Every finding on record at Brendan House

Based on observation, interview, and record review the facility failed to ensure staff properly followed EBP (Enhanced Barrier Precautions), maintained a clean environment with urinal care and used proper hand hygiene for 4 (#s 12, 33, 42, and 54) out of 4 residents sampled for resident care observations; failed to ensure staff used proper hand hygiene during the medication pass for 1 (#85) out of 1 resident observed; failed to ensure staff properly cleaned the glucometer for 2 (#s 20 and 55) out of 2 residents observed for blood glucose measurements; and failed to review vaccine and infection control policies annually. This deficient practice increased the likelihood of spreading infection. Findings include:1. Resident CaresDuring an observation and interview on 7/27/26 at 3:02 p.m., staff member A did not perform hand hygiene before entering or after exiting resident #33's room. Resident #33's room had an EBP precaution sign and EBP cart outside his room. Staff member A stated resident #33 was on EBP precautions due to a history of MRSA (methicillin-resistant Staphylococcus aureus); however, the resident did not have a current MRSA infection.During an observation on 7/27/26 at 3:27 p.m., residents #12 and #54's room had an EBP precaution sign and EBP cart outside their room. Staff member E did not perform hand hygiene before entering residents #12 and #54's room. Staff member E exited the room with a filled, tied garbage bag; staff member E did not wear gloves and did not perform hand hygiene after they exited residents #12 and #54's room. Staff member E walked down the hall to a locked door. Staff member E, with her soiled hand, typed on the keypad above the door handle; staff member E entered the locked room. Staff member E exited the locked room with an empty garbage bag. Staff member E entered residents #12 and #54's rooms without performing hand hygiene and placed the empty garbage bag into a garbage can in the residents' room.During an observation on 7/28/26 at 8:16 a.m., staff member A did not perform hand hygiene before entering resident #33's room (EBP precautions were in effect) with medications (in a plastic medication cup) and a vitals monitor machine on wheels. Staff member A did not perform hand hygiene after exiting the resident's room.During an observation on 7/28/26 at 8:16 a.m., resident #42's room had an EBP precaution sign and EBP cart outside their room. Staff member D did not perform hand hygiene before donning a gown and gloves and then entered resident #42's room. Resident #42 asked staff member D to empty his urinal and re-adjust the pillow at the foot of the bed. Staff member D re-positioned the pillow under the resident's feet and picked up the plastic used urinal from the resident's bedside table. Staff member D emptied the urine from the plastic urinal in the resident's bathroom toilet. Staff member D filled the urinal approximately one-fourth full of water from the bathroom sink. Staff member D emptied the water into the toilet. Staff member D did not disinfect the bathroom sink. Staff member D placed the emptied plastic urinal back on the resident's bedside table next to their television remote and water cup. During an interview on 7/29/26 at 4:01 p.m., staff member M stated the expectation for hand hygiene, in regard to EBP precautions, would include each staff member using an alcohol-based hand sanitizer before entering a resident's room and immediately after they exited the resident's room. Record review of the facility's policy titled, Enhanced Barrier Precautions Policy IPC326, last revised on 07/2026 showed: .3. Personal Protective Equipment (PPE). After care:-Remove (doff) gown and gloves inside the resident room-Discard PPE in appropriate waste receptacle-Perform hand hygiene immediatelyAdditional requirements:-Perform hand hygiene before and after each resident encounter.2. Medication PassDuring an observation on 7/30/26 at 7:49 a.m., staff member B picked up a clean plastic medication cup and set it on top of the medication cart. Staff member B used the alcohol-based hand sanitizer that was on the cart. Staff member B opened the top drawer of the medication cart and began gathering and organizing the stock medication bottles. Staff member B opened the second drawer of the medication cart and pulled resident #85's medication cards from the cart. Staff member B began to remove resident #85's medications from the cards into the previously handled plastic medication cup. Staff member B did not perform hand hygiene before entering the resident's room or before administering the medications to the resident. Record review of the facility's policy titled, Hand Hygiene, IPC104, last revised: 02/2026 showed: .Procedure1. When to perform hand hygiene- .-Immediately before each episode of direct patient contact/care, including clean/aseptic procedures-Immediately after each episode of direct patient contact/care-Immediately after contact with body fluids, mucous membranes and non-intact skin-Immediately after contact with objects and equipment in the immediate patient environment or other activities that could result in hands becoming contaminated-Immediately after the removal of gloves, including between the exchange of dirty and clean gloves2. In addition.C. Before and after handling/administering medicines.I. After removing personal protective equipment.3. Glucometer CleaningDuring an observation and interview on 7/30/26 at 8:16 a.m., staff member C did not perform hand hygiene or clean the glucometer before inserting the glucose strip into the glucometer device. Staff member C did not perform hand hygiene when picking up gloves and a cotton ball and then entered resident #20's room. Staff member C exited the resident's room and placed the glucometer at its station without disinfecting it. Staff member C stated that the resident needed more insulin due to her blood sugar. Staff member C did not perform hand hygiene before picking up additional supplies (gloves and alcohol pad) or before they entered the resident's room.During an observation and interview on 7/30/26 at 8:37 a.m., staff member C stated they needed to obtain a blood glucose for resident #55 before they prepared their medications. Staff member C did not perform hand hygiene or clean the glucometer before they placed a glucose strip in the testing machine. Staff member C gathered supplies (gloves, cotton ball, alcohol pad, and lancet) and entered resident #55's room. Staff member C did not perform hand hygiene before they used the alcohol pad to wipe the resident's middle fingertip. Staff member C did not perform hand hygiene before they donned gloves. Staff member C used the lancet to prick the resident's finger and obtained a blood glucose sample. Staff member C removed their gloves and exited the resident's room without hand hygiene being done. Staff member C returned the glucometer to the glucometer station without disinfecting it.During an interview on 7/30/26 at 9:11 a.m., staff member C stated they should have cleaned the glucometer between each resident with a grey top disinfectant wipe (Sani-Cloth AF3, Large Wipes). Staff member C stated there were no grey top disinfectant wipes at the medication cart and that is why they did not follow protocol. Staff member C stated if the wipes were at their cart, they would have used a grey top wipe to clean the glucometer before they placed the glucose strip in it, and after a blood glucose sample/reading was obtained.Review of the facility's glucometer instructions titled, It Takes 2 To Clean the Freestyle Precision Pro Right! (laminated and placed at the glucometer station) showed:Glucometers must be cleaned AND disinfected after each use. Hand Hygiene 1. Put on gloves2. Clean glucometer with Sani-Cloth wipe3. Disinfect with a second Sani-Cloth wipe4. Allow glucometer to stay wet for 3 minutes5. Continue use or put away.4. Infection control policiesDuring an interview on 7/29/26 at 4:01 p.m., staff member M stated the facility staff reviewed the immunization and infection control policies bi-annually per the facility's protocol. Staff Member M stated they were not aware CMS (Centers for Medicare and Medicaid Services) regulations for long-term care facilities required the policies to be reviewed annually.Record review of the facility's policy titled, Protocol for administering COVID-19 Vaccines, showed: Origination 03/2021, Last Approved 03/2021, Effective 03/2021, Last Revised 03/2021, Next Review 03/2023 . Applicability [Facility Name]

Based on observation, interview, and record review, the facility failed to ensure resident representatives were contacted to provide informed consent before medication, vaccine administration, and adaptive equipment/restraints were used for 4 (#s 10, 60, 94, and 99) of 30 sampled and supplemental residents. Findings include:During an observation on 7/28/26 at 9:11 a.m., resident #99's bed was against the wall with the right siderail up.During an observation on 7/30/26 at 9:42 a.m., resident #94 was sleeping in her bed with bilateral side rails up. The bed was against the wall on the right side.During an interview on 7/27/26 at 3:07 p.m., NF3 stated they had difficulty with the facility for resident consents and notifications. NF3 stated even though they were the responsible party legally for multiple residents, including resident #10, #94, and #99, the facility would have the residents verbally or even sign consents for vaccinations and medications. The facility would not notify the responsible party of events. NF3 stated the facility had resident #99 sign a vaccination consent when he legally should not. NF3 stated they requested to have a printed consent to sign to ensure they are dated properly and signed by them as required. NF3 stated they would know the facility had some residents sign consents instead of the responsible party because she would get some consents for one unit but not the other unit when it was time for vaccinations.During an interview on 7/29/26 at 8:54 a.m., resident #99 stated he had a person who handled all of the signatures for consents, and he was not supposed to sign anything.During an interview on 7/29/26 at 4:08 p.m., staff member M stated the nursing staff could find the responsible party by going to a summary page on the EHR for notifications. Staff member M stated the infection preventionist obtained consent for vaccinations, and the doctor obtained consent for medications before ordering. For adaptive equipment, the nurse or resident care manager would call the responsible party for consent.During an interview on 7/30/26 at 10:10 a.m., staff member J stated the expectation of the facility staff was to obtain consent for new medications or adaptive equipment such as side rails prior to administering them. Staff member J stated facility staff would find who the responsible party was by looking at the profile tab in the EHR to inform them of a change or obtain consent. The expectation was to get a new consent for a medication increase and annually for adaptive equipment/restraints. Staff member J stated if the responsible party was not able to be contacted, the residents that were cognitively intact were asked for verbal consent to start the medication or adaptive equipment. Staff member J stated facility staff were aware of guardians and POA's but did not know if they received training on the difference in POA, DPOA, and Guardianship or how some may be split between several people.During an interview on 7/30/26 at 10:23 a.m., staff member C stated nurses could find the responsible party information in two places: either the hard chart or the EHR under the profile tab. Staff member C stated she was not trained on the different types of responsible parties and their roles but had been at former jobs. Staff member C stated she would call whoever was listed in the profile tab for notifications.Review of resident #10's Letters of Permanent Conservatorship, dated 3/13/25, showed the Western Chapter for the Prevention of Elder Abuse was named conservator of resident #10.Review of resident #10's consents showed:- Psychotropic Medication Consent, effective date of 6/2/26, showed it was for pregabalin. The person noted as consenting was resident #10 on 5/31/26, in person/verbal. The note under 2d. If verbal consent obtained, name and title of witness, was, Not required per [facility] policy.- Bedrail Evaluation and Consent - V2, effective date of 5/17/26, with the name of guardian listed without date, type, or witness of consent.Review of resident #94's Court order, Order Appointing Permanent Full Guardian and Conservator of an Incapacitated Person, dated 6/21/23, showed the, The Western Chapter for the Prevention of Elder Abuse was the appointed Guardian for resident #94.Review of resident #94's Consents showed:- Bedrail Evaluation and Consent - V2, effective date 5/17/26, showed the name of the guardian consenting, but did not have a date, type of consent, signature, or witness information completed.- Vaccine Consent - V2, effective date of 6/24/26, printed version showed the guardian signed on 6/26/26.- Psychotropic Medication Consent, effective date 6/8/26, for escitalopram and olanzapine, did not have the goals or behaviors marked for the use of the medications. The name of the guardian was entered with POA, date of consent blank, and In-person (Verbal) was marked with a note of, medications being reviewed during care conference. Section 2d. If verbal consent obtained, name and title of witness, was blank.Review of resident #99's Letters of Permanent, Full Guardianship, dated 12/17/24, showed the Western Montana Chapter for the Prevention of Elder Abuse was appointed guardian of resident #99.Review of resident #99's consents showed:- Bedrail Evaluation and Consent - V2, effective date of 5/17/26, showed the person giving consent was the guardian. The date of consent, type, and witness were blank.- Bedrail Evaluation and Consent - V2, effective date of 6/11/26, showed the person providing consent was resident #99 on 6/11/26 in person/verbal witnessed by a nurse.- Psychotropic Medication Consent, dated 7/12/24, showed it was for trazodone. A handwritten line through the Trazadone and Zydis with a note of, D/C 7/2/24. [sic] No consent for the current order of trazodone was provided before the end of the survey.Review of resident #60's Montana Statutory (Durable) Power of Attorney, dated 4/19/23, showed it was effective immediately for all medical care with a different primary DPOA than the person on the consents.Review of resident #60's consents showed:- Bedrail Evaluation and Consent - V2 with an effective date of 5/17/26, showing consent by POA through email on 5/17/26. The email was not provided.- Opioid Medication Consent -V2 with an effective date of 5/5/26, for oxycodone, showing verbal consent by the State POA by verbal/telephone. Under 2d. If verbal consent obtained, name and title of witness, with a note of, Not required per [facility] policy.- Psychotropic Medication Consent with an effective date of 6/8/26, for aripiprazole and bupropion. Person providing consent: Resident #60, POA verbally in person. Effective date of consent was blank, and witness of consent was blank.- Vaccine Consent - V2 with an effective date of 6/9/26, showed influenza and Boostrix (TdaP) by POA [Parent] verbally by telephone.Review of the facility policy titled Side Rail Use, last reviewed 12/2024, showed, The informed consent for the use of a side rail(s) is signed by the resident/responsible party. This is necessary to show the informed consent of the resident/responsible party with an intervention that has the associated safety risk of entrapment . side rail usage and purpose of side rail will be addressed by IDT with the resident/responsible party at the admission, quarterly, significant change and annual Minimum Data Set (MDS) care plan process conferences.Review of facility policy, [Facility] Vaccines Protocol, no date, showed, .after performing a chart review and Vaccine Consent documentation .

