resident #65) had no cares completed in 7 hours. (Cath was not emptied, Full bed strip needed, Q2 turns were not complete, . There was a washcloth found stuffed in his peri area (when rounds were completed that morning, there was no washcloth there). No turns or cares had been documented.A review of documents showed the investigation was thorough, but the facility did not identify the event as neglect of care. The resident's care plans and assessments reflected the resident's needs accurately. During an interview on 7/16/26 at 7:53 a.m., staff member B stated she investigated the allegation of neglect and believed the cause was a teamwork failure and staff member E needed education to accept assistance from other staff when it was offered. Staff member B stated staff member E was educated on accepting assistance from her co-workers. Staff member B stated she did not perform any ongoing monitoring of the care provided by staff member E. The staff member had training prior to the event on abuse/neglect during the new employee training. Review of the facility's policy titled, [Facility Name] Resident Abuse/Neglect Allegations [Facility Name], last revision date was November of 2025, showed the definition of neglect was, . is the failure of the facility, its employees or service providers to provide goods and services to a resident necessary to avoid physical harm, pain, mental anguish, or emotional distress. The policy also showed employees who suspect neglect must report their suspicions to their supervisor so an investigation could be initiated.

Based on observation, interview, and record review, facility staff failed to provide safe, competent care while performing direct resident care and utilizing a mechanical lift during a transfer. The failures involved staff not performing appropriate hand hygiene (refer to F880 - Infection Control), failing to report a resident's pain, failing to safely supervise a resident while using a mechanical lift, and failing to keep a urinary drainage bag below the bladder to prevent urine backflow, for 1 (#3) of 16 sampled residents. Findings include: During an observation and interview on 7/14/26 at 8:54 a.m., staff member J entered resident #3's room with the Sara lift and the following steps were observed:-Staff member J told resident #3 he could not find pants or socks in the resident's closet. Staff member J exited resident #3's room and returned with hospital scrub pants and a package of hospital grippy socks. Staff member J did not perform hand hygiene before they donned gloves and a gown. -Staff member J placed the half-full catheter drainage bag on the foot of the bed, and the catheter tubing showed backflow as it was approximately three-fourths full of dark yellow to light orange urine with sediment present. A strong urine scent was present. Staff member J threaded the drainage bag through the left pant leg and then left the drainage bag on the foot of the bed, while they pulled the resident's pants on to approximately mid-thigh. Staff member J failed to keep the drainage bag below the bladder to prevent urine backflow.-Staff member J lowered the bed to the lowest position and asked resident #3 to roll to his right side. Resident #3 could not roll unassisted. Staff member J stated they knew the resident had pain in his right shoulder, which limited the use of his right arm. Staff member J pushed the resident's left shoulder to assist the resident to roll away from staff member J. While on his right side, resident #3 grimaced and let out a quiet moan. Staff member J stated to the resident, I know that side hurts (right side). -Staff member J returned the resident to his back and removed the hospital gown. Staff member J entered the resident's bathroom and returned with two dripping wet wash-clothes (one with soap), and a new brief. Staff member J reached under the resident's gown with his gloved hand and answered a status check using the facility's internal communication system. Staff member J stated into the device that help was not needed. Staff member J did not request assistance with resident care.-Staff member J placed the wet washcloth(s) on the footboard of the resident's bed where they dripped on the floor. Staff member J opened resident #3's soiled brief and tucked the front of the brief between the resident's legs. Staff member J used the wet soapy washcloth from the footboard of the bed to wipe the resident's penis and scrotal area. Staff member K entered resident #3's room and stated to staff member J that the call light was still on and that they were there to help. Staff member J placed the soiled soapy washcloth back on the resident's footboard. Staff member J turned off the call light without removing the soiled gloves. Staff member J did not follow infection control procedure moving from clean to dirty tasks.-Staff member K asked staff member J to raise the level of the bed to more easily provide care. Staff member K entered the resident's bathroom and grabbed one package of disposable wipes and two blue chuck pads. Both staff members J and K rolled the resident to his left side. Resident #3's face showed a grimace. Staff member J stated to the resident, I know this hurts, buddy. Staff member J used disposable wipes to remove stool from the resident's buttock area. While wearing the same gloves, staff member J pulled the clean chuck pads and the clean brief into place. Resident #3 grimaced when staff members J and K rolled him to his back.-While wearing soiled gloves, staff member J picked up resident #3's bedside water cup and offered the resident a drink. Staff member K stated to staff member J, Not while lying down. Staff member J returned the water cup to the bedside table.-Staff member K exited the resident's room. While staff member J pulled the resident's pants up to mid-buttocks, he used the bed remote to raise the head of the resident's bed. The resident's hearing aid was seen on the resident's bed. Staff member J picked up the resident's hearing aid while wearing the soiled gloves. After raising the head of the resident's bed, staff member J picked up the bedside water cup with the same soiled gloves on and offered the resident a drink; staff member J held the water cup while the resident drank.-Staff member J pulled resident #3's legs to the left side of the bed, then pulled the resident's left arm and left shoulder until the resident was in a halfway seated position. Resident #3 grimaced during this position change. Staff member J left the resident unsupported sitting on the edge of the bed to check resident #3's closet for an undershirt. Resident #3 was unable to maintain the position and lay back down on the bed with his legs hanging off the left side of the bed. Staff member J failed to ask for assistance with the transfer to ensure resident safety, and left the resident in the lift and walked away from it.-Staff member J returned to the bed and again pulled the resident's left arm and left shoulder until the resident was back in a halfway seated position. Resident #3 grimaced during this position change. While still wearing the same soiled gloves, staff member J placed a clean shirt on the resident and started to button the shirt closed. Resident #3 slowly laid back on the bed while his shirt was being buttoned. Staff member J pulled the resident's left arm and left shoulder until the resident was once again back in a halfway seated position.-Staff member J placed the drainage bag in the resident's lap. Staff member J, while still wearing the same soiled gloves, reached under his gown to answer a page from the facility's internal communication system. The resident lay back on the bed while the page was answered. Staff member J again pulled the resident's left arm and left shoulder till the resident was back in a halfway seated position. Resident #3 once again grimaced and moaned in pain during this position change. -Staff member J wrapped the [NAME] sling around the resident's trunk and hooked the sling to the lift. Staff member J placed the right leg in the left leg support of the lift and then pushed the lift closer to the resident, pinching the right leg between the lift and the resident's bed. Resident #3 stated, Ouch! Staff member J stated, Oh, sorry, while they pulled the lift away from the resident's bed. Staff member J placed both legs in the leg support of the lift and fastened the leg belt. -Staff member J, while wearing the same soiled gloves, raised the resident into a standing position and then left the resident in a half-standing position while they removed a pillow from the resident's wheelchair. Staff member J placed the wheelchair behind the resident and stood in front of the Sara lift to lower the resident. Staff member J then noticed there were sandals on the seat of the wheelchair. Staff member J, while wearing the same soiled gloves, returned to the wheelchair and removed the sandals from the wheelchair seat.-Staff member J returned to the front of the Sara lift and lowered the resident into the wheelchair. Resident #3's wheelchair had an oxygen tank and tubing attached to the back of the wheelchair. The oxygen tubing, which included the nasal cannula, was resting directly on the floor behind the wheelchair. Staff member J took the drainage bag from the resident's lap and placed it directly on the floor. Staff member J stated they were going to empty the urine bag now, so I can get you out of the way (rather than providing the care after breakfast). -Staff member J then removed the soiled gloves without performing hand hygiene and donned new gloves. After the drainage bag was emptied, staff member J removed their soiled gloves and buttoned the remaining buttons on the resident's shirt. Staff member J picked up the oxygen tubing from the floor and placed the nasal cannula in the resident's nose.-Staff member J noticed the resident's pants were not pulled up completely. Staff member J placed the [NAME] sling around the resident's trunk, hooked the sling to the lift, and raised resident #3 into a half-standing position in order to completely pull up the resident's pants. Resident #3 remained in the half-standing position while staff member J reached under their gown to answer a status check from the facility's internal communication system. After staff member J responded to the status check, staff member J adjusted resident #3's pants and returned the resident to a seated position.During an interview on 7/14/26 at 10:12 a.m., staff member J stated this was their second day working on their own; they had finished their training and facility orientation. Staff member J stated they knew to keep the drainage bag on the same side of the body that the catheter was inserted on. Staff member J could not say what level of the body the drainage bag should remain during cares. Staff member J asked if he could go ask another staff member and left resident #3's room. Staff member J returned to resident #3's room at 10:21 a.m. and stated he could look on the intra-web later for the answer. Staff member J stated they thought it should be below where the catheter is inserted, and I should have done that. Staff member J stated the pain assessment was not in their scope of practice. But they knew to move as fast as possible when giving care to limit the amount of pain the resident experienced. Staff member J stated the Sara lift was the lift they were told to use with resident #3 because the resident could still use his left arm. Staff member J stated as long as the resident was comfortable and not in pain, they could leave the resident in the Sara lift (standing position) while they removed items from the wheelchair or went and grabbed supplies.During an interview on 7/15/26 at 1:24 p.m., staff member M stated they had been employed at the facility for almost a year and received training on many things like catheter care, resident care, hand hygiene, and more, but could not remember exactly. Staff member M stated all CNAs needed to shadow another CNA for six weeks and had a skills checklist completed before being allowed on the floor to work by themselves.During an interview on 7/15/26 at 2:24 p.m., staff member I stated CNAs were to report to the nurse on duty any signs or reports of pain by a resident. Staff member I stated they were not aware of any training the CNAs received regarding non-verbal pain cues, .but it's common sense. Staff member I stated (regarding lift training) all staff members, .get all the training in the world. with a refresher training every year provided by the manager.During an interview on 7/15/26 at 3:05 p.m., staff member K stated CNAs had a two-day workshop once they were hired which covered the following training: policies, resident care, dementia education, how to document, hand hygiene, lifts and how to use them, bathing, laundry, isolation, food handling, and how to feed the residents. Staff member K stated there was more training covered but could not remember all of it off the top of their head. Staff member K stated all CNAs shadow a CNA preceptor for at least four weeks. Staff member K stated some staff members may get longer if they asked for it. Staff member K stated a skills checklist should be done before a new staff member was allowed to work on the floor by themselves. Staff member K stated the checklist was to be completed by the CNA being shadowed by the new staff member. Staff member K stated they believed catheter care training covered the position of a urine drainage bag.During an interview on 7/16/26 at 9:37 a.m., staff member B stated CNAs received six weeks of on-the-floor training with annual refreshers. Staff member B stated the training included using the mechanical lifts and making sure the CNA knew the correct way they were to be used, and for using the lift pads/sling placement, and the leg and safety strap placement for the sit-to-stand (Sara lift). Staff member B stated CNAs could not assess pain as in-depth as a nurse could, but they should have awareness of signs of resident pain. When pain occurred, the CNAs were trained when to report it to the nurse during the initial CNA training.Review of staff member J's competency checklist titled, Initial Competency Assessment-Certified Nursing Assistant, Dept: East View, dated 7/9/26, showed staff member N signed off that staff member J was competent on the following skills: . Overall Care and Safety: Demonstrates ability to observe patient's mental and physical conditions and seek out assistance when necessary. Dated 6/30/26,. Verbalizes knowledge of the delivery of patient care in an environment that optimizes patient safety and reduces the likelihood of medical/health care errors. Dated 6/30/26,. Demonstrates compliance with infection control policies and procedures. Dated 6/30,. Demonstrates ability to find and speak to the patient safety guide as it pertains to meeting regulatory requirements (located on [Facility Name] Intranet). Dated 6/30,. Demonstrates ability to adapt to unexpected events and critical situations and escalates patient care concerns appropriately and reports to the nurse. Dated 6/30, . Safety:. Appropriately assists patients at-risk for falls and assists with implementing safety precautions following health system policy and procedure. Dated 6/30.Review of the facility's policy titled, .Lift and Transfer Guideline, revised on January of 2021, showed: . VII. Types of Lifts . A. Sara lift . d. Brings the Sara lift up to the patient, placing the patient's feet on the footrest and continuing forward until the kneepad is in contact with the patient's knee or upper shin. j. NOTE: Those patients who have suffered a stroke or who can only hold on with one hand or not at all can still be lifted by the Sara lift but require a second nurse to stand by to strive to provide safety . k. Caution: The Sara lift is not designed for long periods of suspension or transportation.

Based on interview and record review, the facility failed to notify the resident, the resident's representative, and the local Ombudsman of the reason, in writing, for the transfer or discharge and the Bed Hold information, if applicable, for 1 (#10) of 2 residents sampled for discharge or transfer. Findings include: During an interview on 7/16/26 at 9:20 a.m., staff member G stated that when a resident was transferred to the hospital the nurse initiates a Bed Hold in the resident's electronic medical record. Staff member G stated the residents do not get a copy of the Bed Hold or Notice of Transfer, and a resident or power of attorney does not sign the form. Review of resident #10's electronic medical record failed to include a Bed Hold and Notice of Transfer for resident #10's facility-initiated transfer on 6/21/26. On 7/15/26, a request was made for a copy of resident #10's Bed Hold and Notice of Transfer form for the 6/21/26 facility-initiated transfer. No documentation or records were received from the facility by the end of the survey During an interview on 7/16/26 at 10:40 a.m., staff member B stated the nurse was responsible for completing a resident Bed Hold and Notice of Transfer form. Staff member B stated it appeared the letter for the bed hold and transfer was not completed because it was not documented in resident #10's electronic medical record.

Based on interview and record review, the facility failed to promote a dependent resident's preferences, to ensure he received a shower when preferred, and on a shower day, he did not receive the shower as he requested, for 1 (#2) of 6 sampled residents. This deficient practice caused resident #2 to have feelings of frustration, feel trapped, and miss breakfast. Findings include:A review of a Facility Reported Event, dated 10/20/25, showed that staff member I failed to provide shower services to a dependent resident, who was resident #2, and this was upsetting to the resident. A neglect allegation was initiated by the facility.During an interview on 12/15/25 at 1:31 p.m., resident #2 stated, I got my shower today. I haven't had an issue since that incident (on 10/20/25). It was frustrating. I always get up before 8:00 a.m. and have my shower before breakfast. I felt trapped because I couldn't do anything. I am dependent on the staff for assistance. The staff have talked to me about it, and I am happy with the outcome. The staff member doesn't work with me anymore and was supposed to be getting more training.During an interview on 12/16/25 at 9:10 a.m., staff member B stated that, Those documents are the bathing preferences, and the care plans you requested. I can tell you the bathing preferences aren't on all of them.During an interview on 12/16/25 at 10:55 a.m., staff member I stated, I would get to know the residents to learn their preferences. I would look at their care plans if I had time, but you really don't have time to look at them. Resident #2 would usually have his shower before breakfast. I worked Mondays and Tuesdays, and I think his showers were on Mondays. I don't recall an issue like that happening with him before. I have showered him a couple of times. He refused to eat breakfast that day, demanding that he get his shower first. I didn't do his shower because I knew staff member H was coming in at 10:00 a.m., and they were assigned to do the bath, not me. I would say a call light should be answered within 10 minutes.During an interview on 12/16/25 at 11:25 a.m., staff member K stated, There are times when staff don't get to all their tasks. Showers are usually done around 6:00 a.m. to 10:00 a.m., sometimes later. We [staff] try to accommodate resident preferences, but sometimes it is hard. He [resident #2] likes to have his shower first thing in the morning. I think the staff member that day didn't do his shower first thing because they knew someone else was coming in, and they were scheduled to do it. I scheduled the person coming in at 10:00 a.m. to do [Resident #2's] shower because I didn't think it would get done if I scheduled one of the other staff members to do it.During an interview on 12/16/25 at 12:01 p.m., staff member H stated, I was late that day, and I wasn't told I had to do his [resident #2's] shower until around 11:00 a.m. I was frustrated that the staff didn't inform me that I had to give him his shower, and he was still in bed. I think the staff that was on that day just pushed it off, knowing I was coming in at 10:00 a.m. and didn't want to do his [resident #2's] shower. I'm pretty sure it's in his care plan to be up earlier than 10:00 a.m.During an interview on 12/18/25 at 10:10 a.m., NF3 stated, He [resident #2] had let me know what was going on, and that he hadn't had his bath yet and was left in bed. I called and left a message with two different staff members. I didn't hear back from them on what was going on. He was frustrated and feeling hopeless because he was dependent on the staff to do things for him.Review of a facility document titled Call History dated 10/20/25, showed resident #2's call light went off twice, once was on 10/20/25 at 6:43 a.m., and it took 47 minutes for staff to respond. The second time was on 10/20/25 at 9:28 a.m., and it took 43 minutes for the resident's call light to be responded to. This showed resident #2's call light was not answered for an extensive time on the day his shower was delayed. Review of resident #2's comprehensive care plan dated, 3/18/25, showed: Goal: Mobility/activity is maintained at optimum level for me, -[Resident name] will be assisted with ADLs as needed while allowing him to be as independent as he can be.;-Intervention: Assist resident with ADLs/mobility as needed;-Assist [resident name] with ADLs/mobility as needed.;-[Resident name] would like his showers on Monday and Friday mornings unless others requests differently;-[Resident name] wants to be up out of bed no later than 0800 each day unless he indicates otherwise. [sic]Review of a facility document titled Activities of Daily Living/Needs and Choices, with a revision date of 6/2025, showed: .Procedure/Responsibilities: I. Resident needs for assistance with Activities of Daily Living (ADL) are identified upon admission and periodically thereafter and recorded in their medical record. A. ADLs include the following: .9. Bathing .III. Nursing ensures assistance with ADL is provided as directed in the care plan or as needed.E. Resident will be given a choice of bath schedule and frequency. [sic]

Based on interview and record review, the facility failed to ensure a resident was free from verbal abuse for 1 (#1) of 6 sampled residents. This deficient practice caused the resident to have feelings of sadness and withdrawal, and the facility identified the concerns, and addressed them prior to the survey. Findings include:Review of a facility-reported event dated 11/13/25 showed, Life Enrichment Manager was informed that a volunteer had verbally abused a resident during bingo. CNO and CDON were notified. Investigation started.During an interview on 12/16/25 at 9:44 a.m., resident #1 stated a volunteer had been mean to her at one point. Resident #1 said the volunteer talked badly to her and made her feel uncomfortable. Resident #1 said the volunteer always told her to go to the bathroom even when she didn't need to. Resident #1 said the facility did follow up with her after the incident, and she was happy with the outcome. Resident #1 said she hasn't had any further issues with volunteers and feels safe at the facility. Review of a written statement dated 11/12/25, by staff member N, showed that [resident's name] was being treated inappropriately at and before bingo. [Resident's name] is made to sit next to staff member C. Staff member C, in front of two family members and a volunteer, has told [resident name] to use the potty, so she don't poop her pants. She has also used the words poopie pants and [resident's name] carries a white hand towel to place on the chair where she sits. She does this in an act of shame. [sic]Review of a written statement on 11/13/25, by NF4, showed, One gal who calls bingo is demanding and rude to the residents. That lady, her name is [resident's name], she yelled out, and the volunteer who makes her sit next to her said, We don't do that here! .Review of a written statement dated 11/13/25, by staff member M showed, Staff member C verbally accosted a resident about bringing a towel to sit on. Staff member C stated, I am not going to clean up after you. [Resident name] becomes withdrawn when staff member C is present the past few weeks. [sic]Review of resident #5's written interview with a date of 11/13/25 showed, During bingo, is there any staff member or volunteer that has talked rude. Not to me but to others yes. She [staff member C] makes residents mad and embarrassed. [sic]During an interview on 12/16/25 at 2:30 p.m., staff member B said the volunteer was immediately put on administrative leave pending an investigation. The investigation showed the incident did happen, and the volunteer was asked not to come back. I will have to check the computer for notes, but I'm pretty sure there was a follow-up with the resident for any negative effects. Education was provided to life enrichment staff on the facilities policy on abuse, neglect, and the reporting requirements. Staff member B stated all volunteers go through HR and HR does a background check on them.Corrective Action:Review of the facilities investigation findings submitted on 11/19/25 showed staff member C was immediately put on administrative leave upon notification of the allegation of abuse. Resident #1 was interviewed and was able to verify the allegations. All life enrichment staff were provided education on abuse, neglect, and reporting requirements.A review of the facility's Follow up with residents regarding abuse claims, dated 11/13/25, showed residents were interviewed individually regarding the abuse allegations, and no other residents reported any mistreatment to them, but did mention the way resident #1 was treated. Staff interviews were conducted, and statements gathered. Staff member C was permanently suspended, education was provided, and the facility had the concerns related to the abuse and volunteers on the monthly agenda for QAPI meeting, which was to occur on 12/30/25, to ensure all corrective actions were in place as identified and no further action was needed.