Based on observation, interview, and record review, the facility failed to ensure medications were administered as ordered for 1 (#8) of 30 sampled and supplemental residents and licensed staff were leaving medications at the resident's bedside for the resident to self-administer the medications. Findings include:During an interview and observation on 7/28/26 at 8:37 a.m., six pills and a Symbicort inhaler were sitting on resident #8's bedside table. Resident #8 stated he had received them from the nurse a while ago. Resident #8 could not remember an approximate time the medications were left on his bedside table.Record review of resident #8's medical record showed a Supervised Self-Administration order for medications dated 7/23/26 at 6:21 p.m.During an interview on 7/28/26 at 12:48 p.m., staff member A stated a supervised self-administration order (regarding medications) meant the nurse did not need to feed the resident the medications but had to watch the resident take the medications. Staff member A stated that to leave medications at the bedside, unsupervised, the resident would need to have an order for bedside administration. Staff member A stated those orders are rare on this block due to the number of residents diagnosed with dementia.During an interview on 7/29/26 at 3:42 p.m., resident #8 stated he had been taking his medications by himself without a nurse watching for . quite a long time . at first they watched me, but then they trusted me to do it on my own. Resident #8 could not recall a definitive time frame on when the nursing staff began to trust him to take the medications without supervision. Resident #8 has lived at this facility since 1/30/26.Review of resident #8's assessment, titled, N Adv - Self-Administration of Medication, effective date 7/28/26 at 14:41 (2:41 p.m.), e-signed by staff member L showed: 1. Self-Administration of Medication . 3. Can the resident accurately tell time to know when medications need to be taken-(a)YES . 22. Self-Administration of Medication Notes-Resident is supervised self administration of oral medication.23. Resident is approved for self-administration of medications-(a)YES24. Resident may keep meds at bedside-(b) NO. This assessment was completed approximately six hours after the medications had been left at the resident's bedside.Review of the facility's policy, Medications, BH219, revised on 7/2026, showed: .F. Medication self-administration:Upon admission, if residents are identified as wanting to self-administer medications, an evaluation will be completed.Residents' ability to self-administer medications will be reviewed quarterly, with significant changes, and annually.For residents determined safe to self-administer medications:The licensed nurse on each shift will ask residents if they have taken their medication, document the medications taken or not taken, and the response.

Based on interview and record review, the facility failed to ensure residents were free from verbal or physical abuse by staff for 1 (#43) of 30 sampled and supplemental residents. This deficient practice was corrected on 11/12/25. Findings include:Review of the facility investigation file, dated 11/12/25, showed the facility had substantiated abuse by a staff member (NF2) against resident #43. Resident #43 reported NF2 had hit her on the arm and called her an asshole. Review of the investigation file on 7/30/26 showed the facility reported the incident according to the required timeframes, assessed the affected resident, evaluated other residents for potential abuse concerns, and kept residents safe from further abuse while the investigation occurred. Staff education on abuse and neglect was completed. QAPI meets monthly and reviews reportable incidents.During an interview on 7/28/26 at 11:15 a.m., resident #43 did not remember or state any concerns related to the incident with NF2, which had occurred last November. Progress notes in the time period afterwards showed follow up evaluations for psychosocial harm, with none noted. The arm bruise was unable to be definitively identified as a result of NF2 hitting the resident's arm, or from her routine insulin injections. During an interview on 7/29/26 at 3:51 p.m., staff members I and K stated NF2 did not have any red flags in her background that were concerning. NF2's employee file contained a passed background check and drug screen. Her abuse and neglect training was up to date, and she did not have any negative occurrences against her license. NF2 started working at the facility on 10/21/25. After the allegation, NF2 was immediately suspended while an investigation occurred, and she never returned to work before her termination upon substantiation of the allegation.Due to the facility's corrective actions taken, this failure was cited as Past Non-Compliance.

Based on interview and record review, the facility failed to ensure resident medications were accurately coded on MDS assessments for 1 (#10) of 30 sampled and supplemental residents. Findings include:Review of resident #10's Quarterly MDS Assessment, with an ARD of 7/16/26, showed the resident was receiving antipsychotics on a routine basis.Review of resident #10's medication list did not show any active antipsychotic medications.During an interview on 7/29/26 at 12:20 p.m., staff member J stated resident #10 was coded for antipsychotics because she took long-term lithium. Staff member J stated they did not realize lithium was a mood stabilizer versus an antipsychotic, and they would go back and correct the previous MDS assessments.

Based on observation, interview, and record review, the facility failed to ensure oxygen tubing was free from contamination for 1 (#27) of 30 sampled and supplemental residents, increasing the risk of respiratory infection. Findings include:During an observation on 7/28/26 at 8:19 a.m., oxygen tubing with a nasal cannula was connected to resident #27's oxygen concentrator and observed lying on the floor; it was not labeled with the date when it was last changed. During an observation on 7/28/26 at 11:34 a.m., oxygen tubing with a nasal cannula was connected to resident #27's oxygen concentrator and observed lying on the floor, without a label or date of when it was last changed. During an observation on 7/28/26 at 3:55 p.m., oxygen tubing with a nasal cannula was connected to resident #27's oxygen concentrator and observed lying on the floor, unchanged from prior observations. During an observation on 7/29/26 at 9:12 a.m., oxygen tubing with a nasal cannula was connected to resident #27's oxygen concentrator and observed lying on the floor, unlabeled. This surveyor observed staff member F ask the resident if she was experiencing any respiratory symptoms like congestion, and the resident told staff member F she does feel congested, like there is a weight on her chest. Staff member F administered the resident's inhaler and morphine. The oxygen tubing was not picked up or replaced during the observation.During an interview on 7/28/26 at 8:19 a.m., resident #27 stated she used oxygen from the oxygen concentrator at night.During an interview on 7/28/26 at 3:50 p.m., staff member G stated oxygen tubing was replaced as needed if it had been damaged or soiled or if it was found lying on the floor. The oxygen tubing was to be hung up off the floor if not in use.During an interview on 7/29/26 at 11:31 a.m., staff member H stated the task of Replace oxygen tubing, nasal cannula and mask was prompted in the CNA tasks in Point Click Care, the electronic medical record system, on Tuesdays at 2100 (9:00 p.m.), every two weeks. There was no documentation for as needed changing of oxygen tubing and nasal cannula. He stated that the tubing was to always be replaced and was not aware that the tubing would be cleaned instead of being replaced. He stated that there was not specific training for oxygen tubing replacement needs other than company policy and a skills check when staff started working at the facility. He stated that tubing lying on the floor would be an indication of the tubing needing to be replaced.A review of the facility's policy, Adult Oxygen Therapy at [Facility Name], BH243 showed: Procedure Infection Prevention . (2) Replace all oxygen tubing, nasal cannula and mask every 14 days or sooner if soiled/nasal prongs are discolored.A review of resident #27's comprehensive care plan, revised 4/8/26, showed supplemental nocturnal oxygen 1-2 L/min via nasal cannula to keep oxygen level above 90%.A review of resident #27's oxygen physician order, dated 6/30/26, showed supplemental nocturnal oxygen 1-2 L/min via nasal cannula to keep oxygen level greater than 90%.A review of resident #27's Treatment Administration Record on 7/29/26 showed that the resident had been administered nocturnal oxygen on 7/28/26.A review of resident #27's task record showed that the resident's oxygen tubing had not been replaced on 7/28/26, 14 days after the last tubing replacement.

Based on observation, interview, and record review, the facility failed to ensure staff properly secured medications and the medication cart, and licensed staff failed to ensure sanitary conditions for stock medications were maintained; these failures had the potential to affect any resident's medications or processes related to them. Findings include:During an observation and interview on 7/30/26 at 7:49 a.m., staff member B pulled a stock bottle of Certa-Vite (multi-vitamins) out of the medication cart. The bottle of Certa-Vite did not have a lid, and a plastic medication cup was placed on top of the bottle. Staff member B stated, I guess they lost the lid to my Certa-Vite. Staff member B removed the plastic medication cup and poured one tab of Certa-Vite into the medication cup. Staff member B poured the Certa-Vite tab into a new plastic medication cup and returned the original plastic medication cup to the stock bottle of Certa-Vite. Staff member B placed the unopened stock bottle of Certa-Vite with the used plastic medication cup back into the medication cart.During an observation on 7/30/26 at 8:16 a.m., staff member C pushed in the lock on the medication cart, locking it (no red alert dot was visible). Staff member C left the medication cart keys sitting on top of the medication cart unattended and out of staff member C's sight while they delivered medications to a resident.During an observation and interview on 7/30/26 at 8:26 a.m., staff member C stated they had to check the sliding scale for a resident. Staff member C used the medication cart's computer to look up sliding scale information. Staff member C left the medication cart unattended and out of their sight with the medication cart's keys sitting on top of the cart and entered the resident's room.During an observation on 7/30/26 at 9:08 a.m., the 300-unit medication cart was left unattended in the dining area. The medication cart's lock was not pushed in (locked), and the red alert dot was visible. The medication cart keys sat on top of the medication cart.During an observation on 7/30/26 at 9:13 a.m., staff member C left the medication cart unattended and out of their sight to search for disinfection wipes. Staff member C did not secure the lock on the medication cart (the lock on the cart was not pushed in and the red alert dot was visible). Staff member C left the medication cart keys on top of the cart and left two stock bottles of Aspirin and an unknown medication on top of the cart. Review of the facility's policy, Medications, BH219, revised on 7/2026, showed: . C. Medication carts are used to store resident medications.Medication cart keys are to always be in the physical possession of the licensed nurse.Medication carts and other medication storage units will be locked when not in direct view of the licensed nurse.

Based on observation, interview, and record review, the facility failed to prevent a severe weight loss in 1 (#5); and the facility failed to complete weekly weights for four weeks, on a new admission for 1 (#87) of 6 sampled residents for nutrition. Findings include:1. During an interview on 7/16/25 at 3:13 p.m., staff member D stated all physicians were notified when a resident was brought to NAR (Nutrition at Risk). Staff member D stated she could not write nutrition orders, but she could order supplements. Staff member D stated weights were supposed to be obtained the first weekend of the month. Staff member D stated she pulled reports on resident weights the following week. Staff member D stated the staff also sent a message if the resident had weight loss. Staff member D stated resident #5 was being followed by NAR, was receiving chocolate glucose control supplement, and Juven. Staff member D stated resident #5 had a significant decline related to progressing dementia. Staff member D stated care plans were updated quarterly, annually, and on admission. Staff member D stated if the care plans needed updated between the quarterly, annually, or on admit, it was the responsibility of the RCM (Resident Care Manager). Staff member D stated she was not involved in QAPI but stated she has been working on a new cycle of nutrition with the kitchen. During an observation on 7/16/25 at 5:15 p.m., resident #5 was in the dining room for evening meal. During an observation on 7/17/25 at 7:32 a.m., resident #5 was in the dining room for morning meal. At 7:55 a.m. the resident was served coffee. At 8:01 a.m. the resident was served his food, ate independently, and appeared to be eating slowly. During an interview on 7/17/25 at 8:51 a.m., staff member E stated resident #5 was supposed to eat in the unit dining room. Staff member E stated the resident was resistant to getting out of bed. Staff member E stated the resident’s daughter wanted him up for meals. Staff member E stated the resident was previously a one to one for supervision while eating but was now under in-sight supervision only in the dining room. Staff member E stated the dietician did bring up weight loss as a concern. She stated the resident had some problems eating and swallowing. Staff member E stated the resident had speech therapy because of difficulty swallowing. Staff member E stated the resident was doing much better with eating and feeding himself when he was up out of bed and in the dining room. During an interview on 7/17/25 at 9:25 a.m., staff member MM stated resident #5 was supervised for meals. Staff member MM stated the residents’ meals were in between minced (finely chopped) and moist (foods that are soft and moist) diet textures. Staff member MM stated the resident used to be a one-to-one assist for meals but now was in sight supervision while in the dining room. Staff member MM stated the resident was working with Speech Therapy. During an interview on 7/17/25 at 10:01 a.m., Staff member B stated the residents were assessed on admission for nutrition concerns. Staff member B stated the dietitian was involved to evaluate interventions, implement interventions, communicate with family, and educate the staff. Review of resident #5’s weight record showed the resident weighed 132 lbs., on 6/9/25 and 120 lbs., on 7/12/25, which is a 9% severe weight loss in one month. Review of resident #5’s Nutrition/Dietary Progress Note, dated 6/10/25, showed staff member D was “unable to meet with the resident due to the flooring crew blocked the room. The resident was added to the NAR program due to severe weight loss in three months.” Review of resident #5’s Nutrition/Dietary Progress Note, dated 6/23/25, showed staff member D and staff member E met and discussed the resident’s worsening pressure wound to his right foot. The plan was to add Juven meal supplement two times daily for wound healing. Review of resident #5’s Nutrition/Dietary Progress Note, dated 6/24/25, showed the resident was to have weekly weights. The resident was followed due to malnutrition diagnosis. Review of resident #5’s Nutrition/Dietary progress note, dated 7/10/25, showed the resident required supervision and cueing during meals. The resident was documented as nutrition at risk (NAR) and was in the program due to a malnutrition diagnosis and wounds. 2. During an observation on 7/14/25 at 4:15 p.m., resident #87 was lying in bed with oxygen on. Resident #87 appeared thin and frail. Resident #87’s skin color was pale. Three unopened sugar free Boost containers were sitting by the television. During an interview on 7/15/25 at 8:08 a.m., resident #87 stated he was terminal and had a decrease in his appetite, but the facility was providing him with Boost at mealtimes. Resident #87 stated he does not always drink them. During an interview on 7/16/25 at 3:10 p.m., staff member D stated all residents who were new admissions were to be weighed weekly for four weeks to help establish a baseline weight. Staff member D stated the weights were documented in the medical record. Staff member D stated sometimes residents would refuse to be weighed but the refusal should also be documented in the medical record. Review of resident #87’s weight documentation from 6/27/25 to 7/17/25, showed a weight of 173.4 pounds on 6/27/25. No other weights were documented in resident #87’s electronic medical record. Review of a facility document titled, “Weight/Nutrition at Risk, BH320,” with an effective date of 3/2025, showed: “Policy 1. All patients/residents will be weighed on admission… and weights will be obtained weekly x 4 weeks and then monthly thereafter…”

Based on observation, interview, and record review, the facility failed to obtain evaluations and provider orders for residents to self-administer medications for 4 (#s 28, 40, 90, and 93) of 11 residents sampled for self administration capabilities. Findings include:1. During an observation and interview on 7/16/25 at 12:55 p.m., resident #90 was lying in bed with her nebulizer running, and the nebulizer mouthpiece was under her blanket. Resident #90 stated she tried to hold the nebulizer up to her mouth but was busy on her cell phone looking for something and became tired. Resident #90 appeared to be short of breath and was coughing throughout the interview. During an interview on 7/16/25 at 12:56 p.m., staff member L stated he usually set up the nebulizer, and resident #90 completed the nebulizer treatment on her own. Staff member L stated the nurses were responsible for filling out the self-administration of medication evaluation and requesting an order from the physician. Staff member L reviewed resident #90's paper chart and EHR, stating he could not find a self-administration evaluation or an order for resident #90 to self-administer medications. A review of resident #90's EHR reflected that resident #90 had an order for Ipratropium-Albuterol solution 3 ML, inhale orally, four times daily. A review of resident #90's paper chart reflected that resident #90 was seen by the physician on 7/16/25 at 4:15 p.m., and physician orders were received for Mucinex, for the resident's cough, and Augmentin and Doxycycline, for pneumonia. 2. During an observation and interview on 7/16/25 at 8:42 a.m., resident #28 was sitting in his recliner watching television. A cup of pills was on his bedside table next to the recliner. Resident #28 stated, They leave them (the pills), and I take them at some point. During an observation and interview on 7/17/25 at 8:50 a.m., resident #28 was sitting in his recliner watching television. A cup of pills was on the bedside table next to the recliner. Resident # 28 stated, Oh, I should probably take my pills, huh? During an interview on 7/17/25 at 10:27 a.m., staff member L went through the paper charts for resident #28 and stated that resident #28 did not have an assessment or physician order for the self-administration of medications. Staff member L stated resident #28 took a half hour to take his medications because of a swallowing issue, so he leaves the pills with the resident so he can take them at his own pace. A review of resident #28's EHR reflected resident #28 had an order for Ipratropium-Albuterol solution 3 ML, inhale orally, four times daily. 3. During an observation and interview on 7/15/25 at 10:12 a.m., resident #40 had a full cup of pills on her table. There was no staff supervision at the time. Resident #40 set the medications off to the side and stated she would take them later. Review of resident #40's medication administration record, dated 7/15/25, showed that for the a.m. medications she received: Famotidine for acid reflux, levothyroxine for hypothyroidism, acetaminophen for pain, and Eliquis, a blood-thinning medication, for atrial fibrillation. Review of resident #40's Annual MDS, with an ARD of 5/19/25, showed she had a BIMS of 7; severe cognitive impairment. Review of resident #40's medical record failed to show she was assessed to safely administer her medications. 4. During an observation and interview on 7/15/25 at 3:22 p.m., resident #93 brought a plastic bag with assorted pills to the nurse. Staff member J stated they had no idea where the resident got them from, and they were not in facility packaging. During an interview on 7/16/25 at 10:37 a.m., staff member I stated that a resident had to have an order for self-administering medications or the nurse would have to remain with and watch the resident take the medications. During an interview on 7/16/25 at 10:42 a.m., staff member J stated “99% of the time we watch the residents take their meds, if I know a resident well, and there are no cognitive issues and no controlled meds, I will sometimes leave the meds with them and keep checking back on them to make sure they took them and didn’t drop any.” During an interview on 7/16/25 at 1:53 p.m., staff member K stated, “The nurses do not leave medications at the bedside. The resident would have to have a medication self-administration assessment and a provider order, for the nurses not to observe the resident taking the meds.” A review of a facility provided list, titled, “Self-Administration,” listed six residents, who were the only residents approved by the facility to self administer medications. Resident #’s 28, 40, 90, and 93 were not on the list. A review of #28, 40, 90, and 93's provider orders, located in the EHRs, failed to show a provider order allowing the resident to self-administer medications. A review of a facility document titled, “Interdisciplinary Team Evaluation of Resident Self-Administration of Bedside Medications,” undated, showed: “… Interdisciplinary Team Evaluation: The interdisciplinary team has evaluated and assessed [blank]’s cognitive, physical and visual ability to carry out the responsibility of self-administering drugs. (Check one) ( ) Yes, [blank] is cognitively, physically and visually able to self-administer all of her/his dispensed medications in a medication cup left at her/his bedside ( ) Yes, [blank] is cognitively, physically and visually able to self-administer certain medications. …”