Based on observation, interview, and record review, the facility failed to identify and investigate a major injury of unknown origin in a timely manner for a cognitively impaired resident, which was found to be a femur fracture, even though a staff member thought the resident's leg looked awkward for a while but neglected to address the concern. The surgeon treating the resident found the fracture was already healing and difficult to repair due to the delay in treatment for the injury of unknown origin, for 1 (#1) of 4 sampled residents. This deficient practice increased the risk of further injury, pain, and or decline in status for the resident and increased the risk of a negative outcome for other residents due to the injury not being identified and or investigated as potential abuse/neglect. Findings include: A record review of a Facility Reported Event showed resident #1 sustained a major injury of unknown origin, which was reported to the State Survey Agency on 10/6/25. It was found the resident had a femur fracture, allegedly caused by a heater. During an observation on 10/21/25 at 11:35 a.m., resident #1 was lying in bed, flat on her back, with her left lower extremity elevated on multiple pillows. Resident #1's bed was in the lowest position. During an interview on 10/21/25 at 11:45 a.m., staff member B stated he assessed resident #1. Staff member B stated resident #1's left leg showed signs of external rotation, swelling, and deformity. Staff member B stated he called the physician and received physician orders to send resident #1 to the emergency room for further evaluation. Staff member B stated he had doubts about the fracture being caused by her foot being caught under the heater in her room. Staff member B stated he did not recall resident #1 being able to move her legs off the side of the bed independently. Staff member B stated there was no bruising or swelling to resident #1's left toes or foot, and the swelling/bruising would have been present if the heater caused the fracture. Staff member B stated he had not been spoken to about resident #1's injury of unknown origin, or what he had observed and assessed with resident #1, on the day of the incident.During an interview on 10/21/25 at 2:40 p.m., NF3 stated he had received a phone call from a physician at [Hospital Name], letting him know resident #1 had sustained a fracture and had asked permission to perform surgery on resident #1. NF3 stated he had given permission to the physician to perform the surgery. NF3 stated this was how he found out about #1's fracture. NF3 stated, [Facility Name] did call me and tell me they thought the fracture occurred from her foot catching on the heater. I am having a hard time understanding how [Resident #1's Name] gets a fracture from a heater. I just don't buy it. I don't feel this was a malicious act, but I do feel there was negligence.During an interview on 10/22/25 at 9:08 a.m., NF4 stated resident #1 had dementia and was non-verbal and non-ambulatory. NF4 stated, [Resident #1] was found lying in her bed by staff, and they had noted her left leg was rotated, and staff thought there was something wrong. I had assessed [Resident #1] with [Physician Name]. The fracture was found to be partially healed and was, at a minimum, two to three weeks old. It was not an acute injury. The bone showed callous formation, and there was no bruising noted on the left leg. The fracture was hard to reduce during the operation.During an interview on 10/22/25 at 11:15 a.m., NF5 stated he had evaluated resident #1 at the hospital. NF5 stated resident #1 presented with swelling and signs of pain in her left leg. NF5 stated, I called [Resident #1's] daughter, and she was claiming physical and sexual abuse, so I completed a trauma assessment and a genital urinary assessment. I had ordered X-rays, a pan scan (a full body CT scan) to quickly identify any areas of trauma. The left leg was swollen but did not show any bruising and when it was discovered there was a fracture, orthopedics was called, and they would come down and assess the resident. Once orthopedics takes over, my part is complete.During an interview on 10/22/25 at 1:24 p.m., staff member D stated she had walked into resident #1's room about 7:00 a.m., on 10/6/25 to perform morning cares. Staff member D stated that resident #1 was dependent on staff for care, including mobility, and both of resident #1's legs were on the bed. Staff member D stated that resident #1's left leg did not look right, so she had called in staff member J to look at resident #1. Staff member D stated she had attempted to roll resident #1, but resident #1 had cried out. Staff member D stated, That is when we called the nurse to come over and evaluate [Resident #1's Name]. Staff member D stated that resident #1's leg had . been looking awkward for a while; we just thought that was normal for her (resident #1). I never said anything to anybody about it. Staff member D stated resident #1 had a history of putting her legs over the side of the bed in the past, but had not seen resident #1 do that in quite a while.During an interview on 10/22/25 at 1:48 p.m., NF7 stated the Orthopedic team received an Orthopedic consult for resident #1 from the emergency department regarding a femur fracture. NF7 stated he had performed the open reduction internal fixation of the fracture (surgical procedure). NF7 stated there was rotation to the left leg with some swelling. NF7 stated, There was no bruising noted to the left leg. The fracture was not an acute fracture. The fracture was partially healed. I would estimate the fracture happened at minimum, two to three weeks ago, but could have occurred as long as eight weeks ago. I had a hard time getting the fracture reduced because of the healing. In my professional opinion, this fracture was suspicious. It was just odd that it was not caught sooner. This patient was non-verbal and non-ambulatory. NF7 stated the acute swelling could have been caused by moving resident #1, and some scar tissue around the fracture was damaged by callous formation on the bone. NF7 stated swelling and acute pain could occur when a fracture has already begun to heal.During an interview on 10/22/25 at 3:01 p.m., staff member H stated, I did not look at the operation report. If I would have seen the operation report I would have done more, I would have looked further back and talked to more staff. I definitely would have done more. I was going off of what staff told me, it seemed like it was an acute event. I felt it was a recent fracture. We determined the cause of the injury. Staff member H stated that after the injury investigation, she had called and talked with an orthopedic provider and asked if the scenario they came up with was possible. Staff member H stated they did not feel the injury required an abuse and neglect investigation.Review of resident #1's CT scan, dated 10/6/25, showed a distal femur periprosthetic fracture. The tibia and fibula were intact.Review of resident #1's operation report, dated 10/7/25, showed: . This patient had no bruising on her entire left lower extremity. This fracture would not move with a femoral distractor placed. On manual palpation, this fracture was mostly healed in a malunited position. saw and osteotomes were utilized to free up fracture fragments. Then, the fracture would mobilize.Review of a facility policy titled, [Facility Names] Abuse/Neglect Allegations [Facility Name], dated 10/2025, showed: . Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident necessary to avoid physical harm, pain, mental anguish, or emotional distress.

Based on observation, interview, record review, the facility failed to identify and respond to increased behaviors indicative of pain or distress in a cognitively impaired resident for 1 (#1) of 4 sampled residents. Findings include: During an interview on 10/22/25 at 12:15 p.m., staff member C stated when a dementia resident exhibits an increase in behaviors, she would assess possible causes such as pain, positioning, incontinence, and perform a general head-to-toe assessment for other physical causesDuring an interview on 10/22/25 at 1:24 p.m., staff member D stated resident #1 exhibited scratching and pinching. Staff member D stated resident #1 had had done that since she was admitted , and it was usually only in the morning during cares. Staff member D stated there had been an increase in behaviors lately for resident #1 but could not say exactly when the behaviors started to increase.During an interview on 10/22/25 at 2:35 p.m., staff members E and F stated that behavior monitoring was done every shift. Staff member F stated if a resident was unable to verbalize the problem and was demonstrating behaviors such as yelling out, pinching, hitting, etc., she would look at basic needs first. Staff member F stated she would start by looking at the last time the resident ate, or the last time the resident was toileted. Staff member E stated, Sometimes the behaviors are just that the resident wants attention. A review of resident #1's behavior monitoring showed, between 9/1/25 and 10/6/25, resident #1 exhibited behaviors including pinching, scratching, and yelling/screaming 15 times.Review of resident #1's pain assessments, dated 9/1/25-10/6/25, showed: three pain assessments were completed, and only one of the pain assessments was completed on a day resident #1 had exhibited behaviors.A review of resident #1s care plan, with a with a start date 10/18/24 and end date 10/9/25, showed, Intervention: Identify stressors that lead to inappropriate behavior. Assess pain. [sic] Resident #1's electronic medical record did not contain evidence that pain was assessed as a possible cause of her increased behaviors.A review of resident #1's Quarterly MDS, with an assessment reference date of 6/29/25, showed: . E0200. Behavioral Symptoms.Physical behavioral symptoms directed towards others.1-behavior of this type occurred 1 to 3 days Section J: Health ConditionsPain management. Received PRN pain medications or was offered or declined? The response marked was 0-no A review of resident #1's Quarterly MDS, with an assessment reference date of 9/27/25, showed: . E0200. Behavioral Symptoms.Physical behavioral symptoms directed towards others, and this occurred 4 to 6 days. Section J: Health Conditions, for pain management, showed the question for if the resident received PRN pain medications or was offered or declined them. The response marked was 0-no.

Based on interview, record review, and policy review, the facility failed to ensure a thorough investigation of alleged abuse and neglect was completed for a resident with a documented fracture for 1 (# 1) of 4 sampled residents; and failed to ensure other residents were protected from potential abuse during the investigation. This deficient practice had the potential to place all cognitively impaired residents at risk for abuse and neglect. Findings include: A review of a Facility Reported Incident submitted to the State Survey Agency on 10/6/25, showed: the incident was classified as an injury of unknown origin. Statements were collected from staff member I on 10/15/25 and staff member D on 10/13/25. No other staff, residents, or resident representatives provided statements or interviews. The investigation included notation, On 10/13/2025, [Facility Name] (re)initiated an internal investigation surrounding the allegations of suspected abuse as indicated in the hospital progress notes. [sic]. The investigation file did not contain evidence the time frame investigated was expanded to include the time frame indicated by the hospital providers. No staff were removed from the floor during the investigation. The investigation failed to show evidence that other residents were identified as being possibly affected for abuse or neglect.Review of a hospital Operative Note, dated 10/7/25, showed: . Procedure: Details. This fracture would not move with a femoral distractor placed. this fracture was mostly healed in a malunited position. [sic]. This indicated the fracture occurred prior to the date of the incident due to the amount of healing that occurred.During an interview on 10/21/25 at 11:45 a.m., staff member B stated he assessed resident #1 and found swelling and left leg rotation. Staff member B stated resident #1 was sent to the Emergency Room. Staff member B stated he did not think the radiator/heater caused the injury to resident #1's left leg. Staff member B stated resident #1's left foot showed no signs of trauma from being caught under the radiator/heater. Staff member B stated he was unaware if resident #1 could independently put her foot for the side of the bed. Staff member B stated resident #1 was dependent on staff for all care. Staff member B stated all resident beds were moved away from the radiators/heaters after the incident.During an interview on 10/21/25 at 2:40 p.m., NF3 stated, [Facility Name] did call me and tell me they thought the fracture occurred from her foot catching on the heater. I am having a hard time understanding how [Resident #1's Name] gets a fracture from a heater. I just don't buy it. NF3 stated he had not seen resident #1 in several years but from what he understood resident #1 was no longer ambulatory and was non-verbal. NF3 stated resident #1 depended on staff for all of her care.During an interview on 10/22/25 at 1:24 p.m., staff member D stated staff members G and H were looking into resident #1's fracture. Staff member D stated staff member G talked to her about the incident. Staff member D stated she tried to explain how she found resident #1 and the events of that morning. Staff member D stated she felt staff member G was not comprehending her recollection of the incident and kept trying to tell her the fracture happened on the heater. Staff member D stated both of resident #1's legs were on the bed, and the left toes and foot were not red, swollen, or bruised. Staff member D stated she had not seen resident #1 put her leg over the bed recently, but she used to.During an interview on 10/22/25 at 1:48 p.m., NF7 stated, There was no bruising noted to the left leg. The fracture was not an acute fracture. The fracture was partially healed. I would estimate the fracture happened at minimum two to three weeks but could have occurred as long as eight weeks ago. I had a hard time getting the fracture reduced because of the healing. There was no torsion or twisting noted to the bone. It was just odd that it was not caught sooner. NF7 stated he thought the fracture was suspicious.During an interview on 10/22/25 at 3:01 p.m., staff member G stated an investigation was started right way. Staff members G and H stated they had done a re-enactment of what they thought to be the cause of the fracture. Staff member G stated he had laid down on the bed, in a supine position, put his left foot down next to the heater (about a 3-inch deep by 4 inches high recessed area), and staff member H started to raise the bed up. Staff member G stated he felt some pain and twisting in the knee area of his left leg. Staff member H stated they had talked to staff member D and staff member I about the incident, but had not talked to any other staff, including staff member B who had assessed resident #1 prior to being sent to the Emergency Room. Staff member H stated, He wrote a nursing note, and I felt that was complete and there was no need to interview him. Staff member H stated she had not looked at the operation report. Staff member H stated, If I would have seen the operation report I would have done more, I would have extended and looked further back and talked to more staff. I definitely would have done more. I was going off of what staff told me, it seemed like it was an acute event. I felt it was a recent fracture. Staff member G stated more interviews were completed, but there was no documentation, and they were completed after the investigation process. Staff member G stated mood and behavior were looked at, but there was no noted change in resident #1's mood or behavior that would have indicated a change in status. Staff member G stated the investigation should have been conducted differently and more thoroughly, I see that now. Staff member G stated resident #1 had a history of putting her legs over the edge of the bed. Staff members G and H did not recognize the fracture as suspicious until after reading a hospital progress note. Review of the facility's complete investigation documents showed no documentation for an investigation involving an injury of unknown origin. There was no documentation showing the results of the facility's re-enactment of the fracture, and no investigation into abuse or neglect involving a fracture until after the initial investigation was completed.Review of resident #1's nursing notes, dated 6/1/25-10/6/25, showed not documentation of the resident putting her legs over the side of the bed.Review of resident #1's Care Plan, dated 6/1/2025-10/6/2025, contained no documentation resident #1 puts her legs over the side of the bed putting her at risk for injury or falls.Review of resident #1's staff documentation, dated 9/1/25-10/6/25, showed resident #1 was dependent on staff for her ADLS (Activities of Daily Living).Review of a facility policy titled, [Facility Names] Resident Abuse/Neglect Allegations, dated10/2025, showed: . [Facility Name] . protect residents during investigations and report incidents, and investigation results II. The DON or designee initiates an investigation .a. Gather initial written reports from all parties involved or witness to the allegation- this includes residents, family members, staff, co-workers, etc.b. Document preliminary findings including any physical indications related to the allegation, interviews with complainants, residents, witnesses and others, etc III. The DON/Manger (or their Designee) will follow-up on the preliminary findings by continuing the investigation .a. Follow-up with in-person/telephone interviews with complainants, residents . witnesses, etc. Document findings from these interviews . [sic]

Based on observation, interview, record review, and policy review, the facility failed to provide necessary care and services consistent with the resident's assessed needs and care plan for repositioning, toileting, and pressure ulcer prevention, at least every two hours as directed by the plan of care for 1 (#1) of 4 sampled residents. Findings include:During an observation on 10/21/25 at 11:35 a.m., resident #1 was lying in bed, flat on her back, with her left lower extremity elevated on multiple pillows. Resident #1's bed was in the lowest position.During an interview on 10/21/25 at 11:45 a.m. staff member B stated, The facility's policy on turning and repositioning is supposed to be done every two hours, and toileting or checking and changing dependent incontinent residents, was also supposed to be done every two hours. Staff member B stated he could not be sure residents were being turned, repositioned, or checked and changed every two hours.During an observation on 10/21/25 at 3:04 p.m., resident #1 was lying in her bed, flat on her back. Her left lower extremity was elevated on multiple pillows.During an observation on 10/22/25 at 10:08 a.m., resident #1 was lying in her bed, flat on her back. Her left lower extremity was elevated on multiple pillows.During an interview on 10/22/25 at 1:24 p.m., staff member D stated, We are supposed to turn and reposition and check and change the residents who are dependent for care every two hours.During an observation on 10/22/25 at 2:14 p.m., resident #1 was lying in her bed, flat on her back. Her left lower extremity was elevated on multiple pillows.During an interview on 10/23/25 at 6:05 a.m., staff member I stated his shift starts at 10:00 p.m. Staff member I stated he started rounds at 1:00 a.m., and 4:00 a.m., and that was when turning and repositioning was done and also when check and changes were done for dependent residents. Staff member I could not verbalize how often the facility required turning and repositioning, or the check-and-changes to be completed. Staff member I stated resident #1 was not positioned from side to side; she was always on her back. Staff member I stated he did have access to resident care plans, and he did know how to access them. Staff member I could not verbalize if there were any specific turning and repositioning or check and change requirements in resident #1's care plan.During an observation on 10/23/25 at 8:10 a.m., resident #1 was lying in her bed, flat on her back. Her left lower extremity was elevated on multiple pillows.During an interview on 10/23/25 at 8:13 a.m., staff member J stated, We are supposed to turn, reposition, and check and change (the residents) every two hours, but the reality is that does not always happen.During an interview on 10/23/25 at 8:43 a.m., staff member A stated it was his expectation for cares to be completed on residents every two hours. Staff member A stated there was no policy for turning and repositioning or a bowel and bladder incontinence policy.During an interview on 10/23/25 at 10:04 a.m., staff member P stated the facility's expectation was residents were to be turned and repositioned every two hours and as needed, depending on the situation for that particular resident. Staff member P stated residents were to be checked and changed at a minimum of every two hours; that was the general rule. Staff member P stated rounds were to be started on night shift after report was given by the off-going shift, and every two hours throughout the night.Review of a facility document titled Care Plan Revisions and Complete Comprehensive Care Plan, dated 6/2025-10/6/2025, showed: . Intervention: Assist resident with ADLs/mobility as neededDescription:.Turn and Reposition q 2 hoursCheck and Change q 2 hoursTotal assist with ADLs . [sic]Review of a facility document titled, Documentation of turn and reposition, dated 10/1/25-10/6/25, showed:-On 10/1/25, documentation showed resident #1 was repositioned one time in a 24-hour period at 9:30 p.m.-On 10/2/25, resident #1 was repositioned one time in a 24-hour period at 1:29 a.m.-On 10/3/25, documentation showed resident #1 was repositioned two times in a 24-hour period, at 4:56 p.m. and 9:00 p.m.-On 10/4/25, there was no documentation that resident #1 was repositioned in a 24-hour time period, and-On 10/5/25, documentation showed resident #1 was repositioned one time in 24 hours at 6:00 p.m.Review of a facility document titled, Documentation of Toileting and Check and Change, dated 10/1/25-10/6/25, showed:- . 10/1/25- 0200 (2:00 a.m.) Activity did not occur. 1100 (11:00 a.m.) Total assistance. 1930 (7:30 p.m.) Total assistance. Resident #1 was checked and changed two times in a 24-hour period.- . 10/2/25-1415 (2:15 p.m.) Total assistance. 1930 (7:30 p.m.) Total assistance. Resident #1 was checked and changed two times in a 24-hr period.- .10/3/25-0545 (5:45 a.m.) Total assistance. 1115 (11:15 a.m.) Total assistance. Resident #1 was checked and changed two times in a 24-hour period.- . 10/4/25-0430 (4:30 a.m.) Activity did not occur. 1915 (7:15 p.m.) Total assistance. 2215 (10:15 p.m.) Activity did not occur. Resident #1 was checked and changed one time in a 24-hour period.- . 10/5/25-1400 (2:00 p.m.) Total assistance. 1915 (7:15 p.m.) Total assistance. Resident #1 was checked and changed two times in a 24-hour period.- . 10/6/25-0200 (2:00 a.m.) Activity did not occur. Resident #1 was not checked and changed in a 24-hour period.Review of a facility policy titled, [Facility Names] Activities of Daily Living/Needs and Choices, dated 6/2025, showed: . I. Resident needs for assistance with Activities of Daily Living.1. Bed mobility. 7. ToiletingReview of a facility policy titled, [Facility Initials] Pain Management, dated 10/2025, showed: . [Facility Name] assesses residents for pain and treat, as necessary Skilled Patients are assessed for pain at minimum daily and the long stay resident are assessed at minimum of weekly. [sic]8. Personal Hygiene Ability . III. Nursing ensures assistance with ADL is provided as directed in the care plan or as needed.A. Provision of assistance with ADL is regularly documented in the medical record. [sic]

Based on observations, interviews, and record review, the facility failed to maintain sanitary linens during the handling and processing of laundry, as to prevent the spread of infection for the residents residing at the facility. Findings include: 1. During an observation and interview on 6/18/25 at 9:27 a.m., with staff member A, M, Q, R, and S, the following observations were made: - Floors throughout the clean side of the laundry room were riddled with trash/debris on the floor, including used masks, paper, dirty laundry, used paper towels, and dust balls. - Staff member N was preparing clean sheets to enter the folding machine, and the clean sheets were dragging on the unclean floor. - Staff member O dropped clean laundry out of the dryer, onto the unclean floor. Staff member O then picked the clean laundry up and placed them in the clean linen bin with other clean items. - Staff member O was walking through the clean linen area while putting her hair in a ponytail. Staff member O then began to fold the clean laundry, without performing hand hygiene first. - Staff member P was preparing gowns to place them into the folding machine, and the clean gowns were dragging on the unclean floor. - The counter in the clean folding room was missing the edging around the sides on the table, creating an un-cleanable surface. During an interview on 6/18/25 at 9:57 a.m. with staff members Q, R, and S, staff members R and S stated they had not been following the laundry department or completing regular observations. Staff member S stated, Based on the observations we just had (above), we sure will be adding it to our list. During an interview on 6/18/25 at 9:57 a.m., staff member A stated there were obvious infection control issues during the walk through, and he would be following up with the team to address the infection control requirements. A request was made for a policy related to the cleaning of the laundry room, but a policy was not received prior to the end of the survey. 2. During an observation on 6/17/25 at 3:31 p.m., a laundry cart, which contained clean laundry, was observed outside of the room labeled linen. The cart was observed with clean clothes on hangers, which were hanging on the side, and the back of the cart was uncovered. During an observation on 6/18/25 at 1:50 p.m., an uncovered laundry cart was observed in the activity room across the hall from room [ROOM NUMBER]. During an interview on 6/18/25 at 1:53 p.m., staff member E stated the laundry cart should be covered. Staff member E said, We keep it covered, but sometimes residents see it and uncover it. Review of the facility's policy titled, [Facility Name]-Linen and Personal Clothing Standards, last revised on 6/2025, showed: .Procedure: I. Nursing A. Places clean linen on linen carts to take to individual rooms. Linen carts will remain covered . G. Ensures laundry cart remains covered when not in use

Based on observation, interview, and record review, the facility failed to review and revise comprehensive care plans for activities and food preferences for 5 (#s 39, 40, 74, 75, and 84) of 23 sampled residents. Findings include: 1. Review of resident #39's, Activities Care Plan, dated 2/22/24, reflected: - . Determine [Resident #39] activity preferences. During an interview on 6/17/25 at 11:51 a.m., resident #39 stated she went to bible study. Resident #39 stated she did not attend any other activities. The activity care plan did not show what other activities the resident was interested in. 2. Review of resident #75's, Activities Care Plan, dated 2/22/24, reflected: - . Determine [Resident #75] activity preferences. During an observation on 6/16/25 at 2:29 p.m., resident #75 was sitting on the side of her bed, anxious, shaking, with erratic breathing, saying unclear words, and the door was closed. Staff member H came in to assist the resident with a sit to stand lift. Staff member H placed resident #75 in her wheel chair, took her to the dining room, and left her at a table without anything to do. Resident #75 remained at the table without anything to do or drink until dinner service. The activity care plan did not show what other activities the resident was interested in for staff to utilize. 3. Review of resident #74's, Activities Care Plan, dated 6/4/25, reflected: - . Determine [Resident #74] activity preferences. During an interview on 6/17/25 at 1:25 p.m., NF3 stated resident #74, . really needs to have activities and loves bowling, sewing, grocery shopping, and social activities. She is really a social person. NF3 stated no one had contacted her about activities of interest for resident #74. NF3 stated she was so upset she had shared her concerns tearfully in the middle of the grocery store with the previous administrator who was going to email the director of activities. NF3 stated she had not heard anything to date, and it had been more than a week ago. The activity care plan did not show what other activities the resident was interested in. 4. Review of resident #40's, Activities Care Plan, dated 9/4/24, reflected: - . Determine [Resident #40] activity preferences. During an observation and interview on 6/16/25 at 3:10 p.m., resident #40 was in his room watching television in his recliner. Resident #40 stated he enjoyed the activities, when they have some. Resident #40 stated the facility did not have much for activities for him (that he was interested in), so he watched television most of the time. The activity care plan did not show what other activities the resident was interested in for staff to utilize, or what staff could offer him within his identified areas of interest. 5. Review of resident #84's, Care Plan, dated 3/11/25, reflected there was no activity plan established for the resident. During an interview on 6/18/25 at 11:18 a.m., staff member I stated activities were discussed during resident council meetings. Staff member I stated residents who did not attend, or were not able to attend, did not participate in the discussion around activity preferences. Staff member I stated she was not aware of the preferences assessment in the EHR system until yesterday (6/17/25) or that individualized resident preferences needed to be care planned. Review of the facility's policy, titled, [Facility name] Life Enrichment (Activities), dated 6/2025, reflected: - . Life Enrichment Program should include an ongoing resident centered activities program that incorporate the residents' interest, hobbies and cultural preferences which is integral to maintaining and/or improving a resident's physical, mental and psychosocial well-being and independence. Activities are to be both facility-sponsored group and individual activities and independent activities. - . After completion of the initial Life Enrichment Assessment form the Life Enrichment Coordinator will be ready to identify and record problems/needs, goals, and approaches on the care plan as it relates to activities.

During an observation on 6/17/25 at 2:10 p.m., three residents were sitting in the dining room. The television was on, and a German speaking movie was playing. The movie contained sexual scenes. The staff changed the channel to music. During an interview and observation on 6/17/25 at 2:30 p.m., staff member U said the most common activity on the memory care unit was Trivia. Staff member U said the staff take some of the residents to the main floor for church and dog visits. Staff member U said not many of the residents residing on the unit go on the outings, but two of the residents went fishing that day. The activity calendar showed a trip to Walmart was scheduled. During record review and observation on 6/18/25 at 10:35 a.m., the activity calendar showed the activity scheduled for the residents was crafts. During an observation on 6/18/25 at 10:35 a.m., five residents were sitting at the dining room tables on the dementia unit. No staff were present, no crafts were being done, and no other activities were being offered to residents on the secure unit. During an interview on 6/18/25 at 11:00 a.m., staff member Q said the residents go off the memory care unit for crafts. Staff member Q said the residents who don't go off the unit have 1:1 visits with staff. Staff member Q said trivia is played by the staff showing a picture to the residents, letting them guess what the picture is, and then talking about the picture. 5. During an observation and interview on 6/16/25 at 2:35 p.m., resident #42 said she did not know any activities were offered at the facility. Resident #42 said she was trying to find the television remote so she could turn this shit off. Resident #42 said she liked country music and not the content the staff turned her television to. Resident #42 said she had to lay in bed too much as far as she was concerned. Resident #42 said if she could walk, the staff would not be able to keep her in bed. Review of resident #42's MDS, with an assessment reference date of 5/5/25, showed it was very important for resident #42 to listen to music she likes, and it was not important at all to do activities with a groups of people. Review of resident #42's flow sheet for the resident's activity attendance showed resident #42 attended two 1:1 activities and three group activities in May 2025. In June 2025, resident #42's flow sheet showed she attended six group activities and one 1:1 visit with staff. The documentation showed the resident attended groups more often than the 1-1 visits, even though she did not feel group activities were important. Review of the facility's policy, [Facility name] Life Enrichment (Activities), dated 6/2025, reflected: Life Enrichment Program should include ongoing resident centered activities program that incorporate the residents' interest, hobbies and cultural preferences which is integral to maintaining and/or improving a resident's physical, mental and psychosocial well-being and independence. Activities are to be both facility-sponsored group and individual activities and independent activities. Based on observations, interviews, and record review, the facility failed to provide activities to meet the needs of the residents for 7 (#s 39, 40, 42, 74, and 75) of 23 residents. Findings include: 1. During an observation and interview on 6/16/25 at 3:10 p.m., resident #40 was in his room watching television in his recliner. Resident #40 stated he enjoyed the activities, When they have some. Resident #40 stated the facility did not have much for activities for him, so he watched television most of the time. Resident #40 stated he was not offered many activities to go do and would go if they were offered. 2. During an interview on 6/17/25 at 11:51 a.m., resident #39 stated she went to bible study. Resident #39 stated she did not attend any other activities and was not aware of other activities. 3. During an interview 6/17/25 at 1:25 p.m., NF3 stated resident #74, . really needs to have activities and loves bowling, sewing, grocery shopping, and social activities. She is really a social person. NF3 stated no one had contacted her about activities of interest for resident #74. NF3 stated she was so upset she had shared her concerns tearfully in the middle of the grocery store with the previous administrator who was going to email the director of activities. NF3 stated she had not heard anything to date, and it had been more than a week ago. 4. During an observation on 6/16/25 at 2:29 p.m., resident #75 was sitting on the side of her bed, anxious, shaking, with erratic breathing, saying unclear words, and the door was closed. Staff member H came in to help using the sit to stand lift. Staff member H placed resident #75 in her wheel chair and took her to the dining room and left her at a table without anything to do. Resident #75 remained at the table. During an interview on 6/16/25 at 1:53 p.m., staff member J stated the facility provided movies on Mondays and popcorn was provided. Staff member J stated trivia was an activity provided for the memory care unit on Sundays. Staff member J stated there was only one person scheduled to work on Sundays, Mondays, Fridays, and Saturdays. Staff member J stated when only one person was available, the activity was combined with the activity provided to residents outside the memory unit, if the residents were able to come off the unit. Staff member J stated the number of residents who could come out for an activity was 2-3 because of the risk and supervision needed. Staff member J stated the remaining residents did not receive activities. Staff member J stated the activities staff were often pulled to provide transportation, and the activities were canceled. During an interview on 6/18/25 at 11:18 a.m., staff member I stated activities were discussed during resident council meetings. Staff member I stated residents who did not attend, or were not able to attend, did not participate in the discussion around activity preferences. Staff member I stated memory care residents often did not have activities because the nursing staff would lay them down immediately after meals, so they were not available to attend activities. Staff member I stated she was often pulled to the floor to cover the nursing department shifts, and the life enrichment aides were frequently pulled to provide transportation and serving meals. Staff member I stated she was not aware of the resident preferences assessment in the EHR system, which was to be completed for each resident, until yesterday, or that resident preferences needed to be care planned. During an interview on 6/18/25 at 4:10 p.m., staff member K stated the facility wasn't completing the assessment for activities for the residents because it was missed during the transition from the old EHR system to the new EHR system. Review of the facility's Entertainment Flow-sheet History, dated 5/19/25-6/18/25, reflected: - Resident #74 did not have any activities for 27 of the 30 days in the month. - Resident #40 did not have any activities for 28 days out of 30 days in the month. - Resident #75 did not have any activities for 25 out of 30 days in the month. - Resident #39 did not have any activities for 25 out of 30 days in the month. During an interview on 6/19/25 at 10:10 a.m., staff member A stated activities staff were pulled to other tasks, when necessary, .because care comes first. Staff member A stated the facility was in the process of hiring two more life enrichment staff to ease the workload.

2. During an initial observation on 6/16/25 at 2:00 p.m., resident #8 did not have access to any fluids while she was in her room. A review of resident #8's dietary information showed resident #8 was to receive thickened fluids. Review of resident #8's care plan, dated 2/25/24, showed the staff were to assist with and encourage food and fluid intake on mildly thick liquids. The care plan directed the staff to observe for signs and symptoms of dehydration. The staff were also to monitor and adjust the fluid intake and output. During an observation on 6/18/25 at 10:30 a.m., resident #8 had a pitcher of water at her bedside. The water in the pitcher was regular consistency, and it was not mildly thickened, as ordered. During an interview on 6/17/25 at 8:24 a.m., staff member I said some residents should have water pitchers. Staff member I said the water pitchers disappeared and some residents just don't have a pitcher. During an interview on 6/17/25 at 2:10 p.m., staff member G said the residents should at least have a cup or a large water jug at their bedside. Staff member G said the residents will come to the staff and ask for something to drink. Staff member G said she was not aware which residents were at risk of dehydration. Based on observations, interviews, and record review, the facility failed to ensure a resident residing on the memory care unit had access to, and the provision of, mildly thickened fluids, for 1 (#8), and the resident received an unthickened liquid; and the facility failed to ensure one resident received adequate assistance for meals and maintaining her nutritional status contributing to a 6.5% weight loss (severe), for 1 (#74) of 23 sampled residents, and the resident's EHR documentation showed she had a weight loss. The lack of the provision of fluids in resident rooms may affect any resident on the unit who wanted something to drink, and they did not have it available or were unable to ask for it. Findings include: 1. During an observation on 6/17/25 at 8:47 a.m., resident #74 was still in bed, with no breakfast, and there was nothing for the resident to drink in the room. There was a new water cup in the room, but it was empty and unopened. During an observation on 6/17/25 at 8:57 a.m., resident #74 was in bed sleeping. Her breakfast tray was brought to the room and left on the bedside table. Staff did not assist the resident with the meal. During an observation on 6/17/25 at 9:26 a.m., resident #74 was still asleep in her bed, with her breakfast tray still untouched. A review of resident #74's EHR weights showed the following: - 5/22/25: 122 lbs., 6.5% loss in last month - 6/8/25: 115 lbs., which was another loss of 7 lbs. in 17 days. During an observation and interview on 6/17/25 at 4:05 p.m., resident #74 was sitting on her bed. The resident had no drinks available at the bedside. NF3 had just arrived and dressed resident #74. NF3 voiced concerns that resident #74 was so dehydrated over the weekend, the nurse on duty was offering to start IV fluids. NF3 stated she had been pushing fluids and trying to get resident #74 back to her baseline status. NF3 stated she had not been approached by dietary staff yet, and resident #74 was a picky eater. NF3 stated, You would think they would want to know what she likes to drink and eat. NF3 stated she keeps soda pop and protein drinks in the personal refrigerator for resident #74, but the resident's mental status would require the staff to come in and encourage her to drink. During an observation and interview on 6/18/25 at 12:54 p.m., resident #74 was in the dining room, her plate of food untouched, but she was eating her Jello cup. Resident #74 stated, I don't know what that shit is referencing the food on the plate, then the resident requested the surveyor get her mashed potatoes and a sandwich. During an interview on 6/17/25 at 7:40 a.m., staff member L stated the residents on the memory care unit did not have drinks at the bed side, but they were offered fluids with meals. During an interview on 6/17/25 at 10:40 a.m., staff member B stated residents residing on the memory care unit were not given fluids at the bedside because residents wandered into other resident rooms, and consume any drinks in the room. The facility was concerned about infection control. A request was made by the surveyor for a policy on maintaining resident hydration, but not received prior to the end of the survey.