Based on observation, interview, and record review, the facility failed to implement care planned assessments for seatbelt use for 1 (#1); failed to include pertinent resident care items including cardiac monitoring and CPAP settings into a comprehensive care plan for 2 (#s 12 & 19); failed to include focus, goals, or interventions on the comprehensive care plan for oxygen use and nutritional supplement use for 1 (#87); and failed to include ADL's and mobility on a comprehensive care plan for 2 (#s 30 and 87) of 43 sampled residents. Findings include:1. During an interview on 7/17/25 at 7:43 a.m. staff member G stated resident #12 had been moved to the pod in May, and she was currently working on her most recent MDS assessment to trigger care plan updates. Staff member G stated care plan updates were also ongoing as resident concerns developed, and this would trigger an update for additional devices or medications. Review of resident #12's hospital H&P, dated 2/20/25, showed the resident had been admitted for syncope and collapse, which resulted in the resident having a cardiac pacemaker placed. Review of resident #12's nursing progress notes, dated 7/7/25, showed, The cardiac monitoring company called this morning to say [Resident #12's] pacemaker monitor was offline … The facility had further communications to replace the lost monitor. Review of resident #12's comprehensive care plan, with an initiation date of 1/31/25, failed to show the resident was on any cardiac monitoring. 2. During an interview on 7/16/25 at 2:12 p.m., resident #19 stated she had always been an anxious person, but was having increased anxiety at night, which worsened her respiratory status. Resident #19 stated she had a paid caregiver who would stay with her at night when she lived at home, and she continued to pay this person to stay with her at night, from 11:00 p.m. to 6:00 a.m., in the facility as well. Resident #19 stated she had a bipap mask to wear when she slept, but it made her very claustrophobic, and she was reluctant to wear it even though she understood it would help when her breathing was difficult. Review of resident #19's physician orders, dated 7/2/25, showed, BiPAP as HS and prn 3L O2 bleed in Trial of nasal bipap over mouth mask. [sic] Review of resident #19's care plan, with an initiation date of 5/8/25, failed to show any documentation of the resident's nighttime sitter. The focus area of CPAP/BiPAP therapy did not have any interventions listed. 3. During an observation on 7/14/25 at 4:15 p.m., resident #87 was lying in bed with oxygen on, and the oxygen concentrator was set to 1.5 liters. There were three full, unopened containers of sugar-free boost, sitting next to his television. A walker was present in the room. During an interview on 7/15/25 at 8:08 a.m., resident #87 stated he had a diagnosis of lung cancer that had spread, and he was terminal. Resident #87 stated he used oxygen all the time. Resident #87 stated he has had a decrease in his appetite, but the facility was providing him with boost at mealtimes. Resident #87 stated he does not always drink them. Review of resident #87’s physician’s orders, dated 6/27/25 -7 /14/25, showed no physician order for the resident's oxygen use or the nutritional supplements provided at meals. Review of resident #87’s comprehensive care plan, with an initiation date of 7/9/25, showed no focus, goals, or interventions for oxygen use or nutritional supplement use. During an observation and interview on 7/15/25 at 10:15 a.m., resident #30 was sitting in a wheelchair at a table in the dining room, reading a book. Resident #30 stated he was able to move his wheelchair on his own by using his feet. During an interview on 7/15/25 at 2:41 p.m., NF3 stated resident #30 had memory problems and required assistance with his ADLs and mobility. During an observation on 7/16/25 at 12:40 p.m., resident #30 was in his wheelchair and was propelling himself, using his feet, back to his room. Review of resident #30’s comprehensive care plan showed no focus, goals, or interventions for ADL’s or his mobility. During an interview on 7/16/25 at 11:04 a.m., staff member S stated that residents #30 and #87 required assistance with ADLs and mobility. Staff member S stated she had a paper, which included information that showed her what each resident needed assistance with. Staff member S stated she did not look at the care plan, just the paper she had, which was basically a care plan. During an interview on 7/18/25 at 8:35 a.m., staff member E stated she helped oversee the care planning process and ensured staff were following the care plans. Staff member E stated care plans were done on admission, quarterly, annually, and with any significant change. Review of resident #87’s comprehensive care plan showed: “Focus-The resident has an ADL self-care performance deficit r/t Date initiated 7/14/25. Goal-Resident will improve current level of function in (SPECIFY ADLs) through the review date. Resident will be able to: (SPECIFY). Interventions-Praise all efforts at self care.” [sic] Review of a facility CNA document showed: “Resident #30- Bed: Ax2, Trans: Ax2, Gait Ax1 / WC. Resident #87-Bed: Ax1, Trans: Ax1 FWW, Gait: Ax1 FWW.” 4. During an observation on 7/16/25 at 10:13 a.m., resident #1 was in his wheelchair in the 100-hall, and there was a seatbelt attached to the chair. During an interview on 7/16/25 at 10:40 a.m., staff member N stated the nursing staff had become normalized” to resident #1 looking like he was going to fall out of his chair, due to his sliding down. During an interview on 7/17/25 at 8:30 a.m., with staff members A and H, staff member A stated physician orders for the seatbelt use were obtained one time. Staff member H stated that physician orders were completed when a device was initially implemented, and no further orders were needed after. Staff member A stated the facility did not have a policy specific to seatbelt use. During an interview on 7/17/25 at 10:16 a.m., staff member E stated when the facility changed to Point Click Care (electronic health record system), there was no template for the assessment for seatbelt use in residents, and this was why the quarterly assessments had not been done for resident #1 since October 2024. Review of resident #1’s care plan, reviewed on 5/25/25, showed: - “Obtain physician’s order to approve use of seat belt (ordered 12/2/23),” “Assess quarterly that [resident #1] continues to be able to unbuckle as he/she wishes and that the safety belt is still functioning in helping with positioning needs in wheelchair.” Review of a facility policy titled, “Care Planning Process, BH125,” with a revision date of 3/2025, showed: … “The care plan must describe the services that are to be furnished to attain or maintain the resident’s highest practicable physical, mental and psychosocial well-being. … 4. Care plans are individualized to address the resident’s problems, needs, severity of condition, impairment, disability, or disease. The care plan addresses needs and care priorities…” [sic] A review of the facility’s policy, Care Planning Process, last revised 3/2025, showed, “… The interdisciplinary team collaborates throughout the provision of care to implement interventions that help achieve optimal outcomes and to communicate and coordinate the support of the resident needs and care goals.”

Based on observation, interview, and record review, the facility failed to provide food at an appetizing temperature for 1 (#47) of 6 sampled residents for nutrition; and failed to ensure kitchen staff were wearing hair restraints, or wearing them properly, during food preparations. This deficient practice had the increased the risk of food borne illnesses for those who received meals in the facility. Findings include:1. During observations and interviews on 7/14/25 at 4:19 p.m., this surveyor was escorted into the kitchen by staff member CC through open double doors in the propped open position; no signage requiring hair coverings was noted; staff member CC walked approximately ten feet into the kitchen without a hair restraint, and was asked if she needed a hair net, her reply was, “Do I need a hair net?” Staff member DD was preparing dinner plates with her hair in a bun and a hat on; the hair by both of her ears had fallen out and was not restrained. Staff member EE was preparing dinner plates with a hair net on which did not restrain her hair from her forehead back approximately three inches. During observation and interviews on 7/15/25 at 12:49 p.m., staff member FF was preparing raw bacon on a cookie sheet pan with no beard covering. Staff member HH stated he did not know the exact hair covering policy. During an interview on 7/17/25 at 9:05 a.m., both staff members GG and JJ stated they were aware of staff not wearing appropriate hair restraints, and it was difficult to monitor because of the high turnover rate. During an observation on 7/17/25 at 9:05 a.m., the front portion of staff member KK’s hair was not covered completely by her hair net and staff member KK stated, My hair is struggling today. Yes, I am supposed to cover all my hair with the net. During an interview on 7/17/25 at 9:10 a.m., staff member GG stated there were hats available for staff who needed help to restrain their hair when a hair net was not enough. Staff member GG stated everyone who works in the kitchen should be supervising hair restraints. Staff member GG stated the main double doors were always propped open to the kitchen. Staff member GG stated she had a sign posted reminding people to restrain hair with nets before entering the kitchen, and stated, “I took them down two weeks ago because people get used to the postings and don’t see them anymore.” Review of a facility policy titled, Uniform Policy, revised 8/24, reflected: . 2. Hair Covering; Hats/hair covering will be worn at all times. a. Shall wear hair covering that will cover all hair…needs to be contained in a hair covering or above the collar, this may be a hair net, Logo [facility] caps or bonnet…” 2. During an observation on 7/15/25 at 7:45 a.m., resident #47 was lying in bed, asleep. Staff member U picked up resident #47’s breakfast tray, took the meal tray into resident #47’s room and set it on the bedside table, and left the room. During an observation and interview at 7/15/25 at 10:50 a.m., resident #47 was sitting at a table in the dining area eating breakfast. Resident #47 stated her breakfast was put in the microwave and given to her. Resident #47 stated it was not very good and cold in some areas. During an interview on 7/15/25 at 11:02 a.m., staff member U stated meal trays arrived between 7:30 and 7:45 a.m. Staff member U stated if a resident is not awake or up, the meal tray is delivered to the room. Staff member U stated, “When she (resident #47) wants her food we will reheat it for her.” Staff member U stated she did not know there were specific timelines or temperatures with food. Staff member U stated she had never used a thermometer to test food temperature after reheating the meal in the microwave. Staff member U could not verbalize how long a tray could sit out before it was unable to be eaten, or at what temperature the food should be heated to upon reheating. During an observation on 7/16/25 at 8:55 a.m., staff member R placed resident #47’s meal tray in front of her, took off the lid and buttered the waffle. The butter did not melt on the waffle. During an interview on 7/16/25 at 8:58 a.m., resident #47 stated her breakfast was cold and the waffle was tough. Resident #47 stated, “It would be better warm.” During an interview on 7/16/25 at 3:10 p.m., staff member D stated, “Food should not be served to a resident after two hours, anything longer than that is unsafe.” Staff member D stated it was not a standard of practice for nursing staff to be reheating or microwaving food. Staff member D stated, “If a resident is not going to eat right away the tray should go into the refrigerator or staff request a whole new tray when they are ready to eat.” Staff member D stated there was thermometers and food risk information on each unit. During an interview on 7/16/25 at 4:10 p.m., staff member N stated he had never seen a thermometer or food risk information on the unit. During an interview on 7/17/25 at 8:35 a.m., staff member E stated staff should not be reheating food for residents. Staff member E stated there was not a thermometer or food risk information on the unit. Review of a facility document titled, “Food Production Standards,” with an effective date of 5/2025, showed: . 5. Reheating of foods a. Food must be reheated to 165 degrees for 15 seconds within two hours. b. Do not mix leftover food with freshly prepared food. 6. If food is not handled as in above, throw it out.”

Based on observation, interview, and record review, the facility failed to provide dignity and privacy for a resident being transported to the shower room for 1 (#53); and failed to provide dignity and privacy for a resident in a dining room without bottoms on, with a catheter, and full catheter bag showing, for 1 (#2) of 3 sampled residents for dignity. This deficient practice resulted in resident #53 feeling embarrassed. Findings include:1. During an observation on 7/15/25 at 8:32 a.m., resident #2 was observed napping in the dining room, in a manual wheelchair, sitting on a chuck (disposable under pad). Resident #2 was facing the dining room and the unit entrance. Resident #2 had her clothing bottoms below her knees. Her catheter was visible, and the full catheter bag was facing outward, without a privacy cover on the outer side. Other residents and several staff were present. Staff weren't addressing the resident's dignity concerns for the visible catheter bag without the cover. During an interview on 7/17/25 at 10:58 a.m., staff member F stated she had been diligently trying several approaches to have resident #2 agree to put her pants on. Staff member F stated that eventually, resident #2 was taken to her room, she used a grab bar to stand, and her pants were pulled up. 2. During an observation on 7/16/25 at 9:02 a.m., staff member M entered resident #53’s room with a white shower chair. Resident #53 was in a hospital gown. Resident #53 was assisted to the shower chair, and he sat down. Resident #53’s back and buttocks were exposed and uncovered while in the shower chair. Staff member M wheeled the shower chair out of resident #53’s room and out past the dining room, where multiple residents and staff were sitting. Resident #53’s back and buttocks were visible to others as he was wheeled past the dining room. The staff member did not attempt to cover the resident's buttocks or back. During an interview on 7/16/25 at 9:30 a.m., staff member M stated residents should be fully covered before leaving their rooms for a shower or bath. Staff member M stated, “I did not check to make sure he (#53) was not exposed. I should have.” During an interview on 7/16/25 at 1:07 p.m., resident #53 stated he was upset and embarrassed that he was exposed to staff and other residents on his way to the shower. Review of a facility policy titled, “Resident Rights and Responsibilities, BHSS907,” with an effective date of 2/2025, showed: … “1. While at [Facility Name], a resident has a right to: … F. Privacy …”