4. During an observation on 6/16/25 at 3:35 p.m., resident #77's call light was hanging off the light located over the bed. Resident #77 was lying in bed and could not reach the call light for use. During an interview on 6/17/25 at 2:10 p.m., staff member G said there were alarms attached to the resident's door, and the bathroom doors. Staff member G stated the cognitive residents should have a call light. Staff member G said the staff just check on the residents every couple of hours. Review of a facility policy, [Facility Name] Patient Call System, dated 6/2025, reflected: . The DON will verify the system is in working condition at all times . .The call system is located near the patient's bed and in the restroom . Based on observations, interviews, and record review, the facility failed to ensure residents had call lights available for 4 (#s 40, 74, 75, 77) of 23 sampled residents. This deficient practice prevented residents from contacting staff for assistance when they wanted to. Findings include: 1. During an observation on 6/16/25 at 2:05 p.m., resident #40 did not know where his call light was located. The call light was under equipment, on a countertop, in the corner of the room. Resident #40 stated if he needed help, he did not know how to call for help. When asked how he would call for help, resident #40 stated, I guess I can't, maybe (I'd) yell. 2. During an observation on 6/16/25 at 2:21 p.m., resident #74 was in her room trying to get up from her bed. Resident #74 had no call light in her room. Resident #74 called out for help and two CNAs came to assist her. Resident #74 stated, I just yell out until someone comes, if I need help. 3. During an observation on 6/16/25 at 2:29 p.m., resident #75 was sitting on the side of her bed, anxious, shaking with erratic breathing, saying unclear words, with the door closed. There was no call light in the room. The bed alarm was not sounding. This surveyor notified staff member H on duty who assisted resident #75 into her wheelchair, who then moved the resident to the dining room table. During an interview on 6/16/25 at 2:35 p.m., staff member C stated they do not have call lights in the memory unit. Staff member C stated residents were checked on every two hours. During an interview on 6/16/25 at 3:00 p.m., staff member B stated residents do not always know how to use the call lights appropriately, and the staff should be rounding on the residents regularly.

Based on interview and record review, the facility failed to update a resident's code status from Full Code to DNR, in the facility's EHR for 1 (#5) of 23 sampled residents, and this failure increased the risk of the resident being resuscitated in a health crisis, when that was not the resident's preference or documented on the resident's POLST form. Findings include: During an interview on [DATE] at 4:07 p.m., staff member D stated if a resident wanted to change their POLST form status from what was entered on admission, he would go over the form with the resident and make sure it is signed by the provider the resident, or the resident's POA. Staff member D stated he was not the person who updated the residents code status in the facility's EHR. Staff member D further stated it was not his expectation that the residents code status on the information bar in the facility's EHR had not matched their POLST form. During an interview on [DATE] at 4:26 p.m., staff member B stated she didn't think there was a concrete process in place for updating the EHR when a resident changed their code status on the POLST form. A review of resident #5's EHR showed her code status as, FULL (has ACP docs). A review of resident #5's POLST form, dated [DATE], showed Section A the box for No CPR was checked. A review of a facility policy titled, Do Not Resuscitate (DNR) or Full or Limited Code, with an effective date of 6/2024, showed: POLICY: Resident's wishes regarding advanced directives and resuscitation will be identified and honored . II. Written information regarding Advanced Directives is given to each resident and family/caregiver upon admission. Advanced Directives and resuscitation status are documented in the medical record

Based on interview and record review, the facility failed to safeguard a resident's personal property when items were missing or sent to laundry and not returned, for 1 (#30) of 23 sampled residents, and the resident was missing a blanket that was very important to him, which was upsetting, and related to his faith. Findings include: During an interview on 6/16/25 at 3:05 p.m., resident #30 said he was missing a blanket, probably some shirts, and the facility had not made any attempts to replace the missing items. Resident #30 stated, It (dirty laundry) goes and never comes back. Resident #30 said he was concerned about the blanket because it (the blanket) had personal meaning to him. During an interview on 6/18/25 at 8:06 a.m., staff member K said a general inventory of the resident's personal belongings was obtained during the admission process, and the inventory was in the electronic health record. Staff member K stated not every personal item was inventoried. During an interview on 6/18/25 at 9:41 a.m., resident #30 said the blanket he was missing was a Jesus blanket, it was yellow and tan in color and had been missing for several weeks. Resident #30 stated he did let a staff member know right away when he noticed it missing, and it went missing on a weekend. During an interview on 6/17/25 at 1:05 p.m., NF1 said she visits often and had seen resident #30 with the Jesus blanket many times. NF1 said resident #30 was a Catholic priest for 30 years, and the blanket meant a lot to him. During an interview on 6/18/25 at 1:08 p.m., staff member V stated when missing items are reported to her, she would let the nurse know. During an interview on 6/18/25 at 1:13 p.m., when asked about the process for missing items, staff member F, reviewed the missing items policy on her computer and stated it would warrant a call to laundry. During an interview on 6/18/25 at 1:45 p.m., staff member E stated there were reports of missing items from residents. During an interview on 6/18/25 at 1:55 p.m., NF2 stated he visited on a regular basis and recalled asking staff about the missing blanket, and staff stated it might be in laundry. NF2 stated he asked staff a second time, and staff replied they would look around. NF2 reported the staff tagged all his (the resident's) stuff and not all of it would come back from laundry. NF2 stated the missing blanket was, Very precious to him (resident #30). A request was made for a list of missing items on 6/18/25, and staff member A reported there was no list of missing items. Review of the facility's policy titled, [Facility name] Lost, Missing or Damaged Items, last revised 6/2025, showed: . III. CNA/Floor Nurse . B. The CNA/Floor Nurse completes their section of the Lost and Found Report. They must notify the Unit Manager, Social Services, Activities and Laundry of the missing item. .IV. Unit Manager . 3. The Unit Manager and Resident/family member/representative will both sign the Lost and Found Report to show that the resolution has been reached and all parties are satisfied with the resolution . C. The Unit Manager maintains a running log of the missing and damaged items on their unit .

Based on interviews and record review, the facility failed to develop a baseline care plan within 48 hours of admission that included the instructions needed to provide effective and person-centered care of the resident, and to meet professional standards of quality care, for 1 (#84) of 23 sampled residents. Findings include: Review of resident #84's face sheet reflected resident #84 admitted on [DATE]. Review of resident #84's baseline care plan, effective 3/19/25 - 4/2/25, reflected the care plan was initiated on 3/19/25, eight days after the resident's admission, and finalized on 3/24/25. During an interview on 6/18/25 at 3:00 p.m., staff member B stated she was not aware the baseline care plan was not completed within 48 hours, or why it was not done. A review of resident #84's MDS assessment, dated 3/17/25, showed the resident had impaired cognition, dementia, anxiety, frequent pain, was supervised, set up, or independent for ADL's, he displayed behaviors and was marked as having depression and anxiety. These care areas may negatively impact a resident if not addressed to the level necessary by staff prior to the Comprehensive assessment or care plan being completed. Review of the facility's policy, Initial Assessment and Development of Interdisciplinary Resident Care Plans, dated 4/2025, reflected: - 1. Admitting licensed staff completes the nursing assessment and baseline care plan upon admission. A copy of the baseline care plan is provided (to) the resident within 48 hours of admission. [sic]

Based on observation, interview, and record review, the facility failed to ensure a resident's venous statis ulcer was assessed routinely; treated promptly; and treatment orders were received and monitored routinely, to demonstrate healing and prevent discomfort for 1 (#124) of 1 sampled resident. Findings include: During an observation on 5/22/23 at 10:23 a.m., staff member S was completing routine wound care for resident #124 to her right posterior lower extremity. Resident #124 had bandages on her right foot, left foot, and left calf. During wound care resident #124 stated she had a lot of pain in the left foot and calf. During an assessment of the left foot and leg, staff member S noted bandages on the back of the resident's calf, and on her left foot, just below the great toe. The resident stated, Someone came in a couple of days ago and put the bandages on, but I do not remember who it was. Staff member S stated he would need to investigate the wounds on her left foot and calf as they were not on the resident's treatment record. Staff member S showed the surveyor a treatment sheet in the treatment book with physician orders to discontinue resident #124's right foot wound care on 5/17/23, remove wrap to the right lower extremity, and the resident may start wearing normal shoes, but no other orders for wound care were included. During an interview on 5/22/23 at 10:40 a.m., staff member S stated he attempted to locate the orders and found a wound care note showing the resident's calf wound care from 5/17/23, but the physician order was not put in system and was not on the treatment sheet for nursing to follow-up. Staff member S stated he could not locate any notes or orders for the resident's left wound. Staff member S stated he would be using the wound protocol for treatment and was calling the wound clinic to notify them of the wounds for further instruction. Staff member S stated CNAs were to verbally let nurses know of any shower skin check issues, but none were noted. During an interview on 5/22/23 at 12:15 p.m., staff member F stated, I am not the wound nurse, even if [staff member B] says I am. I am just now learning, and I follow the wound care nurse from the wound clinic around when she is here, but that does not make me the wound nurse. Staff member F stated she would look at the wounds on Thursday with the wound clinic nurse, but not until then. During an observation and interview on 5/22/23 at 12:34 p.m., staff member D stated she would contact the wound clinic nurse and schedule a phone meeting with the surveyor. The meeting with the wound clinic nurse was not scheduled as of the end of the survey. Staff member D then asked that staff member F assess the wound with the surveyor. Staff member F then assessed the wound. Resident #124 cried out in pain with the bandage removal. Staff member F stated, Looks fine to me, better then when I saw it on the 17th. During an observation and interview on 5/22/23 at 4:31 p.m., resident #124 stated she was still having significant pain in her left calf and could no longer go to activities. Staff member S stated he had not heard back from the wound clinic. Staff member D stated she would have the facility physician come to her room to evaluate the wounds. Staff member T came to resident #124's room and assessed her wounds. Resident #124 cried out in pain when her left leg was touched and when the bandage was removed. Staff member T stated he had concerns for cellulitis and with serpiginous edges and streaking up to midcalf. In addition, Staff member T stated there was early potential cellulitis with an inflammatory rash extending around a wound on the back of the heel. Staff member T stated he will be ordering antibiotics, diuretics adjustments and a venous doppler to rule out deep vein thrombosis. Staff member T asked staff member D to immediately measure the wound and mark the edges with a sharpie marker (for measuring). Staff member D stated the wound measured 13 cm x 10 cm. During an observation and interview on 5/23/23 at 9:48 a.m., resident #124 was observed to look pale, weak, and in bed. Resident #124 stated she had a really bad stomachache and leg hurts, I cannot even bear any weight on it now. Resident #124 stated she had reported the stomachache and leg pain to staff member U, and he closed her door. During an interview on 5/23/23 at 10:15 a.m., staff member U stated he had asked the physician for Zofran to help resident #124's nausea but had not been aware of her being in bed most of the morning. Staff member U stated he would immediately complete a full assessment and notify the physician of the acute changes. Review of resident #124's medical record showed the weekly bath day assessment dated [DATE], but failed to reflect the left foot and calf wounds, or the name of the staff member completing the assessment. No other bath assessments were provided upon request. Review of resident #124's interdisciplinary notes, dated 5/13/23, showed resident #124, had a sore on back of right leg, skin intact, no drainage noted, placed a Mepilex over to protect skin. Review of resident #124's interdisciplinary notes, dated 5/17/23, showed, She mentioned an area that hurt on the left LE (lower extremity). Upon inspection, noted Opti foam border dressing which was removed. Slight shadowing noted to old dressing. Wound appeared to be macerated at edges with yellow tissue present as well as red/pink tissue. Edema to LE noted. [sic] Review of the facility's physician standing orders, signed by the physician on 8/17/18, showed a wound protocol map with the statement, Obtain MD order for wound protocol and document location in the wound assessment at the top of the protocol form. Review of the facility's policy, Wound Assessment, dated 9/1997, showed documentation guidelines include location, dimensions, type of wound, description of wound, presence of tunneling, wound base condition and color, drainage, condition of surrounding skin, and signs or symptoms of infection, including edema, and erythema (redness). Facility staff failed to ensure the resident's venous statis ulcer was assessed routinely and consistently; treated promptly; and treatment orders were received; and monitored routinely.

Based on observation, interview, and record review, the facility failed to ensure a resident's nutrition status was maintained by providing the needed assistance with meals to prevent a severe weight loss for 1 (#78); and failed to provide meal assistance and interventions to prevent a significant weight loss for 1 (#59) of 3 sampled residents. Findings include: 1. During an interview on 5/23/23 at 9:07 a.m., staff member P stated resident #78 was to receive a regular diet with finger foods. Staff member P stated she met with the residents on admission. Staff member P stated she would get a physician consult for pharmacological interventions as needed. Staff member P stated she saw the resident quarterly, including family of the resident if they chose to participate. Staff member P stated she talked to staff frequently to get information. Staff member P stated the MDS coordinator was to notify the physician for weight loss. Staff member P stated she did a weekly and biweekly weight review, and documented it in the resident's medical record. Staff member P stated she would try to determine the root cause of the weight loss. Staff member P stated she participated in quarterly care conferences, and that was where she learned about the resident's weight loss. Staff member P stated there was a care conference last week for resident #78, and she met with the resident's daughter. Staff member P stated she was not sure it was a true weight loss. Staff member P stated the care plan reflected the resident ate independently. Staff member P stated the IDT was going to wait to discuss the weight loss this week. Staff member P stated the resident could benefit from assistance during meal time. Staff member P stated resident #78 was on a supplement three times daily and the resident's intake of the supplement was variable. Staff member P stated the resident was weighed every two weeks and on the days when she took a bath. During an interview on 5/23/23 at 10:15 a.m., staff member C stated she was aware resident #78 had lost weight. Staff member C stated the resident was not eating much, and needed moderate assistance to eat. Staff member C stated staff can get her to drink fluids, but she often refuses to let someone help her with eating. Staff member C stated the resident was not feeding herself anymore, and has been slowly declining within the last month. During an interview on 5/23/23 at 10:27 a.m., staff member N stated staff had noticed a change in the resident #78's eating habits in the last two months. Staff member N stated the resident had good days when she would eat, and bad days when she would not eat, and refused assistance. Staff had been assisting the resident to eat for the last two months. Staff member N stated staff had to work hard to get the resident to eat at dinner time. Review of resident #78's Weight Tracking System Report showed the resident weighed 128.20 lbs. on 4/13/23 and 115.80 lbs. on 5/11/23, which showed a severe weight loss of 9.67% in one month. The facility did not provide requested current nutritional documentation addressing the resident's weight loss. Review of resident #78's care plan for Nutritional Status, dated 5/17/23, showed the resident needed 1:1 assistance during meal times. The care plan did not show the resident had a severe weight loss or implementation of additional interventions to prevent any further weight loss. 33796 2. During an observation and interview on 5/21/23 at 12:15 p.m., resident #59 received a bowl of corn bisque soup for lunch. She did not eat the soup, and staff members M and V did not offer her other foods or provide assistance. Staff were not sure why she received soup and not the regular meal. During an observation on 5/22/23 at 12:30 p.m., resident #59 received a bowl of thin and oily french onion soup. Staff were not sure why she only got soup for lunch. She sat slumped to the right in her chair, did not eat any soup, and received no assistance or food choices. She was taken back to her room at 1:40 p.m., without eating. Review of resident #59's Quarterly MDS, with the ARD of 11/12/22 showed a weight of 120 pounds. Review of resident #59's Quarterly MDS, with the ARD of 2/20/23, showed a weight of 104 pounds, which was a weight loss of 13 percent in 3 months, and a severe weight loss. During an interview on 5/22/23 at 10:16 a.m., resident #59 was unable to answer questions regarding her meal preferences due to limited cognition and hearing. During an interview on 5/23/23 at 4:20 p.m., staff member P stated the 120 pound weight recorded on resident #59's MDS in November was an error. She stated the resident did experience a ten percent weight loss in six months. Staff member P was not able to explain the cause of resident #59's weight loss. She stated the resident was on 'comfort measures,' and the family was happy with the meals provided, and with no other interventions to prevent weight loss. She did not state the family or resident were offered additional food intervention options for weight loss prevention.

Based on observation, interview, and record review, the facility failed to ensure transmission-based precautions were implemented for residents with an unknown vaccination status, or unvaccinated residents when they were admitted to the facility, and residents were then diagnosed with COVID-19, for 2 (#s 405 and 406) and; a hospitalization was necessary for 1 (#405) after the resident developed a cough and complained of a burning in his chest, of 9 sampled residents; and the potential spread of COVID-19 from the lack of implementation of transmission-based precautions for other residents residing on the same unit, and failed to implement transmission-based precautions for 1 (#90) of 1 sampled resident. IMMEDIATE JEOPARDY On 5/22/22 at 4:45 p.m., the facility management team was notified that an Immediate Jeopardy existed in the area of F880. The Severity and Scope identified for the Immediate Jeopardy was identified to be at the level of a J, and upon removal of immediacy, lowered to a G. Findings include: 1. During an interview on 5/22/22 at 9:01 a.m., staff member Q stated resident #405 was admitted to the hospital, yesterday. During an interview on 5/22/22 at 12:16 p.m., staff member D stated resident #405 started complaining of burning in his lungs, so the staff performed a rapid test and the results showed there was a faint positive line and then they confirmed the test with a PCR test. Review of resident #405's Interdisciplinary Notes, showed the following: - On 5/12/22, the resident was admitted with a diagnosis of right arm cellulitis, post end colostomy following a diverticuli perforation, and a left ankle fracture. - On 5/21/22, [Resident #405] was coughing this am while pulling am meds. He also voiced that his chest felt like it was burning when breathing. No SOB. Vitals are WNL at this time. Rapid test collected, positive results. Called [staff member Q], directed to collect NP swab and send to lab for PCR. Lab collected. Results positive [sic]. Physician was notified and orders were obtained to send resident #405 out to hospital per the resident's request. Review of resident #405's Lab Results, showed the following: - On 5/12/22 the resident tested negative for COVID-19. - On 5/21/22 the resident tested positive for COVID-19. Review of resident #405's Admission Assessment, dated 5/12/22, did not show the resident's vaccination status for COVID-19. Review of the facility's untitled spreadsheet for the facility's resident's Covid-19 Vaccination Statuses, undated, showed, has none for resident #405. Review of resident #405's Discharge Summary, dated 5/21/22, showed the following: - A discharge diagnosis of COVID-19 lung infection. - . So, he has diagnosis of COVID-19 infection, pulmonary, rule out pneumonia, exacerbation of interstitial fibrosis, exacerbation of chronic hypoxic respiratory failure and all the diagnoses as noted above. He had a PCR positive. Recommendation to transfer to negative airflow room at [Hospital] .He is discharged stable, but I am concerned going to be much worse condition. He will be sent over there when the negative airflow room comes to fruition, and I have dictated the discharge summary and talked to the patient. [sic] - A physical examination, showed, LUNGS: So, he started having symptoms of COVID-19 and on exam he has diffuse rales, diminished breath sounds in both bases .VITAL SIGNS: He has 99.9, pulse is up to 100, he is breathing at 24, O2 is at 4 L. Review of resident #405's Infection Control Care plan, dated 5/12/22, showed the following: - An identified problem as COVID. Goal of, [Resident #405] will remain free from infection while at Grandview. - Staff will take the resident's temperature twice daily and report to nursing when temperature is elevated per CDC/CMS guidelines. - Staff to monitor for signs and symptoms of upper respiratory infections. Staff to notify resource nurse if symptomatic. - Staff are to report changes to physicians and obtain orders as indicated. - Nursing to place [resident #405] into defined Enhanced Precautions when admitted or leaving facility for outside appointment during their stay as indicated. - [Resident #405] may eat in the dining room using current definded [sic] parameters. - Staff to provide life enrichment activities in a communal setting using current defined parameters. - [Resident #405] will be encouraged to wear masks at all times outside of his room. Review of resident #405's History and Physical, dated 5/16/22, failed to show his vaccination status for COVID-19. Review of the facility policy, Senior Services Pandemic Protocol (COVID-19), revised date of 11/21/21, showed: -V. Covid Cases in the Facility, A. Thing's facilities should do when there are COVID-19 Cases in their facility or sustained transmission in the community . Recommended PPE includes: a. Respirator/Facemask ., b. Eye protection, c. Gloves, d. Gowns, e. If there are cases in the facility restrict Resident/Patients (to the extent possible) to their rooms except for medically necessary purposes . - The policy failed to address the vaccination status for residents and/or staff. - The policy failed to address a new admission process for residents who have an unknown or unvaccinated status. Review of the facility's untitled spreadsheet for COVID-19 Vaccination Statuses, undated, showed: - There were three residents that were either unvaccinated or had an unknown vaccination status. Two of those three residents tested positive for COVID-19 on 5/21/22. -There were nine residents who had resided on the 500 wing. -There was one partially vaccinated resident that had discharged , prior to the survey, on 5/21/22. According to CDC guidelines, updated 2/2/22, showed, Empiric use of Transmission-Based Precautions (quarantine) is recommended for residents who are newly admitted to the facility and for residents who have had close contact with someone with SARS-CoV-2 infection if they are not up to date with all recommended COVID-19 vaccine doses. Reference: Centers for Disease Control and Prevention, Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Home, posted 2/2/22, found at https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html#anchor_1631031062858, accessed on 5/24/22. 2. During an observation on 5/22/22 at 9:03 a.m., there was a transmission-based precaution supply cart outside of resident #406's room. On the cart was a face shield with initials written on it, touching the clean gowns on the cart ,and another face shield was also leaning up against the new face shield box. There were gloves, hair covers, and booties on the lower shelves. There was a garbage can in front of the supply cart. There were no Sani-cloth wipes or N95 masks on the cart. During an interview on 5/21/22 at 3:17 p.m., staff member Q stated the facility had one resident positive for COVID-19, resident #406. He said the doctor had ordered a new medication for the new strain of COVID-19 the resident had. During an observation on 5/22/22 at 8:16 a.m., staff member Q was wearing his N95 mask strapped to the back of his arm above his elbow. During an observation and interview on 5/22/22 at 8:53 a.m., next to resident #406's transmission-based precaution supply cart, there was a garbage can in front of the cart and on a cabinet were a face shield, booties, and hair covers. Staff member Q stated those should be thrown away and must be extras, referring to the supplies on top of the cabinet. During an observation on 5/22/22 at 8:57 a.m., there was one certified nursing assistant and one nurse on the 500 wing who were wearing a surgical mask over the top of their N95 masks. No eye protection was being utilized. During an observation and interview on 5/22/22 at 9:11 a.m., staff member R stated he wore a face shield, an N95 mask, and a surgical mask when entering resident #406's room and wore an N95 mask and a surgical mask when going into other resident rooms. He said he does not wear a face shield when caring for other residents. Staff member R stated when leaving resident #406's room, he did not change either of his masks after providing care to resident #406. He stated it was not required to do so because he was adding the face shield and other personal protective equipment when entering resident #406's room. Staff member R said when leaving resident #406's room he took off all of the personal protective equipment except his masks (both N95 and surgical) and booties, in the resident's room. Staff member R stated he carried the personal protective equipment, which was removed in resident #406's room, out to the garbage can next to the personal protective equipment supply cart in the hallway. Staff member R stated he then disposed of the soiled personal protective equipment, including the booties, in the garbage. The garbage can sat in the hallway, in close proximity to another resident's room. The resident in the adjacent room was sitting in a recliner close to the door, with her door open. During an interview on 5/22/22 at 9:40 a.m., staff member Q stated staff members were to wear face shields during patient care. During an interview on 5/22/22 at 12:16 p.m., Staff member D stated they did not have a personal protective equipment shortage. She said the expectation for personal protective equipment when caring for residents who are COVID-19 positive were airborne contact room, N95 mask, gloves, and a face shield. Staff member D stated in a COVID-19 positive area staff should be wearing N95 masks and simple masks into other resident rooms, including hallways on a positive unit. She stated the individual expectation for donning and doffing was donning before you went into the room and doffing before you left the room. The garbage can should have been right inside the room because staff should not have been leaving the room with the soiled personal protective equipment on. She stated double masking was a personal choice and staff had been coached that it was not a requirement, but staff should have been changing them with every positive room or any other isolation room. Staff member D stated they had a machine for when they were reusing N95 masks that would disinfect them, but it was not needed at that time as they had plenty of masks. Staff member D stated they then started to test other residents and staff members. She said no staff members had tested positive for COVID-19. Staff member B stated the vaccination percentage for residents residing in the cottages continuously changed because of the short stays and were working on the getting the residents up to date on their boosters. Staff member D stated if new admissions were not vaccinated then they would be in quarantine, and staff would wear simple/surgical masks, and no other PPE would be required when caring for those residents. Staff member D stated staff education was completed on the spot through reminders on the job. Staff member D stated the facility also had an educator who conducted PPE and handwashing audits. She stated staff education was completed yesterday morning (5/21/22). She said the facility protected other residents by isolating residents to their rooms, staff wore proper PPE, and not having communal meals. She stated surveillance for COVID-19 was vitals that were captured twice a shift, and employee screenings upon the start of their shifts. Staff member D stated N95 masks should not be stored on arms at any time, should be discarded after use, and face shields should be sanitized with the purple wipes. She said signage for precautions should be on the back of the resident's door. During an observation on 5/23/22 at 8:24 a.m., staff member S came out of resident #406's room and left the door open while putting on a new N95 mask, face shield, and gloves. Staff member S stood halfway in and out of resident #406's room, grabbed a glass out of the room, shut the door at 8:25 a.m., and went to the kitchen with all of her PPE on. During an interview on 5/23/22 at 8:27 a.m., staff member S stated resident #406 was symptomatic and was tested [for COVID-19] on Saturday. She stated he seemed to be doing okay with no complaints or shortness of breath. She stated she went back into the room to take something out of it but did not immerse herself in the room, so she did not need new PPE. She stated she had training on infection control and transmission-based precautions for COVID-19 in the last few months and as mandatory. During an interview on 5/23/22 at 8:33 a.m., staff member Q stated the unit did not have any negative air pressure rooms. During an observation on 5/23/22 at 8:33 a.m., staff member T was sitting on the 400 hall with an N95 around her neck, dangling in front of her face with a surgical mask in place over her nose and mouth. During an interview on 5/23/22 at 8:39 a.m., staff member T stated she should not have had the N95 dangling on her neck like that. She had been on the 500 hall. She stated that if you go through the door of a covid positive resident you should change your personal protective equipment. Review of resident #406's Interdisciplinary Notes, showed the following: - On 5/13/22, resident #406 was admitted to the facility with diagnosis of sepsis, falls, and cholecystectomy. - On 5/19/22, resident #406 had complaints of an upset stomach and loose stools. - On 5/21/22, resident #406 had two positive COVID-19 tests. Review of resident #406's History and Physical, dated 5/16/22, failed to show the resident's vaccination status for COVID-19. Review of resident #406's Admission Assessment, dated 5/13/22, failed to show the resident's vaccination status for COVID-19. Review of resident #406's Lab Results for COVID-19, showed: - On 5/7/22 the resident's COVID-19 test was negative. - On 5/13/22 the resident's COVID-19 test was negative. - On 5/21/22 the resident's COVID-19 test was positive. Review of the facility's untitled spreadsheet for the facility's resident's COVID-19 vaccination statuses, undated, was blank for resident #406 other than a date of birth. Review of resident #406's Physician Progress Note, dated 5/21/22, showed, a diagnosis of COVID-19. Review of resident #406's Infection Control Care Plan, dated 5/13/22, showed: - An identified problem as COVID. Goal of, [Resident #406] will remain free from infection while at Grandview. - Staff were to take the resident's temperature twice daily and report to nursing when the temperature was elevated per CDC/CMS guidelines. - Staff were to monitor for signs and symptoms of upper respiratory infections. Staff were to notify resource nurse if symptomatic. - Staff were to report changes to physicians and obtain orders as indicated. - Nursing to place [resident #406] into defined Enhanced Precautions when admitted or leaving facility for outside appointment during their stay as indicated. - [Resident #406] may eat in the dining room using current definded [sic] parameters. - Staff to provide life enrichment activities in a communal setting using current defined parameters. - [Resident #406] will be encouraged to wear masks at all times outside of his room. Review of the facility policy, Guidelines for Isolation Precautions, with a revision dated of 2/2022, showed: - III. Airborne Precautions, In addition to Standard precautions, use Airborne Precautions for patients known or suspected to be infected with microorganisms transmitted by airborne droplet nuclei. Organisms falling into this category include . Sars CoV2 (COVID-19) . A. Patient Placement 1. Place Patient in a designated negative pressure room. 2. Keep the room door closed and the patient in the room . B. Personal Protective Equipment: (N95 respirator or PAPR respirator) 1. Employees are to wear an N-95 particulate air respirator or a purified air particulate respirator (PAPR) when entering the room of a patient with known or suspected pulmonary tuberculosis. Remove respirator and dispose of in a waste receptacle after leaving the patients room. - . B. Personal Protective Equipment: (mask) 1. Wear a mask when entering the room of the patient/resident . 4. Remove mask and dispose of in waste receptacle when leaving the patients room. 5. Masks are one time use only, must be discarded before leaving a patient's a room and a new one used before entering . - V. Contact Precautions . Conditions requiring contact isolation . Sars CoV 2 (COVID-19) . 32997 3. During an observation and interview on 5/22/22 at 8:02 a.m., a red stop sign was on the door of resident #90's room. The resident was in bed. Resident #90 asked where her breakfast was. A certified nurse aide entered resident #90's room. The staff member was not observed to take any infection prevention precautions before entering the resident's room. During an interview on 5/22/22 at 8:59 a.m., staff member O said since resident #90 was on isolation precautions she would be eating breakfast in her room. Staff member O did not know what infection control precautions were required for resident #90. During an interview on 5/22/22 at 12:30 p.m., staff member N said resident #90 had MRSA (Methicillin-resistant Staphylococcus Aureus) in a wound. Staff member N said resident #90 was on contact precautions. The staff member said all staff were required to use full PPE (personal protective equipment) when in resident #90's room. Staff member N said the unit had just found out about the MRSA this morning. The staff member said resident #90's wound was cultured at the wound care clinic, but she was not sure of the date. Staff member N said the PPE would be found, in hanging bags, on the back of the resident's door. The staff member said no cart or other items would be placed in the hallway in order to protect the resident's privacy. During an observation on 5/22/22 at 3:31 p.m., the hallway around resident #90's room was clear of carts, tables, or other objects used for storage. During an observation on 5/23/22 at 7: 33 a.m., a plastic three drawer cart was outside resident #90's room. During an observation on 5/24/22 at 7:55 a.m., staff member P removed PPE from the cart outside resident #90's room. During an interview on 5/24/22 at 8:07 a.m., staff member P said resident #90 had MRSA in a wound and the resident was on precautions. Staff member P said the PPE cart was placed outside resident #90's room the other day. Review of a labortory report for resident #90, collected on 5/17/22, showed the culture was verified as positive for MRSA on 5/20/22.

Based on observations, interview, and record review, the facility failed to implement on-going interventions attempting to prevent 10 falls, one with a fracture, for 1 (#34); and failed to identify and assess the needs of a morbidly obese resident, and prevent a fall with fracture for 1 (#69) for 6 sampled and supplemental residents. Findings include: 1. During an observation on 5/12/21 at 3:06 p.m., resident #34 was in bed. The resident had regular socks on, and the fall mat was propped against the wall. Review of resident #34's Care Plan, dated 3/17/21, showed staff were to assist the resident with wearing non-skid footwear. Review of resident #34's Risk Manager Worksheets showed the resident fell 10 times from 12/07/20 through 5/3/21. Falls included: 12/7/20 - The resident was attempting to get out of bed, and his feet slid on the floor, and he fell . He had bare feet, and the bed alarm was ringing. 12/11/20 - The resident was found on the floor trying to transfer from his wheelchair to his bed. He did not use his call light. 1/11/21 - The resident was found on the floor in his bathroom. 1/14/21 - The resident was found on the floor. He had a laceration to the left side of his face, close to his eye, and was sent to the emergency room . 1/21/21 - Staff observed the resident slide from his bed onto the floor. The bed alarm was not connected, and there was no fall mat in place. The note did not indicate the facility followed up with staff regarding the bed alarm and fall mat not in place. 2/6/21 - The resident was found on the floor. He was educated on calling and waiting for help. 1/30/21 - The resident was found on the floor in his room. He stated his walker tipped over. 2/14/21 - The resident was found on the floor sitting on the fall mat. Resident is reminded to call for help when he needs to transfer but he does not. 2/17/21 - The resident fell face first out of his wheelchair when staff was wheeling the resident to a doctor appointment. Pt. acquired trauma to nose post fall. Staff educated on all transferring [sic] pt in wheelchair with footrest on. 5/3/21 - Resident ambulating fast around unit agitated and upset, refused assistance from staff, tripped over own feet in room. Review of resident #34's Risk Manager Worksheets did not include investigations for root cause or new fall interventions to prevent further falls. During an interview on 5/12/21 at 2:08 p.m., staff member M stated the facility had recently started Staff Fall Huddles to determine what interventions might be implemented, but the facility had not initiated this process prior to resident #34's falls. She stated the fall huddle would look at interventions and causes for each fall. Staff member M did not recall the date the staff huddles had begun. During an interview on 5/13/21 at 9:09 a.m., staff member BB stated he was pushing resident #34 down to the second floor after a doctor appointment, and the wheelchair did not have foot pedals. Staff member BB stated the resident's feet must have hit the ground, and he fell face first out of the wheelchair. Staff member BB said the resident was ready to go when he picked him up, and staff member BB did not notice the lack of foot pedals. He stated there probably was a policy for using footrests during transportation. During an interview and observation on 5/13/21 at 9:40 a.m., resident #34 stated as soon as his feet hit the carpet, they stuck and he fell face first out of the wheelchair. He stated he had currently not fallen in a month because he was getting stronger. He was able to walk out of the bathroom independently. Review of resident #34's physicians note, dated 2/17/21, showed the patient has been having some difficulties with unavoidable falls. The patient did have to be briefly hospitalized [DATE] for head trauma on anticoagulation. Resident #34 had an emergency room visit two days later, for another fall and left elbow injury. The patient is seen in his wheelchair. His nose is swollen. IMPRESSION: Nasal fracture, nondisplaced. I do want him however set up for hip protectors and especially a helmet, the helmet of all things to try to protect him for head injury and brain bleed. We will also need staff instructions to avoid further injurious falls, try to get going with an up-step in fall prevention . Review of resident #34's Care Plan for falls, dated 3/7/21, showed one new approach, dated 4/28/21 for adding the foot pedals to wheelchair for all appointments and outings. The fall out of the wheelchair occurred 2/17/21. The Care Plan included a move to a larger room in the dining room where more staff could keep an eye on him. Resident #34's Care Plan did not include the bed alarm or the fall mat. No other interventions to prevent falls were implemented on the care plan, after resident #34 had experienced 10 falls. 2. During an interview on 5/11/21 at 12:04 p.m., resident #69 said she had been admitted to the hospital, in November of 2020, because she was falling a lot at home, and she had a lot of back pain. She said she was doing pretty good at the hospital getting stronger. She said the decision was made for her to be admitted to long term care for further therapy. Resident #69 said she came to the long- term care unit the beginning of December 2020. She said, Even though I came from 'their' hospital I had to stay in my room for Covid isolation. Resident #69 said she was in the facility a couple of days, and she wanted a shower. Staff told her she could not shower in the shower room because she was still on isolation precautions. She said she had started working with the therapy department. The resident said her therapy guy told her he could make some adaptations to her in-room shower, so she could shower there. Resident #69 said the therapy guy put some rails and some type of chair in the shower stall. She said she got ready to get in the shower, and the therapist was helping her. She said she was concerned because the therapist was not a very big guy, and she said I'm a big woman. The resident said she got in the shower stall, sat on the bench, and the therapist turned the water on. She said the therapist encouraged her to stand up using the rails to support and balance herself. The resident said, I told him I was going down, I'm going down, and he said let's try this and let's try that meaning different ways to sit back on the bench or for him to give her more support. The resident said it was impossible as the shower stall was way too small. She said the therapy guy tried to lower me to the floor, but that did not work out very well. She said she was sitting on the floor of the shower stall, and the therapy guy and a couple of other staff, were trying to get her out of the stall. She said they could not get her out, and she had to scoot out backward using her feet to push herself out. The resident said it took three people and a lift to get her off the floor. The resident said she was pretty embarrassed about the whole thing. Resident #69 said she continued with therapy, but her leg pain was getting really bad, and she could not do many of her exercises. She said, Finally they sent me out for an x-ray, and I had a broken ankle. During an observation on 5/13/21 at 8:23 a.m., of resident #69's in-room shower stall, showed the shower contained a built-in 15 inch by 10 inch seat in the corner of the stall. The available floor space of the in-room shower stall measured 35 inches wide by 25 inches deep with the built-in seat taking up a portion of that measured floor space. Review of resident #69's Daily Care Plan, not dated, showed: - Diagnosis/History: Severe lumbar stenosis w/bilat paresthesias, [CONDITION(S)] . , - Other: Teds, Grip socks when transfering [sic], - Transfer/Ambulation: Hoyer, - Bed Mobility: Assist x2, and - Miscellaneous: Therapy to use speciality [sic] walker. Review of resident #69's hospital discharge orders, signed 12/8/2020, showed: - Diagnosis/Procedure: Severe lumbar stenosis with bilateral parathesias [sic], and [CONDITION(S)], - Activity: as tolerated, - Therapy Orders: Physical Therapy Eval and Treat: Yes, Occupational Therapy Eval and Treat: Yes, - Therapies: Physical Therapy: Sit<>stand x2, SBA (stand by assist), cues for anterior wt. (weight) shift and, Occupational Therapy: Cont. OT POC (plan of care). Review of resident #69's occupational therapy treatment encounter note, dated 12/10/2020, showed: - Precautions/Contraindications: Fall Risk, - Reason for referral: . admitted for severe spinal stenosis w/BLE paraesthesis [sic], - : . Seated on edge of TTB (tub transfer bench) pt (patient) began to slip forward. Unable to reposition secondary to pt's weight. Required [NAME] (maximum assistance) to lower to floor. Assist x3 and Hoyer lift required for fall recovery. Pt report of R (right) ankle being twisted in fall and pain, and - Complexities: Complexities/Barriers Impacting Session: Obesity. Review of resident #69's History and Physical, dated 12/14/2020, showed: - History of Present Illness: She is a [AGE] year old resident of the [facility name] who has a past medical history of hypertension, anxiety, depression, was admitted to the TCU at [facility name] for increased weakness. She was just newly diagnosed with severe lumbar stenosis and bilateral paresthesias., and - Diagnoses: 1. Lumbar spinal stenosis as noted above with bilateral paresthesias, recurrent falls. 2. Depression. 3. Obesity. 4. Hypertension. 5. Lumbar spondylosis, moderate to severe canal stenosis, L2-L3, L4-L5, and severe canal stenosis L3-4. Review of resident #69's Admission Minimum Data Set, with an assessment reference date of 12/14/2020, Section J showed the resident had a fall with major injury (bone fractures, joint dislocations, .) since her admission on 12/08/2020, Section K showed the resident's weight was 297 pounds. Review of resident #69's physician's progress note, dated 12/22/2020, showed: - [Facility name] Skilled Nursing Facility Progress Note: The patient, 59, is known to have lumbar spinal stenosis with bilateral paresthesia and recurrent falls, depression, [CONDITION(S)], hypertension . The patient is not deemed a surgical candidate due to her [CONDITION(S)]. The patient, unfortunately, had a setback. Had another fall in the shower. This time she avoided landing on her knees like she did at home, but she twisted the left ankle. This happened a week ago. Continued to have ankle pain, so I was requested to see the patient. The patient is resting in a recliner. She is morbidly above ideal weight. and, - Plan: I am going to get a left ankle x-ray as I think it would be important to make sure there is no occult injury. With her reduced sensation, it could be possible to miss a fracture, so we are going to get an x-ray and go from there. Review of resident #69's physician's telephone orders showed the following: - 12/22/2020 (L) ankle xray Dx: (L) ankle injury, fall in shower. - 12/23/2020 CT scan left ankle. Walking boot- velcro- AAT (activity as tolerated). - 12/23/2020 Non wt (weight) bearing until CT scan on 12/29. - 12/29/2020 May weight bear as tolerated. Try 6 ace wrap ankle for comfort. Review of a facility document for resident #69 titled, Physician Visit Record, dated 12/29/20, showed: - Nurse's Communication: Reason for Visit: Lt ankle fx r/t fall. The facility's investigation report related to resident #69's fall on 12/10/2020 was requested on 5/12/2021 at 3:45 p.m., The facility did not provide the requested information prior to the survey team's exit on 5/13/2021 at 11:30 a.m. Staff member B was told the information could be faxed to the provided fax number. The requested information had not been provided via fax.