Based on interviews and record review, the facility failed to ensure the medical provider was notified of a resident's severe weight loss, for one (#6) of 43 sampled residents. This deficient practice did not allow the physician the opportunity to plan or implement weight loss interventions. Findings include: During an interview on 7/15/25 at 8:32 a.m., resident #6 stated she had lost 26 pounds in the last month or two and was not sure why her appetite had declined.Review of resident #6's electronic health record showed resident #6 weighed 308 pounds on 1/6/25 and 248 pounds on 7/16/25, which was a 19.51% loss over the past six months; and on 6/9/25 she [resident #6] weighed 276 pounds, which was a 10.14% loss over the past month.During an interview on 7/16/25 at 9:16 a.m., staff members Z and AA stated resident #6 was independent with feeding herself, and they were not sure why resident #6's appetite was declining. Staff members Z and AA stated resident #6's son and daughter-in-law were aware of the weight loss. During an interview on 7/16/25 at 1:52 p.m., staff members AA and BB stated they were not aware resident #6 had lost 60 pounds over the last six months, or 26 pounds in the last month. During an interview on 7/16/25 at 3:08 p.m., staff member D stated resident #6 was admitted to the Nutrition at Risk Committee in May of 2025. Staff member D stated physicians were to be notified of significant weight losses when residents were admitted or discharged from the Nutrition at Risk Committee. Review of the electronic medical record for resident #6 showed a Nutrition at Risk Committee note, dated 6/24/25 at 2:29 p.m., reflected: .Significant weight loss in 6 months . Resident Care Manager to notify provider of weight loss .During an interview on 7/17/25 at 7:55 a.m., staff member F stated she did not notify resident #6's physician of the weight loss, I dropped the ball, I should have, it was my fault.During an interview on 7/17/25 at 8:53 a.m., staff member A stated the physician for resident #6 should have been notified of resident #6's significant weight loss in order to be involved with her care. Review of a facility policy titled, Weight/Nutrition at Risk, BH320, last revised 1/2023, showed: .All significant changes in weight (5% in 30 days; 10% in 180 days), .will be reported to the patient's/resident's provider .

Based on observations, interviews, and record review, the facility failed to provide residents access to grievance forms and the opportunity to file grievances anonymously for 1 (#8) of 43 sampled residents. Findings include: During an interview on 7/15/25 at 1:17 p.m., resident #8 stated the nurse practitioner told him he was dying, and his kidney function was down 63%. Resident #8 stated he was rushed to the hospital, and the hospitalist stated he was not dying, and his kidney function numbers were not that bad, and gave him a bolus of IV fluids. Resident #8 stated he was angry that the nurse practitioner put him and his wife through that trauma. Resident #8 stated he tried to figure out answers from the staff and was not able to get any answers. Resident #8 stated he was not aware of any grievance forms and had not seen grievance forms. Resident #8 stated he was very vocal about his concerns about the nurse practitioner scaring him and his wife with false information, but his wife would most likely want to file a grievance anonymously if she had the opportunity. Resident #8 requested a couple of forms to complete from the surveyor to file a grievance related to his concerns about the nurse practitioner scaring him and his wife with false information, and his concerns with the quality and temperature of food.During an observation on 7/15/25 at 1:30 p.m., no grievance boxes or forms were observed on the walls or in common areas of the unit. During an observation and interview on 7/15/25 at 1:33 p.m., staff members U, E, and Y looked through the nursing station on the unit and the file cupboards but were not able to locate any grievance forms. Staff member E called staff member B, who stated she would bring a form to the unit. Staff member E stated the forms were not kept on the units in the years she had worked for the facility.During an interview on 7/15/25 at 1:37 p.m., staff member H stated he had a form on his computer but was unsure of the process for handling it and would need to call staff member B for the process. Staff member H stated the forms were not readily available for residents to use anonymously.During an interview on 7/15/25 at 1:45 p.m., with staff member B and J, staff member B was unable to find grievance forms on the 400-hall but did locate forms in the back office on the 600-hall. Staff member J stated he did not know where to find the forms and would need to call a manager on duty for assistance and did not know how residents would complete a grievance anonymously.During an interview on 7/15/25 at 2:01 p.m., staff member A stated the residents did not have access to grievance forms on the units to complete them anonymously. Staff member A stated that the residents can ask staff for a form. Staff member A stated the form staff member B found in the 600 hall was not the correct form. Staff member A stated the facility preferred to address concerns in the moment rather than handling forms filed anonymously.A review of the facility's policy, Patient Complaints and Grievances, revised 7/2025, reflected:- 1. At the time of admission or check-in, patient registration staff will provide patients and patient representatives with the Patient Rights & Responsibilities, which will describe how to submit Complaints and Grievances as well as the investigation and resolution process. There was no information or instructions for residents to file a grievance anonymously. A review of the facility provided, Facility Rights and Responsibilities, dated 4/15/25, reflected:- . (20) GRIEVANCES. To voice grievances to the facility or the resident council about care or treatment you or other residents receive, without discrimination or reprisal. The facility shall establish written procedures for receiving, promptly handling, and in- informing you or the resident council of the outcome of any grievance presented, including those with respect to the behavior of other residents. You also have the right to ask a state agency or a resident advocate for assistance in resolving grievances, free from restraint, interference, or reprisal. There was no information or instructions for residents to file a grievance anonymously.A review of the facility provided list of grievances, with no date, did not reflect any grievances filed for resident #8, including after he returned from the hospital and voiced his concerns.

Based on observation, interview, and record review, the facility failed to keep a resident free from a physical restraint for 1 (#60) of 1 sampled resident. This deficient practice caused the resident to be unable to get out of a Broda chair independently, and caused the resident to be agitated and yell to get out of the chair. Findings include:During an observation on 7/16/25 at 8:42 a.m., resident #60 was sitting in a Broda chair. The back of the chair was reclined at about a 45-degree angle, and the footrest was in the up position. The resident's feet were unable to reach the floor. Resident #60 was sitting parallel to a table in the dining room. Resident #60 was yelling that he wanted out of the chair, and he was trying to climb over the arm of the chair.During an observation on 7/16/25 at 8:52 a.m., resident #60 continued to be in the Broda chair, sitting parallel to a table in the dining room. Resident #60 was attempting to get out of the Broda chair, but he was not able to. The Broda chair was reclined at about a 45-degree angle, and the footrest was in the up position, so his feet were not able to reach the floor. Resident #60 became agitated, then he threw a blanket and three pillows onto the floor in the dining room. Resident #60 stated, Get me out of this chair, multiple times. Resident #60 tried to climb over the arm of the chair and slide off the end of the chair.During an interview on 7/16/25 at 9:12 a.m., staff member N stated, We put [Resident #60] in the Broda chair to prevent falls. From what I understand, he was falling out of his wheelchair all the time, so we started putting him in this one (Broda chair) so he couldn't fall. During an interview on 7/16/25 at 10:17 a.m., staff member S stated she frequently worked with resident #60, and the use of the Broda chair was either a directive of nursing or physical therapy. Staff member S stated that resident #60 had been using the Broda chair for about three months. During an observation on 7/16/25 at 12:55 p.m., resident #60 continued to sit in the dining room in the Broda chair. Resident #60 appeared anxious and agitated, stating, I want out of this chair, get me out of this, repeatedly. During an interview on 7/16/25 at 1:05 p.m., staff member LL stated that resident #60 was always upset when he was in the Broda chair, but he would fall out of his wheelchair.During an interview on 7/16/25 at 1:42 p.m., staff member N stated, [#60's name] is uncooperative and agitated today. Staff member N stated the (Broda) chair was most likely the cause of resident #60's agitation. Staff member N stated he was not sure of any alternative interventions implemented for the falls, before the use of the Broda chair, for resident #60.A review of resident #60's care plan, dated 3/1/25, with a revision date of 6/24/25, showed no alternate interventions for falls were attempted prior to the use of the Broda chair.A request for the restraint policy and procedure was made on 7/16/25.During an interview on 7/16/25 at 2:30 p.m., staff member A stated there was no policy or procedure for restraints because the facility was a restraint-free facility.During an interview on 7/17/25 at 7:50 a.m., staff member P stated she had not worked at the facility for very long. Staff member P stated if a resident needed a different type of chair or special equipment, physical therapy should do an assessment and give a recommendation on the equipment. Staff member P stated she did not believe an assessment had been completed on resident #60 for the use of the Broda chair and did not believe an assessment was done to assess the safety of resident #60 in the Broda chair.Review of resident #60's Physical Therapy Discharge Summary, dated 2/26/25, showed: Equipment issued: Recommend continued use of hospital bed, full body mechanical lift for transfers and standard manual w/c.Review of resident #60's Significant Change MDS, with an Assessment Reference Date of 6/25/25, showed a restraint was not coded.Review of #60's physician orders, dated 2/2025 to 7/17/25, showed no physician order for a restraint.

Based on interview, and record review, the facility failed to complete a baseline care plan within 48 hours of admission, to include the minimum health information necessary to properly care for 1 (#87) of 6 residents sampled for baseline care plans. This deficient practice puts the resident at risk of not receiving necessary care and services. Findings include: During an interview on 7/16/25 at 10:40 a.m., staff member N stated he does not review the resident care plans, and he did not look at resident #87's baseline care plan.During an interview on 7/18/25 at 8:35 a.m., staff member E stated she helped oversee the care planning process and ensured staff are following the care plans. Staff member E stated baseline care plans are completed within 48 hours of admission. Staff member E stated that nursing staff were supposed to help initiate and update care plans.Review of resident #87's baseline care plan, dated 6/27/25 at 5:47 p.m., showed the baseline care plan was not filled out and did not identify any information pertinent to care for the resident. Baseline care plan information did not include resident #87's cognitive status, ADL status, bowel or bladder status, transfer status, respiratory status, specifically oxygen use, communication status, mobility device use, or type of diet. Review of Resident #87's diagnosis list showed a diagnosis of Lung Cancer, Pain and Diabetes Mellitus, Type II.Review of a facility policy titled Care Planning Process, BH125, with a revision date of 3/2025, showed: . The care plan must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being Care plans are initiated upon admission .