Based on observation, interview, and record review, the facility failed to provide 1 (#2) of 6 sampled residents with the necessary respiratory equipment on admission, to include ongoing respiratory services and monitoring, and a staff member failed to follow the physician order [REDACTED]. Review of resident #2's discharge orders from the hospital to the skilled nursing facility, dated 12/23/19, showed the resident had [DIAGNOSES REDACTED]. The discharge orders also showed the resident was to receive 3L (liters) of oxygen continuously and was to use a Bi-PAP (bilevel positive airway pressure) machine at bedtime with an 8/4 pressure setting. The resident was admitted to the skilled nursing facility on 12/23/19. Review of resident #2's baseline care plan, dated 12/23/19, showed the resident was to have a C-PAP 3L O2 bleed. The baseline care plan was updated on 1/21/2020 and showed resident #2 was to have a Bi-PAP- 3L O2 bleed. Review of resident #2's interdisciplinary notes, dated 12/26/19, showed Weras (sic) oxygen at 3L/min via nasal cannula except at hs res. (sic) wears [MEDICAL CONDITION] ans (sic) oxygen is fed into [MEDICAL CONDITION] machine. Review of resident #2's history and physical, dated 12/27/19, showed [DIAGNOSES REDACTED]. Review of resident #2's TAR (treatment administration record), dated 12/2019, failed to show documentation of the use of a Bi-PAP. The TAR showed, [MEDICAL CONDITION] on QHS through night which was documented starting on 12/24/19. During an interview on 2/4/2020 at 11:20 a.m., staff member B said resident #2 did not have a Bi-PAP or C-PAP her first night in the facility. She said the resident's son brought in the resident's C-PAP from her home on 12/24/19. Staff member B said there was confusion with the nurses on the differences between a Bi-PAP and a C-PAP. She said the nurses thought they were basically the same thing. Resident #2's nursing progress notes did not show she was monitored through the night on 12/23/19 when she did not have her C-PAP. Review of a facility document, dated 1/21/2020, showed a respiratory care service came to the facility and provided training on the use and care of Bi-PAPs and C-PAPs for nine nursing staff. Review of resident #2's TAR (treatment administration record), dated 1/2020, showed [MEDICAL CONDITION] @ HS c O2 hooked in. The TAR was not signed off for 6 of 31 days, January 1, 2020 to January 31, 2020. The TAR was signed off for 1/14/2020, but as noted in the event report on 1/16/2020, for the event on 1/15/2020, the med aide failed to make sure the O2 was bled into resident #2 C-PAP. Review of resident #2's interdisciplinary note, dated 1/15/2020 at 8:30 a.m., showed the resident's [MEDICAL CONDITION] did not have the O2 bled in during the night and she (night nurse) had been in the room d/t (resident name) being restless and SOB (short of breath) just prior to report. SaO2 reportedly in the 70s. The note also showed This nurse was called into the room to check on her (resident) by the other RN. Noted that the O2 tubing had been placed in nares incorrectly, placed correctly and sat (the resident) more upright in bed. SaO2 went from 78% to 86-88%. The physician was notified of the situation with the resident. The note also showed the [MEDICAL CONDITION] was placed back on the resident by the nursing specialist with O2 initially at 6L, B/P 136/78, pulse 97, SaO2 97%, breathing unlabored. Review of resident #2's interdisciplinary note, dated 1/16/2020 at 2:42 a.m., with the event date of 1/15/2020, showed pt (sic) on 3lpm via nc during day, [MEDICAL CONDITION] 3 lpm bleed at night. per (sic) shift report hs med aide told cna she would put [MEDICAL CONDITION] on after hs breathing tx. [MEDICAL CONDITION] (sic) on without 3lpm bleed. cna (sic) reported to noc rn that pt was sob. assessed (sic) pt and found [MEDICAL CONDITION] w/o bleed in. corrected (sic) with improvement of sx. At 0445 (4:45 a.m.) same shift cna #2 reported pt sob with transfer from bed to bedside commode. nc (sic) in place but not hooked up to wall O2. SaO2 75%. Replaced to wall O2 /c SaO2 improving to baseline 92%. Pt appeared symptomatic with [MEDICAL CONDITION]. Returned to bed, breathing treatment given but with persistent increased work of breathing. Periorbital [MEDICAL CONDITION] noted worsening since midnight noted. Report given to day shift nurses at this time, orders received for [MEDICATION NAME] and [MEDICAL CONDITION]. Review of resident #2's interdisciplinary note, dated 1/16/2020 at 2:44 a.m., showed the resident's son was at the facility. The nurse offered to make a sign for the wall to remind staff to make sure the correct tubing was hooked to the wall O2 and the LPNs/RNs are to transition [MEDICAL CONDITION]<>NC. The resident's son understood and agreed. Review of resident #2's interdisciplinary note, dated 1/17/2020 at 10:41 a.m., a social services note, showed the resident had experienced increased fatigue and was not performing as well in therapies. The note also showed It was during this time that (resident name) had an incident where she was not receiving the proper oxygen therapy which was causing difficult breathing and anxiety. Review of resident #2's interdisciplinary note, dated 1/17/2020 at 11:43 a.m., showed (Resident name) is being watched for a significant change d/t a change in status. Therapy has noticed a decline when working with her. Review of resident #2's interdisciplinary note, dated 1/17/2020 at 4:52 p.m , showed Labs drawn at 4:00 p.m. by lab tech per DR. order r/t possible stroke. Review of resident #2's interdisciplinary note, dated 1/17/2020 at 4:53 p.m., showed Res. (sic) went to East campus at 15:00 (3:00 p.m.) for CT scan of head per Dr. order r/t (R) side facial drooping. Res. went in her w/c by nonemergent transport with ss worker accompanying. Res. (sic) returned at 16:15 (4:15 p.m.). Review of resident #2's interdisciplinary note, dated 1/17/2020 at 8:58 p.m., showed Unsteady and much too weak to ambulate, wheeled by staff to & from supper. Needing asst. (sic) to eat supper, very weak although interdisciplinary notes, dated 12/25/19, showed Able to feed self with setup . Transfers with one assist. Review of resident #2's interdisciplinary note dated 1/17/2020 at 10:48 p.m., showed Tried to assist (resident name) to bathroom, she was too weak to stand. Review of resident #2's physician progress notes [REDACTED]. The physician noted I did check back in prior notes and there was no real reference to any prior right facial drooping, so this does appear to be new and family expressed concerned (sic). The physician's impression was Hypoxic episode related to obstructive sleep apnea. His plan was to order a CT of the head and to compare it the head CT she had on 12/10/19 which had showed no acute findings. Review of resident #2's CT radiology report, dated 1/17/2020, showed a small area of infarction in the posterior left frontal lobe likely subacute to chronic. Review of resident #2's interdisciplinary note, dated 1/22/2020 at 7:41 a.m., showed the nursing specialist brought up a (hospital name) Bi-PAP. The Bi-PAP machine was set to 8/4 setting per the admission order. The settings were confirmed with the charge respiratory therapist who said the settings were accurate. Review of resident #2's physician progress notes [REDACTED]. Small posterior left frontal stroke coincident with hypoxic episode in mid January. During an observation on 2/4/2020 at 11:15 a.m., a Bi-PAP machine was set up on a table beside resident #2's bed. During an interview on 2/4/2020 at 11:20 a.m., staff member B said the facility did not supply residents with items like C-PAP or Bi-PAP machines. She said it was the facility's policy the resident would have someone bring their equipment from home. Staff member B said the physician had been notified the resident did not have a Bi-PAP. Documentation of this notification to the physician was requested from the facility on 2/4/2020, it was not provided by the end of the survey. During an interview on 2/4/2020 at 11:20 a.m., staff member B said there was confusion among the nursing staff on the differences between a Bi-PAP and a C-PAP. She said the nurses thought they were basically the same thing. Review of a facility document, dated 1/21/2020, showed respiratory care services came to the facility and provided training on the use and care of Bi-PAPs and C-PAPs for nine nursing staff. During an interview on 2/4/2020 at 1:30 p.m., with staff members A and C, staff member A said resident #2's physician told the facility that the hypoxic event suffered by resident #2 more than likely caused the infarction in the posterior left frontal lobe of her brain. Staff member A said staff member B misspoke and the facility did not have a policy stating residents were to bring in their equipment from home. Staff member C said it was more like a past practice. Staff member C said the facility did not supply their residents with physician ordered C-PAPs/Bi-PAPs.

Based on observation, interview, and record review, the facility failed to prevent and evaluate the cause of an avoidable, Unstageable pressure ulcer to the left heel, that led to the development of an additional Unstageable pressure ulcer to the right heel, and a reoccurring one to the left buttock, for a resident that was at high risk for pressure ulcers for 1(#1) of 42 sampled residents. Findings include: During an observation and interview on 7/8/19 at 1:54 p.m., resident #1 was sitting in her recliner with her heels resting on the bar to her side table. No interventions were noted to be place at the time for the prevention of pressure ulcers. Resident #1 stated her pressure wounds were from spending too much time in bed. During an interview on 7/10/19 at 2:29 p.m., staff member G stated the interventions for resident #1's pressure ulcers was heel lift boots, off loading heels, and a pillow to float heels. Staff member G stated resident #1 received [MEDICATION NAME] cream on her buttocks every shift and with toileting. Resident #1's heels were painted with [MEDICATION NAME] twice daily. During an observation on 7/11/19 at 10:07 a.m., resident #1 was sitting in her recliner, with both her heels resting on the floor, without a protective boot. Resident #1 was not sitting on a pressure relieving cushion in her recliner. During an observation and interview on 7/11/19 at 10:09 a.m., staff members G and I performed wound care with resident #1. Staff members treated resident #1's sacral wound, which staff member I stated was an Unstageable pressure ulcer, measuring 2.7 cm x 3.2 cm. Staff member I stated resident #1 tends to sit in her recliner often and should be using a pressure relieving seat cushion at all times. Staff member I then noted resident #1's seat cushion was in resident #1's wheelchair, not in her recliner. Staff members G and I were unable to explain how the pressure area had developed. Next, staff members G and I observed the wound on resident #1's left heel. Staff member I stated that the wound was a resolving blister, but since the bed of the wound could not be observed, it was diagnosed as an Unstageable pressure ulcer. Staff member G stated the measurements of the wound were 2.3 cm x 1.9 cm. The wound was a dark red/light brown color, with slight bogginess in the middle. Staff members I and G stated that resident #1 should always wear heel lift boots to help relieve pressure, except when ambulating. Staff members G and I then stated resident #1 also had a pressure ulcer on her right heel. Upon observing resident #1's right heel, staff members G and I stated this was also an Unstageable pressure ulcer with measurements of 1.9 cm x 1.8 cm. Staff members I and G were unable to verbalize the factors that led to the development of the pressure ulcer on resident #1's bilateral heels. After treating resident #1's right heel with [MEDICATION NAME], staff members G and I assisted resident #1 back to her recliner, lifted her heels on the foot rest of the recliner, applied foam boots to both heels, and positioned a pillow under resident #1's feet. During an interview on 7/11/19 at 8:57 a.m., staff member F stated resident #1 had a pressure sore on her left heel and did not recall how she got it. Staff member F stated resident #1 wanted pillows under her legs, and she had booties. Staff member F stated the other day resident #1 did not want her heels to touch the bed. Staff F did not mention using a care plan to know interventions are used for resident #1's pressure ulcers. During an interview on 7/11/19 at 8:58 a.m., staff member H stated she did not know how resident #1 had developed a pressure sore on her left heel, but the first time it was noted was on 7/4/19. During an interview on 7/11/19 at 9:26 a.m., staff member G stated the treatment order for resident #1 included: treating a left heel pressure ulcer with [MEDICATION NAME] and keeping the heel in a boot; and monitoring the sacral wound, which, according to staff member G, healed open to air (without a dressing). During an interview on 7/11/19 at 10:42 a.m., staff member G searched through resident #1's care plan, and stated she could not find interventions explaining the recommendations for pressure relieving devices (i.e. boots and seat cushion). During an interview on 7/11/19 at 10:50 a.m., staff member K stated there was no root cause analysis for resident #1's left heel pressure ulcer as noted on 7/4/19. Staff member K stated resident #1 should have an air mattress with a pump. Staff member K stated resident #1 had heel lift boots, and her seat cushion should have been under her at all times, even in her recliner. Review of resident #1's Braden Scale for Predicting Pressure Sore Risk, dated 6/10/19, showed, If the residents total is 18 or less, consider him/her at risk for a pressure ulcer development. Resident #1 scored a 15. Review of resident #1's admission note, dated 6/28/19, showed the presence of pressure ulcers to both buttocks but had no mention of pressure ulcers on her bilateral heels. Review of resident #1's Weekly Bath Day Assessment showed the following: -7/2/19 Skin interventions being utilized were, wound rounds, wound treatment, fluids, Foley catheter, education, wheelchair cushion, and protein encouraged. -7/9/19 Skin assessment in the comments showed, blackened area to L outer heel. -7/9/19 Skin interventions being utilized were, wound rounds, wound treatments, Foley catheter, [MEDICATION NAME], Rooke boots/float heels, turned/repositioned per policy, wheelchair cushion, and pressure reducing mattress. Review of resident #1's care plan showed the following: -6/28/19, At risk for breakdown. Turn and position as per policy guidelines or as directed. Monitor skin integrity weekly and when assisting with adl's. (sic) Notify charge nurse of changes. -7/1/19, Admit skin assessment 6/28/19 Left buttock: L: 1.4cm, W: 2cm, D: 0.1cm, Right buttock: L: 0.5cm, W: 0.4cm, D: 0.1cm. No mention of alteration of skin to either the right or left heel were noted in the skin assessment. -7/6/19, Left heel wound, identified on 7/4/19. The care plan had no mention of interventions that should be in place to prevent the worsening or development of new pressure ulcers. Review of resident #1's Interdisciplinary Notes showed the following: -6/10/19 resident #1 was admitted to the facility noted no pressure ulcer to left and right heel. -6/28/19 resident #1 was readmitted back to the facility with wounds to her buttocks. No mention of heel wounds were noted. -7/4/19 resident #1 was seen for wound rounds for buttock. Wounds to buttocks were open to air and deemed healed. (Resident #1) is noted to have foam heel protectors in place and when questioned she reports mild discomfort of her left heel. There appears to be a pressure sore, a dry blister that is unstageable and measures 3x4cm. Will paint with [MEDICATION NAME] BID and monitor. -7/9/19 resident #1 was noted to have a small blackened area to her right heel. Review of resident #1's Treatment Record showed, blister left heel paint with [MEDICATION NAME] BID heel lift boots in bed, initiated on 7/4/19. Family brought in heel lift boots on while in bed. Review of resident #1's wound care order dated 7/4/19, showed blister to left heel- paint with [MEDICATION NAME] BID- monitor. Heel lift boots in bed. Remind (resident #1) to have her family bring in a pair of heel lift boots. Review of resident #1's (Facility) Wound Alert dated 7/11/19 showed the following: -Right buttocks reddened area blanchable less than 2 seconds, cool and soothe with off loading using cushion on all surfaces. Left buttocks unstageable wound-dry scabbed area measures 2.7 cmx3.2 cmx0.1 cm with previous chronic scar tissue. -Right heel pressure sore unstageable dried eschar peri wound is blanchable within 2 seconds. measures 1.9 cm x 1.8 cm. Painted with [MEDICATION NAME]. -Left heel pressure unstageable dried dark area appears to be resolving, center of wound firm, 2.3 cm x 1.9 cm. Paint with [MEDICATION NAME] off load with heel foams at this time, family requested to bring in heel lift boots, not in room at this time.

Based on observation, interview, and record review, the facility failed to provide the necessary supervision and assistance needed for a resident who had swallow deficits and a choking episode, which required staff to provide the [MEDICATION NAME] Maneuver, for 1 (#89) of 42 sampled residents, and failed to implement interventions for ongoing risks related to choking. Findings include: During an observation on 7/8/19 at 4:50 p.m., in the resident dining room, resident #89 was left unattended in the back of the dining room, behind the serving table, in his wheelchair. Resident #89 was positioned behind a bedside table. Resident #89, with his tongue thrusting out, was coughing on his thickened water. No staff came to check on the resident. He then set his drink down on the bedside table to use his clothing protector to wipe his face and wheeled out of the dining room. A staff member wheeled resident #89 back into the dining room entrance and resident #89 proceeded to go to a different table and took his soiled clothing protector off and set it on another resident's place setting and drinks. Resident #89 returned to his bedside table where two bowls of pureed food and his drink were waiting. Resident #89 fed himself with an adaptive spoon, and due to his frequent tongue thrusting, he had to place the spoon far back in his mouth in order to empty the spoon. Resident #89 resorted to picking up the bowl and placing it against his lips to scoop the food with the adaptive spoon without taking a break, or switching to a drink in between bites of food. No staff were directly supervising or encouraging resident #89 to slow down or alternate food with liquids. Record review of resident #89's nursing note and alert, dated 7/4/19, showed, Res was in dining room sand resident chokking, he was unable to clear his airway and started turning blue. Res was lifted out of WC and [MEDICATION NAME] was started. After three deep thrusts I was able to dislodge te object res swallowed it so I was unable to see what it was. Res had been seen at res table by the pole, appeared he was taking food. He is currently resting in his room. (sic) During an observation and interview on 7/10/19 at 2:40 p.m., staff member L showed resident #89's diet card. The 1:1 for dining intervention was written on the bottom right corner of the diet card. This notation was covered by a yellow post-it note labeled puree. Staff member L stated that the staff members serving meals may not have seen the intervention, because of where the post-it was placed on the diet card. Staff member L stated the discipline that implemented the intervention was responsible for updating the diet cards. During an interview on 7/10/19 at 11:38 a.m., staff member N stated, Staff, as a whole, periodically keeps an eye on (resident #89). During an interview on 7/10/19 at 2:30 p.m., staff member O stated, an incident would create an alert in the Kardex of the electronic medical record. She stated therapy, dietary, nursing, and all management would receive an alert in the case of a choking incident. During an interview on 7/11/19 at 8:33 a.m., staff member M stated she was not present for the choking incident that occurred on 7/4/19, but heard resident #89 had taken another resident's bread and choked on it. Staff member M stated all staff are to keep a close eye on resident #89 as he wanders. Staff member M had noticed that resident #89 would push the adaptive spoon so far back into his mouth, he would gag on it, when eating too fast. Resident #89 coughed a lot but usually forcefully coughed enough to clear his throat on his own. Staff member M stated the protocol for notification after performing the [MEDICATION NAME] Maneuver was to notify management, doctor, resident representative, dietician, and therapy. Staff member M stated the expectation of the nurse is to implement interventions necessary to keep the resident safe, while waiting for a call back from the provider. Staff member M stated management, therapy, and the oncoming shifts would see an alert in the electronic medical record notifying staff of the incident. During an observation on 7/11/19 at 9:06 a.m., resident #89 was left unattended in the back of the dining room, behind the serving table, in his wheelchair. Resident #89 was positioned behind a bedside table. Resident #89 had three bowls of pureed food and a drink. Resident #89 was using an adaptive spoon and had difficulty removing the food from his spoon. Resident #89 spilled food onto his clothing protector, scooped the food off, and ate it. Resident #89 then placed the spoon far back into his throat and gagged. Resident #89 tipped his head back and continued to cough, moan, and made a wet, gurgling sound with his tongue thrust out. Staff member O came over and adjusted the resident's clothing protector and told him he was okay. Staff member O walked away; no one was directly supervising resident #89. Record review of resident #89 Speech Therapy note on 7/8/19, showed a recommendation of 1:1 supervision for consuming food/liquids. High Choking/Aspiration Risk. No documentation was found for notification of the physician, resident representative, or assessment of resident #89's wellbeing related to the choking.

Based on observation, interview, and record review, the facility failed to assess and provide pain management interventions during treatment of [REDACTED].#104) of 42 sampled residents, who described his pain as excruciating. Findings include: During an interview on 7/10/19 at 10:34 a.m., resident #104 stated he first noticed the pressure ulcer on his right heel prior to his arrival at the facility. Resident #104 explained the wound itself looked as if it were 90% healed, but .the bad part is the pain. Resident #104 described the pain on his right heel as excruciating, especially when staff performed dressing changes. Resident #104 stated he was unsure if he took pain medications prior to dressing changes on his right heel. During an interview on 7/10/19 at 10:51 a.m., staff member T stated resident #104, is fine, and has not needed or requested pain medications prior to dressing changes on his right heel. During an interview on 7/10/19 at 11:24 a.m., after staff member T was alerted to resident #104's pain, staff member T stated she would perform a dressing change on resident #104's right heel wound in about ten minutes. Staff member T stated, We ended up giving him a pain medication, so we are going to wait for that to kick-in. This was after the surveyor approached the topic of the resident's pain with the staff member. During an observation on 7/10/19 at 11:36 a.m., staff member T performed a dressing change on resident #104's right heel. While staff member T removed the compression stockings, resident #104 groaned in pain, and said Ow! multiple times. Staff member T did not perform a pain assessment, alter treatment, or implement pain relieving measures for resident #104 during the dressing change. During an interview on 7/10/19 at 2:37 p.m., staff member T stated she was not sure of the source of resident #104's pain. Staff member T stated resident #104 takes [MEDICATION NAME] as needed, but only requests it at night, and is not taking any scheduled pain medications. Staff member T stated the dressing change she performed earlier in the morning on 7/10/19 was the first time resident #104 had requested pain medication prior to a dressing change. During an observation on 7/11/19 at 9:02 a.m., staff member G performed wound care on resident #104's right heel. While staff member G removed resident #104's compression wraps and bandage, resident #104 grimaced and tensed his right leg. Staff member G described the wound as a Stage II pressure ulcer, with dimensions of 1.9 cm x 1.2 cm (length x width); she continued to describe the peri-wound as dark pink and beefy red. The wound itself, she said, had slightl red drainage; and yellow, dry, and flaky skin was noted to the top part of the wound, which staff member G peeled off. Resident #104 continued to grimace and tense his right leg throughout wound care. Staff member G did not perform a pain assessment, alter treatment, or implement pain relieving measures for resident #104 during wound care. During an interview on 7/11/19 at 9:18 a.m., staff member G stated she was not sure if resident #104 took pain medications prior to wound care on his right heel. Staff member G said she had not performed a pain assessment with resident #104. Staff member G consulted resident #104's MAR indicated [REDACTED]. Staff member G stated resident #104 takes [MEDICATION NAME], 50 mg tablets, one tablet by mouth once daily, as needed for pain; and [MEDICATION NAME] 1% gel, apply 2-4 grams to affected areas of joint pain up to four times daily. Review of resident #104's care plan, dated 6/11/19, showed under the category, Pain, resident #104 will achieve a consistent level of comfort while maintaining as much function as possible. Interventions under this goal include: -administer pain medications on scheduled and/or as needed basis; -if finding that adequate pain control is not occurring and remains greater than a 5/10 after 30 minutes after pain medication administration, document and notify primary care provider; and, -pre-medicate for pain as needed to optimize participation in therapies, activities and meals. Review of a Training Competency document, dated 2/1/19-2/28/19, showed staff member T met the standard for assessing and reassessing pain; and utilizing appropriate pain management techniques. Review of resident #104's pain assessment notes, between 6/28/19 and 7/11/19, showed five out of 27 pain assessments were completed. Out of those five, one assessment, dated 7/8/19, did not note the location of the resident's pain; one assessment, dated 7/4/19, showed resident #104 was experiencing a burning and restless pain in his right foot; assessments dated 6/26/19, 6/27/19, and 6/30/19 showed resident #104 was experiencing pain in both knees only.

Based on interview and record review, the facility failed to thoroughly investigate an allegation of abuse, for 1 (#76) and prevent further abuse resulting in feelings of not being treated like a human, and fear of physical abuse, for 1 (#451) of 37 sampled and supplemental residents. Findings include: 1. During an interview on 5/15/18 at 2:40 p.m., resident #76 stated (staff member M) had been bird dogging me from the beginning of my stay here. A few weeks ago, (staff member M) said to me 'You keep that mask on or there will be trouble. I'll put you in your room, and you won't come out.' Resident #76 stated he did not need to wear the protective mask, and staff member M did not believe him. During an interview on 5/15/18 at 3:00 p.m., staff member N said she had been the nurse on duty that day, and she thought it was just a misunderstanding between the staff member and the resident. She said she told staff member M he needed to speak nicer to the residents. She thought the event had occurred on the 24th of (MONTH) (YEAR). During an interview on 5/16/18 at 1:36 p.m., NFI stated he was making rounds on 4/27/18, and he was visiting with resident #76. They sat in the lobby, and saw staff member M. Resident #76 and his wife became upset, and said staff member M was not supposed to be working in the cottage, because of their complaint against him. NF1 took the concern to the facility social worker, who stated he knew nothing about resident #76's concern. He discussed it with staff member L, who then did move staff member M to another area. Review of a communication note from staff member L, dated 4/29/18, showed she did talk to staff member M about the incident with resident #76. Staff member M stated the resident did become upset with him, because of the mask not being worn. Staff member M stated he was under the impression that the situation had been taken care of already. Staff member L wrote I assured staff member M he was not in trouble. Review of a written communication from staff member O, undated, showed, The way staff member M talks to residents is unacceptable. Review of staff member E's communication of the situation showed, The patient could not remember the details (of the interaction with staff member M) when interviewed. I will speak to NF1 on Monday to determine the original issue as presented to (NF1). In the meantime, the staff member has been reassigned a different patient load. The follow-up note, dated 4/30/18, showed Per NF1, staff member M was insistent the resident wear a mask for his own safety. The resident refused and the CNA said that he wouldn't be able to leave his room without a mask. An RN became involved and allowed the resident to leave the room. During an interview on 5/17/18 at 10:20 a.m., staff member D stated she had been involved in the incident, but had thought it had just been a misunderstanding, and not verbal or mental abuse. 2. Review of a State Survey Agency Report provided from the facility, dated 5/13/18, showed resident #451 reported staff member M had been verbally abusive, arrogant, and not treating (resident) like a human being. Resident #451 expressed to a nurse that he felt like staff member M was verbally abusive towards him and that after he told staff member M off, and it could have gotten physical. He also stated he would be afraid if he saw staff member M at his door. During an interview on 5/17/18 at 9:40 a.m., resident #451 said, If you are asking me if staff member M acted like this before, the answer is yes. During an interview on 5/17/18 at 10:35 a.m., staff member P stated she absolutely believed resident #451's allegation. Review of a written communication, dated 5/13/18, by staff member Q, showed resident #451 felt embarrassed, and was made to feel a burden when staff member M would take care of him. The resident stated, He should not be taking care of people or have this kind of job. Staff member Q wrote Later, staff member M tried to explain why the resident did not want him in his room, but he mostly just shrugged it off. I told him you have to put yourself in their place and think about how difficult it is to be in their position and to have someone have to physically take care of your toileting needs. The event with resident #451 occurred after the event with resident #76, showing the event with resident #76 was not addressed sufficiently to ensure resident protection in the future relating to staff member M.

Based on record review and interview, the facility failed to evaluate a staff member's use of assitive devices and transfer technique used for a resident who had a fall while being assisted by the staff member, and the resident sustained [REDACTED].#1) of 3 sampled residents. Findings include: Review of resident #1's care plan, and an interdisciplinary note, dated 11/14/16 at 1440 (2:40 p.m.), showed a staff member was about to ambulate (resident #1) to the bathroom per his request, when his knees gave out. The staff member assisted (resident #1) to the floor as she could not hold him up. He fell next to the bed. He hit his right head and scraped his right back shoulder getting a skin tear. The (sic) checked all range of motion and it was all intact. He was able to assist staff to a standing position and (resident #1) was able to ambulate with his walker without pain. After (resident #1) sat on the toilet, he started to complain of some slight hip pain but did not want to be assessed in the ER. (Resident #1's) son and the nurse will monitor for increased pain and send him later if needed. The nurse dressed his head laceration and skin tear per protocol. (Resident #1's) neurological checks were within normal limits for him. 155/78, 62, 97.6, 91% 16. Son came in the room at 1445 (2:45 p.m.) and the staff notified him of the fall. The MD on call was notified at 1450 (2:50 p.m.). Review of the Reporting Form, for the five day summary report, which was sent to the State Agency, showed that After the day of the fall - (resident #1) continued to have more pain. At that time, the MD decided to have a CT scan - in case of a hairline fracture that did not show up on the x-ray. At that time, a pelvic fracture was detected. The Orthopedic specialist and MD decided, along with family and resident, to do comfort measures to include pelvic rest, pain medication, and to be weight-bearing as tolerated. A review of the resident's clinical record showed the resident's [DIAGNOSES REDACTED]. Review of the resident's MDS, with an ARD of 12/1/16, showed in section G0110, that the resident's transfer ability was extensive assist with one person. Review of the resident's Kardex showed he ambulated with a front wheeled walker, one person assist, and gait belt. He transferred with one person. This information for the resident's transfer status was not documented in his care plan. Review of the resident's Faber Fall Risk Assessment, dated 10/1/16, showed a moderate risk of falls, and showed, Follow all measures above PLUS write Fall Risk on Kardex, team decides other measures . The reference to above was in regards to For all residents initiate: Use gait belt, non skid footwear, maintain hazard free environment, call light within reach at all times, ambulatory devices within reach, encourage resident and family to ask for assistance . In an interview on 2/14/17 at 7:25 a.m., staff member A said the Kardex and the care plan were the same for interventions that staff used to assist the resident with transfers and ambulation. Review of the Policy/Procedure-Fall Protocol, for the facility, which had a revision date of 6/16, showed All falls are immediately investigated to determine the root cause and actions to be taken to minimize future falls and/or injury. Review of the Transfer/Levels of Assistance and Equipment Used policy, with the effective date of 05/2016, showed under section IV Gait Belts Ambulates (sic) residents by grasping belt firmly in middle of resident's back, walking along side and slightly behind resident using necessary equipment. Under section V, for falls, it showed, All falls will be handled as follows: Use a wide stance and control their core with gait belt. Push against resident's knees with your knees, while pulling resident toward you with belt. Easing the resident to the floor by allowing them to slide down your leg. May ease to floor with them. Do not attempt to hold up as this may cause injury. In an interview on 2/15/17 at 8:44 a.m., staff member A said The whole story was not documented about the CNA's easing the resident to the floor. The CNA told me he (resident #1) turned away from the bed after she had gotten him up out of bed holding the walker. This left his back open to stand behind. The CNA had stood to the resident's left, holding the gait belt with one hand. There was no documentation, per staff member A, of the staff taking a wide stance. The investigation did not include whether the transfer policy was followed, per staff member A. She stated the CNA stood to his side. Staff member A stated there was no documentation why the resident hit his right side during the fall, and Typically, they (CNA's) are supposed to have two hands on the belt. One on the back. How (name of CNA) held the gait belt was not documented in the investigation. In an interview on 2/15/17 at 10:15 a.m., staff member A said Several days after the fall I told her (the CNA assisting the resident) she should have been behind him and holding the gait belt. She knew she should have been behind him holding the gait belt. This conversation was not documented.