Based on interview and record review, the facility failed to update care plans as resident conditions and physician orders changed for 2 (#s 13 and 60) of 43 sampled residents. Findings include:1.Review of a facility document provided to resident #60’s physician, dated 6/11/25, showed: … “Resident #60 has poor appetite and intake he does drink his boost… Staff attempt 1 on 1 with meals and encourage intake…” Review of resident #60’s care plan, with an initiation date of 6/11/25, showed severe weight loss as a focus area. The care plan was not updated to include one on one feeding provided by staff as needed or the use of nutritional supplements. During an interview on 7/16/25 at 1:05 p.m., staff member LL stated, During an observation and interview on 7/16/25 at 1:05 p.m., staff member LL picked up resident #60’s meal tray and put it in a cart to be thrown away. Everything on the meal tray was still covered and untouched. Staff member LL stated, We don't make him (resident #60) eat, he is on comfort care. During an interview on 7/16/25 at 3:10 p.m., staff member D stated, “Resident #60 is on comfort care, so we can’t make him eat. Staff member D stated resident #60 was being followed in the nutrition at risk meetings because of his weight loss. Staff member D stated patient #60 requires encouragement and one on one occasionally with meals, and staff are to be offering alternative meals if he does not eat. During an interview on 7/18/25 at 8:35 a.m., staff member E stated she helped oversee the care planning process and ensured staff were following the care plans. Staff member E stated care plans were done on admission, quarterly, annually, and with any significant change. Staff member E stated it was her expectation that nurses on the floor also assist in revising resident care plans. 2. During an interview on 7/17/25 at 7:43 a.m., staff member G, stated resident care plans were updated in an ongoing matter as things developed. Adding something like a catheter, medications, or behaviors would indicate a care plan update. Review of resident #13's physician orders, dated 7/9/25 - 7/11/25, showed the resident's catheter was removed for a voiding trial and there were orders to, bladder scan every four to six hours and straight cath for retention of greater than 500ml urine. Review of resident #13's care plan, with an initiation date of 7/8/25, showed risk for infection due to indwelling catheter as a focus area. The care plan had not been updated to include the removal of the catheter or the two new orders of bladder scanning and as needed straight catheterization. Review of a facility policy titled, “Care Planning Process, BH125,” with a revision date of 3/2025, showed: … “2. Care plans are reviewed and updated after each MDS assessment, and as the resident’s needs and strengths change, and to update time frames, goals, approaches, and objectives.”

Based on observation, interview, and record review, the facility failed to provide assistance with meals for a resident who required encouragement and one on one for eating for 1 (#60) of 5 sampled residents for nutrition. This deficient practice increased the risk for the resident not receiving necessary care and services with meals. Findings include:During an observation on 7/15/25 at 8:15 a.m., resident #60 was lying in bed sleeping. Resident #60's breakfast tray was sitting on his bedside table, covered and untouched.During an observation on 7/16/25 at 8:42 a.m., resident #60 was sitting in a Broda chair parallel to the table, with his feet elevated and the back of the chair reclined. Resident #60's breakfast tray was sitting on the table. The tray had a cover over the plate of food, the milk and juice each had a cover over them, and the container of boost was unopened. Staff member N was the only staff member near the dining area. Resident #60 could not reach his tray of food.During an observation on 7/16/25 at 8:45 a.m., staff member R entered the dining area and picked up resident #60's meal tray. Staff member R did not offer any assistance to resident #60 or offer an alternative prior to taking the tray away.During an interview on 7/16/25 at 8:58 a.m., staff member S stated resident #60 was agitated and that was probably why he did not eat. Staff member S stated staff was to encourage resident #60 to eat or provide one on one assistance to resident #60.During an observation on 7/16/25 at 12:55 p.m., resident #60 was sitting in a Broda chair with the feet elevated and the back reclined. The Chair was parallel to the dining table. Staff member LL was sitting at the end of the dining table with two residents between resident #60 and staff member LL. Resident #60's meal tray was still covered, and he could not reach his fluids. Resident #60 stated, Hell yeah, I'm hungry. Staff member LL got up from the end of the table and sat next to resident #60. Staff member LL did not uncover the meal tray or attempt to encourage or assist resident #60 with his meal.During an observation and interview on 7/16/25 at 1:05 p.m., staff member LL picked up resident #60's meal tray and put it in a cart to be thrown away. Everything on the meal tray was still covered and untouched. Staff member LL stated, We don't make him (resident #60) eat, he is on comfort care.During an observation on 7/16/25 at 1:20 p.m., resident #60 was sitting in the dining area yelling, I'm hungry.During an interview on 7/16/25 at 1:30 p.m., staff member S stated resident #60 feeds himself, staff do not need to assist him, but there are times when he needed encouragement to eat. Staff member S stated breakfast comes to the unit about 7:15 a.m. and lunch arrives about 12:15 p.m.During an interview at 1:35 p.m., staff member N stated resident #60 feeds himself. Staff member N stated, Today he (the resident) is just agitated and uncooperative, so he's not eating.During an interview on 7/16/25 at 3:10 p.m., staff member D stated, Resident #60 is on comfort care, so we can't make him eat. Staff member D stated resident #60 was being followed in the nutrition at risk meetings because of his weight loss. Staff member D stated patient #60 requires encouragement and one on one occasionally with meals, and staff are to be offering alternative meals if he does not eat.During an observation on 7/17/25 at 8:12 a.m., resident #60 was lying in bed asleep. Resident #60's meal tray was on his bedside table.Review of resident #60's care plan showed: Focus: Severe weight loss-date initiated 6/11/25,Goal: Resident to consume greater than 50% of each meal-initiation date 6/11/25.Interventions: Encourage to eat 50 percent or more of meals.-If intake 50 percent or less, offer substitute or supplement.Review of a facility document titled, Weight/Nutrition at Risk, BH320, with an effective date of 3/2025, showed:. 4. To ensure all residents are having their nutritional needs met.

Based on observation, interview, and record review, the facility failed to ensure an Unstageable pressure injury received care and services to prevent worsening of a pressure injury after admission for 1 (#5) of 3 sampled residents for pressure ulcers. Resident #5 was admitted with an Unstageable pressure injury to his right heel. There was a lack of information to determine if the wound was worsening. Findings include:During an observation and interview, on 7/16/25 at 11:11 a.m., staff member I performed a dressing change on resident #5's right heel. Staff member I donned clean gloves and removed the soiled dressing. The dressing was saturated with yellow exudate and yellow slough was covering the wound. The wound was not cleansed prior to putting the clean dressing on. Staff member I stated wound care orders were usually on the TAR, but she did not see any orders for wound cleansing. The wound was covered with Aquacel and wrapped in Kerlix.During an interview on 7/17/25 at 8:48 a.m., staff member E stated resident #5 was supposed to have boots on for offloading. Staff member E stated, for wound prevention, the resident had an air mattress. Staff member E stated a foot cradle was tried, but the resident did not like it. Staff member E stated the resident was also supposed to be turned and repositioned. Resident #5 was identified to have nutrition at risk. Staff member E stated staff member D had recommended Juven for the resident for wound healing. Resident #5 was to receive every other day dressing changes. During an interview on 7/17/25 at 9:30 a.m., staff member MM stated resident #5 was to use a boot (pressure relieving) on his heel, be turned and repositioned, his bed had an air mattress, and staff were to float his heels while in bed. Staff member MM stated the resident was to leave the boot on all day. Staff member MM stated resident #5 was to be up to the dining room for meals.During an interview on 7/17/25 at 9:58 a.m., staff member B stated there was a policy for wound care, and upon admission staff were to assess and evaluate any wounds the resident had. The interventions were to be care planned and staff were to follow physician orders for wound care. Staff member B stated the staff had pressure ulcer training recently. Staff member B stated the resident came in with the wound to his right heel.Review of resident #5's wound consult notes showed the wound was Unstageable on 6/23/25, and it was a Stage II pressure injury on 7/7/25. The note on 6/23/25 showed the wound was Unstageable due to the inability to debride the wound due to pain. No additional wound care notes were provided during the survey.Review of resident #5's Orthopedic Progress Notes, showed the heel wound was described as having partial thickness, and the resident had a boot for offloading.Review of resident #5's Skilled Nursing visits showed the heel wound was Unstageable on 6/14/25 and 6/20/25. On 7/3/25 the heel wound was to be offloaded continuously to ensure wound healing and wound care had been consulted on 6/23/25. On 7/8/25, the heel wound was not mentioned. An addendum to a note, dated 6/30/25 for the encounter note dated 6/25/25, showed the heel wound was being managed by the wound team and offloading with daily dressing changes.Review of a Skin and Wound Evaluation, dated 7/10/25, showed the heel wound was an Ustageable pressure deep tissue injury present on admission which measured 2.9 cm x 2.2 cm. The wound had light seropurulent drainage with a faint odor. The wound was documented as slow to heal. This was the only Skin and Wound Evaluation provided by the facility. Review of the facility policy, titled Skin and Wound Care, showed any skin breakdown on admission was to be reported to the provider, the family member and/or the Representative and the Resident Care Manager immediately. All identified pressure or open wounds were assessed, photographed, and measured weekly by the licensed nurse in order to identify progress towards healing, and any new treatments needed.The heel wound documentation provided by the facility did not show measurements, or weekly assessments, and did not show complete wound care including cleansing the wound.Review of resident #5's Care Plan showed there were not any new interventions or changes for wound management since 6/21/25. Interventions included evaluation, monitoring, and measuring the wound at regular intervals, but time frames were not specified.Review of the facility policy titled, Skin, Wound and Pressure Injury Prevention showed: . skin, wound and pressure injuries will be treated using the skin, wound and pressure injury care guideline . Comprehensive wound and pressure injury documentation will be completed weekly until discharge, unless otherwise indicated per provider's direction. Photograph wound or pressure injury on admission . Photographs will be completed once weekly until discharge.

Based on observation, interview, and record review, the facility failed to ensure a resident was provided tube feeding without complications to maintain his weight for 1 (#69) of 2 sampled residents for tube feeding. Findings include:During an observation on 7/15/25 at 8:25 a.m., resident #69's doorway had an enhanced barrier precaution sign posted. Resident #69 was in his recliner with his feet up and had his call light on. A tube feeding was hanging on a pole behind a bedside table with a suction machine on top of it. An unidentified CNA entered the room and resident #69 stated his tube feeding was leaking again. The unidentified CNA left to get staff member NN. Both the CNA and staff member NN entered the room. Neither staff member put on PPE other than gloves. The unidentified CNA cleaned up the leaked tube feeding and dumped the suction container into the sink and placed the container back on the bedside table. Staff member NN cleaned the tube feeding off resident #69's abdomen. She then adjusted the lock on the tube feeding where it was attached to the resident.During an interview on 7/15/25 at 8:44 a.m., staff member NN stated resident #69's tube feeding had just started, and it was locked so the pressure from the machine running had caused it to open and leak. Staff member NN stated she went into the resident's room, cleaned up the tube feeding that had leaked, then she unlocked the clamp so the tube feeding would administer.During an interview on 7/16/25 at 3:15 p.m., staff member D stated she had realized there was no more Isosource tube feeding bags when she saw the empty shelf in the kitchen. Staff member D stated she did not have a role in ordering supplies and could not write orders for diet or tube feeding supplements. Staff member D stated she informed the units they would need to temporarily use a different tube feeding formula and wrote progress notes for the substitution. Staff member D stated the alternate formula had been used for all residents receiving tube feeding for the last two days. She stated they were out of Isosource, and the current formula being used did not have the same caloric nutrients as the Isosource.During an interview on 7/17/25 at 9:17 a.m., staff member HH stated, he ordered to a par level of six for the Isosource 1.5 tube feeding formulas, but he had no way of knowing how many were needed in a day and it varied. Staff member HH stated he had Isosource ordered but the construction in front of the distributor blocked their route and delayed the shipment. He stated he doubled the order and was told it would be delivered that afternoon.During an interview on 7/17/25 at 10:50 a.m., staff member F stated the unit was told to substitute the Fibersource and it was supposed to be only substituted for one tube feed for the resident. She stated the Isosource was again delayed, so they had been using the Fibersource until the Isosource was delivered. Staff member F stated there was no new physician order for the change in the tube feeding. Staff member F stated staff member D came to the unit to inform the nursing staff of the delay in the Isosource delivery. She stated the kitchen staff had delivered the alternate tube feeding formula.Review of resident #69's physician orders, for his tube feeding, showed he was to be given Isosource 1.5. The TAR showed Isosource had been given when it was not available on 7/15/25 and 7/16/25. There were no new orders for the temporary change of the tube feeding formula from Isosource to Fibersource. The resident's orders showed the physician was not notified of the change in tube feeding formula. There was an order added for daily weights for two days entered on 7/15/25. As of 7/17/25, no weights had been documented. Review of resident #69's progress notes showed:- Nutrition Note on 7/14/25, No nutrition concerns at this time. Tolerating enteral nutrition at goal rate. Followed by NAR program. Diet Isosource 1.5. No significant weight loss in 1 or 3 months. No 6-month weight history.- Nutrition Note on 7/15/25, Kitchen is out of Isosource 1.5. Provide Fibersource HN at ordered rate until Isosource 1.5 is back in stock. RD to continue to monitor.Review of resident #69's weight on 3/10/25 showed 160 lbs. On 3/31/25 his weight was 149.5 lbs. There was a 6.65% weight loss between 3/10/25 and 3/31/25. A review of the weights for July 2025 showed no weights were documented in the EHR for the resident. Review of the facility policy, Adult Confirmation and Management of Feeding Tubes/Nasogastric Tubes, AGN470, last revised 5/25/25, showed, Patient weights should be obtained Monday, Wednesday, and Friday.

Based on observation, interview, and record review, the facility failed to prevent and provide services necessary to promote healing on one facility acquired pressure ulcer for 1 (#62), and the wound was Unstageable, tunneling, and difficult to heal, of 23 sampled residents. Findings include: During an observation on 9/12/23 at 9:28 a.m., resident #62 was in his bed in low fowler's position (head slightly elevated), with no positioning devices or pillows except one pillow under his head. During an observation at 9/12/23 at 2:08 p.m., resident #62 was in his bed in low fowler's position, with no positioning devices or pillows except one pillow under his head. During an observation on 9/12/23 at 2:18 p.m., staff members I, L, and N entered resident #62's room to complete wound care, and check and change the resident's brief. Resident #62 was in low fowler's position. Staff member I removed the sacrum wound dressing, and found feces up to, and in, the sacrum wound. The sacrum wound was cleaned and measured, and staff member I stated the sacrum wound was, 3.5 cm x 2.5 cm with tunneling all over and it's hard to get it all washed out when BM gets in there. The wound was irrigated with Vashe liquid, and the staff waited five minutes to proceed as directed in the order. At 2:37 p.m., staff member I applied Medi honey with the applicator of the bottle touching entrance of the wound, squeezed it into the wound, and around the outside of the sacrum wound. Staff member I then applied an abdominal pad across the buttocks and taped on the outside of the right and the left buttock. The sacrum wound bed was exposed at the bottom of the dressing, allowing future bowel movements to potentially enter the wound bed. Staff member I stated to staff member L, There is redness to the inside of his knees, please place pillow between his knees and place [Resident #62] on his side. Resident #62 stated he had no pain during the positioning, and the dressing change. Resident #62 had redness from his rectum to his scrotum, that was not treated during the observation. Resident #62 was then turned back onto his back, with a gown and brief put on. Resident #62 was then positioned in low fowler's position with a pillow under and between his knees by staff member N. During an interview on 9/12/23 at 2:50 p.m., staff member M stated, Oh yeah, we usually use triad cream on redness on his scrotum. But I don't think the sacral wound order is very good, we can't keep the BM [feces] out. Yesterday the nurse said she found a lot of BM in the wound and had to do a lot of irrigation. So that's two days that I know of. I didn't like the order a month ago when all they were doing was triad cream. I felt like it needed Medi plex and more aggressive treatment then. If I don't like the order I can go to [staff member J], I'm not really comfortable talking to the wound nurse yet. I've only been here since April. But I can talk to [staff member J]. The wound nurse is a PA. I've only ever even seen her once. I haven't gone to [staff member J] on this one, because I figure the wound team is on it, I guess. During an interview on 9/12/23 at 2:58 p.m., staff member J stated, Usually if the nurse has concerns, they can send the doctor a Volt [secure messaging system] message. Usually, they do so directly, or they can come to me. During an observation on 9/13/23 at 7:57 a.m., resident #62 was in bed, in low fowler's position, with a pillow under his right shoulder to his hips, facing the wall. There were no pillows between his knees. During an observation on 9/13/23 at 8:09 a.m., resident #62 was in his bed in high fowler's position (slightly declined upright), with his bedside table over the bed, in front of him. During an observation on 9/13/23 at 11:17 a.m., resident #62 was in his bed, in low fowler's position, with a pillow between his knees. During an observation on 9/13/23 at 11:49 a.m., resident #62 was in his bed, in low fowler's position, with a pillow between his knees. During an observation on 9/13/23 at 4:06 p.m., resident #62 was in his bed, in low fowler's position, sleeping. No pillow was present. During an interview on 9/13/23 at 4:07 p.m., staff member O stated, when a resident was to be repositioned every two hours, We just move the pillow from one side to the other side. Staff member P stated, We move the pillow to the opposite side back and forth every two hours. And pull them up in bed if necessary. Staff member Q stated, We just keep moving the pillows side to side. Staff member R stated to staff member Q, What you really should be doing is turning him all the way on his side, and putting a pillow between his knees so he is off his butt. During an interview on 9/14/23 at 7:56 a.m., staff member S stated she would expect resident #62 to be turned completely on his side because he has a sacrum wound. During an interview on 9/14/23 at 8:56 a.m., staff member A stated she could not provide the documentation of any VOLT messages, regarding resident #62, sent to the physician requesting wound dressing changes to decrease feces from entering the wound. A review of resident #62's medical record reflected the following: - Resident #62 was admitted to the facility on [DATE]. - Resident #62 developed a deep tissue injury on 7/31/23, approximately 5 cm x 9 cm, on the sacrum. - An order was placed on 8/2/23 for an air mattress, which the admitting care plan, dated 5/14/21, reflected as an intervention already in place, and a Medi plex dressing over the wound. - Resident #62 was seen on 8/14/23. Staff member V noted, Certainly some degree of pressure played a role in this skin injury .keep dry and offload as possible .2cm x 3cm ulcer of the sacrum; equivalent to a stage 3. An order was placed on 8/14/23 for betadine to buttock ulcer two times daily, with no special dressing. -On 8/16/23 staff member T noted, Sacrum with unstageable pressure injury. Nursing staff to maintain pressure injury prevention measures. - On 9/7/23 staff member U noted, .without 90g of protein, offloading, this will likely no heal. Struggling to do both .Sacral wound Stage IV nearly to bone certainly down to deep tissue and ligaments surrounding this area. No undermining in every direction .[sic] - Wound measurements were documented on 9/9/23 at 11:45 a.m. as 2.5 cm x 3.5 cm x 1.5 cm. Review of resident #62's Actual Skin Problem Care Plan, dated 5/24/23, reflected resident #62 admitted to the facility with the following pressure ulcers: Stage I to the right lateral ankle and Stage II to the left upper buttock. The document reflected the buttock wound was resolving. The care plan interventions included the following: - Position off area - Pressure re-distributing mattress: Atmos Aire 4000 A review of the facility's Mattress Overlay request form, dated 8/2/23, reflected the Air Mattress was placed on resident #62's bed on 8/2/23. Review of resident #62's Actual Skin Problem Care Plan, dated 8/21/23, reflected resident #62 had a Stage IV pressure ulcer to the sacrum.

Based on observation, interview, and record review, the facility failed to maintain an adequate nutritional status for 1 (#62), resulting in a severe weight loss; and failed to provide a physician ordered therapeutic diet for 1 (#66) of 23 sampled residents. 1. During an observation on 9/12/23 at 9:22 a.m., resident #62 was in his bed in low fowler's position (head slightly elevated) and stated he was unable to reach his water on the bedside table. During an observation and interview on 9/12/23 at 2:09 p.m., staff member L was in resident #62's room assisting with a bed bath and wound dressing change. Staff member L stated resident #62, is not wanting food lately but loves the shakes, boost, I think. So, I offered him a bite of strawberries but he said no earlier. He drank the shake. He didn't eat last night either. He eats independently, but he's my buddy so I come and encourage him. During an observation on 9/13/23 at 7:57 a.m., resident #62 was in bed, in low fowler's position, with a pillow under the right shoulder to the hips, facing the wall. There were no pillows between his knees. Resident #62's meal tray was on the bedside table, approximately three steps away from the bed, out of reach for resident #62. During an observation on 9/13/23 at 8:00 a.m., staff member L entered resident #62's room to offer food to resident #62. Staff member L was talking to him while offering bites of sausage. Staff member L left the room to get drinks. Staff member L gave him a shake, cranberry juice, coffee, and milk. Staff member L left the room with the meal tray set-up in front of the resident. During an observation on 9/13/23 at 8:09 a.m., resident #62 was in high fowlers position (slightly reclined), with his meal on the bedside table. The bedside table was over the bed, in front of resident #62. There were no staff present in the room. Resident #62's hands were contracted, with a tremor present. Resident #62 was attempting to drink cranberry juice from a cup. Resident #62 was fidgeting with the cranberry juice cup, nearly tipping the cup onto himself. Resident #62 continued to hold onto the cup rim while the cup remained on the tray, making multiple attempts to pick up the cup, without success. There was no food eaten during this observation period. During an observation on 9/13/23 at 8:33 a.m., resident #62 was in bed with the bedside table in front of him. Cranberry juice was spilled on his clothing, bedding, and the cup was lying in the bed. One bite of sausage was gone from the tray, and no other items appeared eaten. During an interview on 9/13/23 at 8:45 a.m., staff member L stated, He's (resident #62) not eating except the bites I give him. Not sure if it is just him pleasing me or what. His hands are really shaky, and I noticed he spilled his cranberry juice all over himself. During an observation on 9/13/23 at 8:51 a.m., resident #62 was watching television, with the bedside table over the bed in front of him. Resident #62 was chewing the piece of sausage staff member L had given him. Resident #62 attempted to grab his milkshake on the tray, with his eyes closed, and his hands were tremoring. One quarter of his milkshake was gone, and one bite of sausage was eaten when the tray was picked up. During an interview on 9/13/23 at 9:00 a.m., staff member K stated resident #62 was on the 'at risk for weight loss' list. Staff member K had ordered mighty shakes to be given three times daily because of the pressure injury. Staff member K stated her expectation would be staff feeding resident #62. Staff member K stated the last dietary assessment was on 8/15/23 and showed resident #62 was independent with meals. Staff member K stated, based on observation, she thought he needed assistance with meals. Staff member K stated she thought the facility should move resident #62 to a total assist with feeding at the bedside. Staff member K placed an order to change resident #62's meals to total assistance at the bedside. During an interview on 9/13/23 at 1:16 p.m., staff member Y was in resident #62's room feeding him. Staff member Y stated, [Resident #62] ate great today. He just doesn't like the squash. Resident #62 was eating his meal, as staff member Y fed him. The plate of food was nearly gone. During an interview on 9/14/23 at 9:02 a.m., staff member L stated, He ate six bites of waffles, half of a link sausage, four bites of oatmeal, one bite of fruit, and all his milkshake. I had to help him totally. He couldn't do it on his own. He couldn't even pick up his milk. Review of resident #62's EMR weights reflected: - 3/5/23 weight 189.86 lb. - 6/3/23 weight 179.3 lb. - 8/8/23 weight 172.83 lb. - 9/7/23 weight 168.52 lb. This data reflected a severe weight loss of 21.34 lbs. for a 12.6% weight loss over a six-month period. 2. During an interview on 9/13/23 at 8:37 a.m., resident #66 stated he wanted food. Meal trays had been passed. Staff member I stated, He (resident #66) is NPO, we don't feed him anymore. During an interview on 9/13/23 at 9:47 a.m., staff member Z stated, [Resident #66] is someone I have seen repeatedly. His family wanted him fed. His sister is a great advocate but now it has changed to his daughter as the POA. His sister brings someone in to work with him on exercises. These orders are the current expectation. [Resident #66] says he wants to eat. I've educated him on the aspiration risk. His daughter is the POA and said do whatever he wants. I also educated her on the risks. I worked with him for several days to determine the safest food texture and technique. I didn't want to just give an order for three meals a day. I educated the nurses that he can have pureed meat, potatoes, and anything pudding textured with a maximum of two ounces at a time. As the therapist I write the order. I do not put the order in the computer, I went over the order with [staff member J] and gave her the order. Staff member Z stated resident #66 had been treated as NPO because of the order not having been followed since written on 6/30/23. The oral food order was for comfort, per resident #66's request. During an interview on 9/13/23 at 9:56 a.m., staff member J stated, Nurses are supposed to put orders in Meditec, put it on the pocket care plan, and we have another nurse review the order as a second check. During an interview on 9/13/23 at 3:38 p.m., staff member A stated resident #66's oral feeding was something his sister brought up, and he needed to be in the proper position to be able to even have any food at all. It was really only for his enjoyment, and if there was a diet order, he would be getting a full tray all the time, which would not be good for him either. Staff member A did not have an answer for why oral food intake was ordered twice on paper, and never put in the computer. Staff member A stated order processing had not been a QAPI concern. Review of resident #66's EMR reflected no order placed in active orders, or history for oral intake, per the speech therapist's orders written on 6/30/23 and again on 7/14/23. Review of resident #66's Physician's Orders, dated 6/30/23, reflected the following: -Patient may have limited PO intake for quality of life . Review of resident #66's Physician Orders, dated 7/14/23, reflected: -Continue previous feeding orders (6/30/23). Nursing staff only may feed upright in bed . Review of resident #66's Physician SNF: Progress note, dated 8/23/23, reflected, Continue tube feedings and oral intake for comfort .