Based on record review, observations, and staff interview, the facility failed to ensure one 1 (#13) of 31 sampled and supplemental residents, who entered the facility without a pressure ulcer, did not develop one during the course of her stay. The facility failed to: -Complete regular skin assessments; -Develop a comprehensive care plan to address the stage III pressure ulcer; -Implement prescribed treatment and safety precautions to protect the pressure ulcer and promote healing; -Assess and implement nutritional interventions to promote wound healing in a timely manner; and -evaluate a medication per the pharmacist's recommendation that had the potential to impact nutritional status. Findings include: Resident #13 was admitted to the East campus on 6/15/11 with [DIAGNOSES REDACTED]. a. Skin assessments: According to the facility's Pressure Ulcer Prevention Policy and Procedure, a licensed staff member checked residents' skin on bath days; weekly skin rounds were done on an ongoing basis by an RN. Wound rounds were done weekly by the interdisciplinary team. Skin assessments revealed the resident developed a stage III pressure ulcer (full thickness tissue loss with subcutaneous fat potentially visible) to his left heel. The progression of the pressure ulcer was documented in skin assessments. The care plan also directed nurses to complete weekly skin assessments. Skin assessments noted the the size and depth of the pressure ulcer as follows: -7/13/13: Nursing first completed a Skin Assessment on this date at 7:34 p.m. determining the resident had a blister; however, this assessment was completed seven days after the blister was first found (see b below). It described the blister as being dark, flaccid, intact and 6 cm in length by 8 cm in width. The next skin assessment form was not completed for 26 days after this skin assessment (8/8/13). -8/8/13: 8 cm in length and 6 cm in width with no depth documented. The tissue was described as necrotic (dead tissue)/eschar; no drainage was present. - 8/20/13: 2.5 cm in length and 2.8 cm in width with no depth documented. Necrotic tissue was present with eschar and purulent (containing or composed of pus) brown drainage. This skin assessment was completed 12 days after the previous skin assessment. -8/27/13: 3.3 cm in length and 3.1 cm in width with no depth documented. The wound was documented as being necrotic with eschar and purulent brown drainage present. -9/6/13: No length or width or depth was documented. The wound was documented as being necrotic with eschar and slough skin present and purulent drainage. -9/10/13: 3.3 cm in length and 3.1 cm in width; no depth was documented. -9/17/13: 3.5 cm in length and 3 cm in width with a depth of .3 cm. -9/24/13: 3 cm in length and 3 cm in width with a depth of .3 cm. -10/5/13: 2 cm in length and 2 cm in width with a depth of .3 cm. The pressure ulcer on resident #13's left heel had progressed to a stage 3 pressure ulcer per the assessment. -10/14/13: 2.5 cm in length and 1.5 cm in width with a depth of .3 cm. -10/22/13: 2.9 cm in length 1.7 cm in width and a depth of .3 cm. -10/29/13: 2.5 cm in length and 3 cm in width with a depth of .5 cm. This was the deepest the pressure ulcer was recorded as being (.5 cm) from the first skin assessment up through this date. -11/5/13: 3 cm in length by 2.5 cm in width with a depth of .5cm. b. Chronological Progression of pressure ulcer and decline in resident's condition: On 4/12/13, the pharmacist documented on the resident's drug regimen review that the resident's appetite had decreased and his weight was at 168 pounds. The pharmacist recommended a medication change from [MEDICATION NAME] to [MEDICATION NAME]. There was no documentation that the facility followed through with the recommendation. The medication [MEDICATION NAME] has potential gastrointestinal side effects of nausea, diarrhea, dry mouth, anorexia, constipation, cramps, vomiting, taste changes, and decreased appetite.? At the time of the survey, the resident continued to receive 20 mg a day of [MEDICATION NAME]. The facility completed the Braden Scale for predicting pressure sore risk on 5/29/13 for resident #13. The score was 19. According to the form, a score of 18 or less indicated high risk for pressure ulcers. On 7/6/13 at 8:47 a.m., the nurse documented in the interdisciplinary notes that a CNA reported the resident's left heel was bruised with a small blister. The nurse wrote that [MEDICATION NAME] was applied and that nursing would continue to observe and assess. A physician's telephone order dated 7/6/13 at 8:30 p.m., addressed the left heel blister with an order for [REDACTED]. Staff member W documented in an interdisciplinary notes on 5/24/13 that the resident's weight was 171 pounds on 5/8/13. On 7/12/13, staff member W documented the resident's weight at 151 pounds. This is equivalent to an 11.6% significant weight loss (greater than 7.5% in 3 months is significant). According to a previous dietitian note dated 9/9/11, the resident's ideal body weight was between 128 - 160 pounds; he was 5'7" tall. Staff member W, the RD documented on 7/12/13 that the resident had a UTI, increased weakness, and was needing assistance with meals. The diet was changed from pureed to mechanical soft and the resident was receiving restorative dining services. The RD noted he had a significant weight loss. She did not document the presence of the left heel blister. There were no nutritional interventions aimed at increased calories or protein intake implemented at this time in spite of the significant weight loss. On 7/13/13 at 8:44 p.m., the nurse's noted the resident's son was concerned with the condition of the resident's left heel. The nurse obtained an order for [REDACTED]." A Rooke boot is designed to surround the foot, heel and calf, insulating and protecting the healing limb and for preventing and healing pressure ulcers.? According to the treatment record, on 7/14/13 a heel lift boot was ordered to be on the left foot at all times and a Rooke boot to be on the right foot when the resident was in bed and a slipper on when the resident was up. On 7/15/13, the physician noted in a progress note that the resident had a significant decline over the past 6 months, including a weight loss of 22 pounds. The physician made no mention of the resident's left heel skin condition. The weekly summary charting, dated 7/17/13, noted that the resident's skin integrity was intact. The author did not identify the resident's left heel blister, the use of heel protection or the use of the Rooke boot. The facility did not identify the resident's left heel wound on the significant change, MDS, with an ARD of 7/19/13, which was in relation to weight loss. On 7/21/13 at 9:30 p.m., per the nurse's interdisciplinary note, the resident's son found a shoe on the resident's left foot and was upset, stating that it "had happened before" and asked why it kept happening. The nurse immediately took the resident to his room and applied the heel lift boot. On 7/24/13, the facility completed a Braden Scale for predicting pressure sore risk. The total score was 16 which determined the resident was at risk for pressure ulcer development. According to the form, a score of 18 or less indicates high risk for pressure ulcers. On 8/7/13 at 9:30 a.m., the physician ordered a consult with a wound care nurse to evaluate and treat. An appointment was made by the facility for 8/14/13. On 8/9/13 at 4:46 p.m., the RD documented the resident's weight was down further during the past month. The RD noted [MEDICATION NAME] thickened with two applesauce twice a day was "begun this week. He has a heel wound being addressed....MVI qd (multivitamin once a day) ordered today." This was the first nutritional intervention aimed at increasing the resident's nutritional (calorie and protein) intake since the significant weight loss that was present on 7/12/13 and presence of the left heel wound first observed on 7/6/13. According to the treatment record, on 8/14/13 the physician prescribed wound change of the dressing every 2 - 3 days, cleanse with normal saline, pat it dry. The wound clinic doctor noted on 9/11/13, on the patient treatment update, that the resident's left heel pressure ulcer was thought to be related to [MEDICAL CONDITION]. On 9/13/13 at 12:30 p.m., the physician gave an order for [REDACTED]. On 9/24/13 the wound care center sent orders for the left heel dressing to be changed daily and as needed and instructed that the heel should be off loaded at all times. The order read, "Change L heel drsg (dressing) daily and PRN. [MEDICATION NAME] 1 - 2 layers (if wound is drying slightly moisten the 1st layer of [MEDICATION NAME] at the wound base), [MEDICATION NAME] heel." On 10/10/13 the order was changed to change the left heel dressing three times a week, and to wash with normal saline. According to the treatment record, on 10/22/13 the physician prescribed left heel treatment of [REDACTED]. On 11/4/13 at 8:20 a.m., resident #13 was observed being wheeled out to the dining room in a wheelchair. His chair had no foot rests attached and his feet dragged over the floor. At 8:40 a.m., a fire alarm sounded. An unidentified CNA pushed resident #13 towards his bedroom. While going from the linoleum to the carpet, his left foot hit the transition strip and bounced up. The resident moaned. Staff member F, a nurse, was interviewed on 11/7/13 at 10:00 a.m. She indicated that resident #13 had lived in the main facility before transferring to the cottage on 10/22/13. During the period prior to the move, the resident experienced a decline in his physical condition. He declined from being able to walk independently to needing to use a walker. According to staff member F, the resident "was so weak" and he took "hours to eat his meal." The consistency of the resident's food changed as staff tried to increase his nutritional intake and ability to eat. Staff member F reported the resident's weight dropped and he went to the hospital with a pneumonia. Staff member W, the RD was interviewed on 11/6/13 at 8:05 a.m. She stated she was made aware of resident #13's left heel wound at the end of July or beginning of August. She did not know of the skin issue prior to that time. She stated she encouraged his supplement and added a multivitamin. She remarked the resident had a significant weight loss, two UTIs, medication changes, and swallowing issues prior to the development of the pressure ulcer. The resident required meal assistance, received a mechanically altered diet and thickened liquids were ordered. According to the RD, the resident was so sick and weak, he was only able to tolerate foods that were pureed. She stated a supplement was tried, but the resident did not like it. When the resident's weight was in the 140s, the facility started him on a non-milk based supplement. The resident's care plan, with a start date of 10/9/13, identified the risk for skin breakdown, but did not include the use of the Rooke boot per the physician's orders [REDACTED]. Resident #13 entered the facility without a pressure sore and developed a stage III pressure ulcer while residing in the facility. He became sick, weak, declining in independence, had bouts with UTIs, a URI, and pneumonia. The resident did not receive necessary services in a timely and routine manner to promote healing of the pressure ulcer. REFERENCES ? Skidmore Roth, L, Mosby's Nursing Drug Reference 23rd Edition, Mosby Elsevier, St Louis, Missouri, pg 294 ? http://www.osbornmedical.com/patients/classic-rooke-boot/ - manufacturer of the Rooke Boot

Based on record and policy reviews, observations, staff and resident interviews, the facility failed to assess residents for safety while smoking for 2 (#s 15 and 16) of 2 residents. On 1/5/12 at 12:00 p.m., the facility administrator was given verbal notice that an Immediate Jeopardy (IJ) was present regarding resident #15's not smoking safely. On 1/5/12 at 4:45 p.m., an acceptable allegation to abate the IJ was received from the facility administrator. The letter outlining the allegation to abate the IJ included the following: "1. We are putting the resident indicated in your letter (letters of the resident's name) under supervision during any time he smokes to ensure his safety which includes the resident shutting off his oxygen supply during the time he smokes. 2: (sic) (letters of the resident's name) has chosed to be relocated today to another nursing facility who allows smoking on their campus." Upon review, the IJ was abated. Findings include: 1. Resident #15 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On 1/3/12 at 1:00 p.m., the surveyor received the non-smoking policy and a Behavioral & Safety Acknowledgement-Smoking with Oxygen document for resident #15. The facility's No Smoking Policy stated: "In keeping with our healing ministry Benefis Extended Care Center is a smoke free campus. For purposes of clarity "No Smoking" is the same as no tobacco use, i.e., no cigarettes, cigars, pipe tobacco, or chew use will be tolerated on our property. Procedure/Responsibilities: 1. Patients Responsibilities: A. The admitting nurse is responsible for screening all patients for tobacco use upon admission to the hospital and indicating their tobacco status. B. All patients, identified as tobacco users are provided smoking cessation education. The healthcare provider discusses available treatment options, including appropriate pharmacotherapy and support programs. C. The healthcare provider (nurse or physician) documents all tobacco dependence treatment efforts in the patient record, including prescribed medications and referral to outpatient support programs. D. Nursing staff enforces the Benefis Extended Care Center No Tobacco Use Policy. E. Physicians assist nursing staff with tobacco cessation counseling and provide tobacco cessation alternatives to patients. F. In the event that a patient refuses to comply with this policy and leave their patient care area to utilize tobacco the patient may choose to leave against medical advice (AMA) and will be offered a form for their signature ...2.. Employees abide by the policy at all times and report observed violations to management. 3. When a patient chooses to leave the facility AMA, employee will follow guidelines detailed in Policy: Patient Dismissal Against Medical Advice (AMA)." The No Smoking Policy included a document labeled Safe Smoking Assessment. The top of the document contained the following, "This assessment must be completed upon admission for ALL residents who wish to smoke. The resident or responsible party will receive a copy of the Smoking Policy. This assessment should be performed annually and after a significant change in condition. The completed assessment is placed in the resident's record." The Behavioral & Safety Acknowledgement-Smoking with Oxygen (Resident #15's name), Benefis Extended Care Center Resident document was completed for this resident. The document contained the following: "This is a behavioral and safety acknowledgement created regarding the educated risks that you, (Resident's name), are taking regarding your smoking habits. Benefis Extended Care Center is a non-smoking campus. Smoking by any residents and/or patients, guests and staff must be done off the Benefis Extended Care Center property. Smoking is a risk to your health. Smoking causes you to be at an increased risk of coronary heart disease, stroke, lung cancer, and chronic obstructive lung disease. Smoking while on oxygen is dangerous and has led to death. Oxygen spreads fire more rapidly and increases the rate at which things burn. It is dangerous to smoke and to use a lighter or match around oxygen. Benefis Extended Care Center Recommendations to (Resident's name) are as follows: 1) We first recommend you to stop smoking for your overall health, safety and well-being. If you make this choice, we will assist you with smoking cessation through patches, gum, etc..." The resident checked on the form that "I decline this option." The document continued with the following: "...2) If you choose to smoke, we recommend that you remove your oxygen tank from your wheelchair prior to going outside to smoke. We also remind you that you are not to smoke on (Facility's name) property. If you make this choice, we will assist you with removal of the oxygen tank prior to leaving and return of the oxygen tank upon your return..." The resident checked on the form "I decline this option." The document continued with the following: "...3) If you choose to smoke and continue to wear your oxygen - we ask for your acknowledgement that you understand and are taking all responsibility and liability involved in that decision. You are acknowledging that you are at risk for health problems up to and including death - based upon this decision. Again we remind you that you are not able to smoke on (Facility's name) property..." The resident checked on the form "I choose to make this decision." The resident and two facility staff members witnessed the agreement on 1/12/11. According to the record, the West 2 unit nurse documented the following: that on 1/4/11 at 9:52 a.m. and 1/11/11 at 10:10 a.m., "Resident requires minimal assistance with ADl's (sic), propels self throughout facility in electric scooter, goes outside to smoke, is able to make needs known. Is pleasant and cooperative with care." According to the record, the West 2 unit nurse documented the following: that on 1/4/11 at 1:20 p.m., "Resident had no nausea, vomiting, or loose stools this shift. Resident stayed in room, but was seen going outside to smoke, resident was educated on importance of staying in room." On 1/12/11 at 12:17 p.m., a West 2 unit nurse documented the following in the Interdisciplinary Notes, "Resident was educated on smoking with oxygen. Behavioral and Safety Acknowledgement form was reviewed with him and signed. Form placed in chart." There were 31 entries from 1/1/11 to 1/5/12 documented in the Interdisciplinary Notes of nursing staff awareness that resident #15 was smoking outside the facility. On 8/5/11 at 2:07 p.m., social service documented the following in the Interdisciplinary Notes, "...He and I then went on to talk about him smoking with his oxygen and I again encouraged him not to." On resident #15's Annual MDS with an ARD of 10/13/11, Section C0500 was coded to indicate the resident was cognitively intact. On the Initial MDS with an ARD of 12/4/10, Section J1300, tobacco use, was coded 1 for Yes. On the Annual MDS with an ARD of 10/13/11, Section J1300, tobacco use, was coded 1 for Yes. The activity care plan dated 10/20/11 contained the following, "P (problem)...(Resident's name) continues to smoke...A (action)...I have agreed to not smoke on (facility's name) property. I have been showed where I am allowed to smoke. I take my oxygen tubing out of my nose when I smoke and have signed an agreement regarding the safety of this." The above statement conflicted with the Behavioral & Safety Acknowledgement-Smoking with Oxygen document, resident #15 declined to take his oxygen off while smoking. On 1/3/12 at 5:25 p.m., the surveyor observed resident #15 leave the facility on his scooter with the oxygen tank. The resident stopped outside of the West 1 door on the ramp and lit his cigarette. The resident then traveled along the sidewalk outside the front of the facility. Resident #15 was observed lighting a cigarette without turning off the oxygen.. On 1/4/12 at 4:50 p.m., during the evening meeting with facility staff, the surveyor asked for the resident's Safe Smoking Assessment. Staff member H, the unit manager of West 2, stated that the resident was "absolutely not safe to smoke unsupervised." The unit manager stated the facility had the resident sign the Behavioral & Safety Acknowledgement-Smoking with Oxygen document because he was not safe to smoke. During the evening meeting on 1/4/12, staff member G, the DON stated the Behavioral & Safety Acknowledgement-Smoking with Oxygen document replaced the Safe Smoking Assessment document. On 1/4/12 at 5:30 p.m., the surveyor observed resident #15 going out the West 1 door on his scooter, with the oxygen tank. The regulator on the oxygen tank was in the on position. The resident stopped just outside the West 1 door and lit his cigarette. The resident's oxygen cannula was underneath the resident's chin. During the observation resident #15 was observed lighting a cigarette without turning off the oxygen. During an interview with resident #15 at the same time of the observation. The resident stated he only smoked after meals, usually one cigarette at a time. He was told by the facility to smoke across the street from the facility. The resident stated he kept his cigarettes and lighter in the basket on his scooter. The resident stated he did not turn off his oxygen before lighting his cigarette. When the surveyor approached resident #15, he was observed to extinguished his cigarette. During the observation the regulator on the oxygen tank was in the on position with the dial set at 2 liters. On 1/5/12 at 11:05 a.m., staff member H, stated resident #15 was transferred to West 2 unit on 12/8/10. The resident was smoking before the transfer to West 2 unit. Staff member H stated resident #15 was on 2 liters of oxygen. Staff member H stated the resident was not a safe smoker so she did not fill out the Safe Smoking Assessment. The facility went reviewed the Behavioral & Safety Acknowledgement-Smoking with Oxygen document with the resident. The facility provided the resident with a reflective vest and reflective flag for the resident's scooter. The facility staff also showed resident #15 the area where he could smoke, which was across the street. Resident #15's actions and the facility staff not intervening with interventions to keep the resident safe regarding his smoking paraphernalia with him and safe to smoke off campus independently. On 1/5/12 at 12:00 p.m., as a result of these findings, a determination of immediate jeopardy was made due to resident #15's unsafe smoking practices. Based on the accepted allegation to abate the IJ, the IJ was abated on 1/5/12 at 4:45 p.m. The letter outlining the allegation to abate the IJ included the following: "1. We are putting the resident indicated in your letter (letters of the resident's name) under supervision during any time he smokes to ensure his safety which includes the resident shutting off his oxygen supply during the time he smokes. 2: (sic) (letters of the resident's name) has chosed to be relocated today to another nursing facility who allows smoking on their campus." Resident #15 and any residents admitted to the facility that smoke are at risk of smoking without supervision. Systems need to be in place to address the safety of these residents who smoke as much as possible. 2. Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The surveyor observed resident #16 enter the facility on 1/4/12 at 7:20 a.m. by himself while in his wheel chair. Resident #16 had his cigarettes and lighter on his lap. The surveyor observed resident #16 return to the East Wing dining area and speak with staff member R. Resident #16 kept his cigarettes and lighter. During an interview on 1/4/12 at 8:00 a.m., staff member R stated that resident #16 kept his own cigarettes and lighters. She stated that resident #16 was supposed to sign in and out when he left the facility to smoke. She further stated that resident #16 did not always sign in and out of the facility as been arranged. Staff member R stated she was not sure where he smoked outside. The surveyor observed resident #16 leave the facility without signing out or telling staff he was leaving. He went outside to smoke on 1/4/12 at 9:43 a.m. According to resident #16's admission MDS with an ARD of 5/30/11, section G0400, A and B (upper and lower extremity) were coded 2 for impairment on both sides. Section G0110, B was coded 4/3 (total dependence of two people) for transfers. Section G0110, G was coded 3/3 (extensive physical assist of two people) for dressing. Section G0110, H was coded 3/2 (extensive physical assist of one person) for eating. The surveyor was unable to locate resident #16's plan of care for smoking safely and unsupervised, and to safely store his own smoking materials. Resident #16's plan of care indicated that resident #16 had deformities of the hands. The facility noted in the plan of care that the resident needed to leave the campus to smoke. During an interview with staff member I on 1/4/12 at 11:15 a.m., she stated she had, "just created resident #16's smoking care plan that morning, along with his smoking assessment". Staff member I stated, "I did not actually perform the smoking assessment the morning of 1/4/12, but I have seen resident #16 smoke before, so I based the assessment on that". Staff member I further stated she, "did not know where resident #16 placed his cigarette butts when finished, since there was no ashtray outside". Staff member I stated that resident #16 used to keep his smoking materials locked up in the nursing cart and since then, he has forgotten to give them to the nurse. At the time of the survey, resident #16 was keeping his smoking materials with him. Staff member I further stated she didn't think resident #16 was safe to smoke unsupervised and if the facility was a smoking facility. She stated she did not feel that resident #16 would be assessed as a safe smoker.