Based on interview and record review, the facility failed to keep a resident free from abuse, resulting in the resident feeling belittled and ashamed, for 1 (#49) of 3 sampled residents. Findings include: During an interview on 12/20/22 at 9:02 a.m., resident #49 stated she had an issue, back in October 2022, with NF1. Resident #49 stated one morning she woke up, and she was soaked with urine, after having an incontinence episode. Resident #49 stated NF1 was rude and curt with her, and told the resident, Anyone can feel when they have to go to the bathroom, why didn't you go last night? You are a grown woman. You are thoroughly disgusting, and you stink. I would rather have someone else to take care of today. Resident #49 stated this made her feel belittled and ashamed. Resident #49 stated she told the nurse on duty what had happened, and NF1 was taken off the resident's care right away. Resident #49 stated she currently felt safe at the facility. During an interview on 12/20/22 at 2:54 p.m., staff member C stated since the incident between resident #49 and NF1 on 10/19/22, resident #49 had been sleeping more often, and had an uncharacteristic angry outburst towards staff member C when the staff member was trying to help the resident. Staff member C stated she had abuse training in the past year at the facility, and was aware that verbal abuse was a type of abuse. During an interview on 12/20/22 at 3:06 p.m., staff member B stated NF1 was immediately let go, and other staff and residents were interviewed. Staff member B stated the nursing staff was also educated on interventions to approach and assist resident #49 with her incontinence. During an interview on 12/20/22 at 3:14 p.m., staff member A stated abuse allegations were reviewed in QAPI, and during management huddles on Mondays and Fridays. Staff member A stated leadership ensured social work followed up with resident #49 after the incident in October with NF1. Staff member D stated resident #49 also had therapy sessions every week, and staff member D helped the resident process anything she needed to after the sessions. Review of a facility reported incident, dated 10/19/22, showed NF1 was removed from the schedule, and an investigation was started after the event. The results of the investigation showed, .it was determined that unacceptable performance was displayed . requested [NF1] . contract to be ended immediately. Review of an e-mail between the facility and contract staffing company, dated 12/20/22, showed NF1's termination date was 10/19/22. Review of a facility document, Core Mandatory Part III Clinical Assessment, dated 8/29/22, showed NF1 passed an assessment for abuse training. Review of a facility policy, Abuse: Definitions, Reporting, Education, and Prevention, BH106, dated 12/2021, showed: 1. Each resident has the right to be free from abuse, mistreatment, neglect . Residents must not be subjected to abuse by anyone, including but not limited to staff, .

Based on observation, interview, and record review, the facility failed to identify and act on a resident's injury after a fall, causing a delay in treatment, which was later found to be a fracture, for 1 (#31) of 31 sampled residents. Findings include: During an observation and interview, on 2/4/20 at 8:41 a.m., resident #31 was sitting in a wheelchair at a dining table. Resident #31 stated he was in a lot of pain from his left hip and knee, which was from a recent fall on a Friday, and he was upset and frustrated that no other assessment was done to figure out what was wrong. Resident #31 stated he had to ask the nursing staff for an x-ray (of hip) because one had not been done. He stated he still felt he had to do everything independently because staff expected it, even though it was harder to do since the fall. The resident stated he was in the wheelchair more instead of using a walker. During an observation on 2/4/20 at 3:00 p.m., resident #31 was observed on a bed in the hallway being taken off the unit by two staff. During an interview on 2/4/20 at 3:25 p.m., staff member H stated resident #31 was going out for an x-ray, which the resident requested. During an interview on 2/6/20 at 10:16 a.m., staff member G stated for resident falls nurses would complete documentation in the Midas program (electronic health record program), then do follow up charting in Meditech (electronic health record program), and assess the resident for injuries and usually get them up with a lift. Staff member G stated when they do a post fall huddle the nurse or physical therapy, if available, will put fall interventions in place to protect the resident. During an interview and observation on 2/6/20 at 10:36 a.m., resident #31 was in his room, in the dark, lying in bed, flat on his back. Resident #31 stated he had gotten an x-ray after he requested it, and he was told his left hip was broken. Resident #31 stated he had to use a lift machine (mechanical lift) now for at least six weeks to do transfers, and he had to be in the wheelchair the whole time. During an interview on 2/6/20 at 10:39 a.m., staff member H, stated resident #31 was mainly independent with minimal assist before the fall. Staff member H stated resident #31 typically had pain in his joints but had been complaining about left hip and knee pain more since the weekend. Staff member H stated resident #31's x-ray results showed a minimally displaced impaction [MEDICAL CONDITION] femoral neck, and there were no other significant events, other than the fall, to have caused it. Staff member H stated resident #31 had a new order for aspirin 325 daily for [MEDICATION NAME], to elevate the left leg, and non-weight bearing status for six weeks, with weekly x-rays for nonsurgical healing of the fracture. Staff member H stated the aides and nurses would reference the pocket care plan to know resident #31 was now non-weight bearing, but the pocket care plan needed to be updated. Review of resident #31's fall risk report for 1/24/20 showed, resident #31 had landed on his left side and sustained left side skin tears to the hand and elbow. Resident #31 had stated he had fallen when self-transferring from the wheelchair to the bed. Review of resident #31's Fall Care Plan for 1/24/20 showed under the care plan problem, number two was circled with skin tears LUE written in. No other resident centered information was noted or circled. The fall care plan did not show the resident transfer status, changes to the transfer status, or increased level of assistance needed from the fall. Review of resident #31's nurse alert charting showed, resident #31 had complaints of pain and not feeling well since 1/28/20 related to his fall on 1/24/20. There were no nursing notes documented for follow up of the fall or the resident not feeling well on 1/26/20 and 1/27/20 to show the resident and his pain had been monitored or addressed. Review of resident #31's nursing progress notes showed, on 2/3/20, Resident is (complaints of left) hip pain this morning and then (complaints of left) knee pain, he stated 'I can't even walk.' Resident has been visualized bearing weight on his (left) leg without difficulty. PRN and scheduled [MEDICATION NAME] administered . Resident is requesting an x-ray stating 'I broke my leg.' Nine days had passed since the resident fell , with no follow up from the facility related to a potential injury from the fall, although the resident had increased pain and change in ambulation. Review of resident #31's nursing fax request to the physician on 2/3/20 showed, Resident had a fall on 1/24/20. He has been able to bear weight but has (complaints of) pain since. He is requesting an x-ray to his (left) hip and knee. The request showed the x-ray was prompted by the resident rather than the facility, showing the resident's needs were not anticipated or identified by the facility staff, causing a delay in necessary treatment. Review of resident #31's physician visit notes, dated 2/4/20, showed, Left hip x-ray showed a minimally displaced impaction [MEDICAL CONDITION] femoral neck. recommended non weightbearing . Nursing reports that (resident #31) had a fall on 1/24/20. He has been able to bear weight, but has complained of pain since. (Resident #31) is requesting an x-ray to his left hip and knee. (Resident #31) does report that he is having more difficulty bearing weight on his left leg. Review of resident #31's February MAR indicated [REDACTED] - 2/1/20 at 6:00 p.m. for pain all over - 2/2/20 at 6:45 p.m. for pain all over - 2/3/20 at 10:30 a.m. for pain all over - 2/3/20 at 3:15 p.m. for left leg pain - 2/4/20 at 10:10 a.m. for left hip pain Review of resident #31's January MAR indicated [REDACTED] - PRN [MEDICATION NAME] administered 1/25/20 at 10:35 for left leg pain - PRN tylenol administered 1/30/20 at 10:00 for left shoulder pain, initialed on 1/31/20 Record review of the facility policy, titled, Fall Risk Assessment/Prevention, dated March 2017, showed, under the Fall Event: . 9. Evaluate circumstances around the fall, what further fall prevention can be done and put these interventions in place. 10. Initiate Alert charting for 5 days post fall.

Based on observation, interview, and record review, the facility failed to adequately assess, evaluate and treat, one Stage II pressure ulcer, and failed to prevent, assess and monitor the worsening of one unstageable pressure ulcer for 1 (# 4) of 19 sampled residents. Findings include: 1. Review of resident #4's Nurse Note, dated 6/14/17, showed the resident had a healing Stage II pressure ulcer. The resident does not have any foot problems. Review of resident #4's Nursing Progress Note, dated 6/16/17, showed Right heel deep tissue injury observed today and Prevalon boot was placed to both right/left feet. The electronic record did not include an incident report or cause for the deep tissue injury. During an interview on 10/10/17 at 1:20 p.m., resident #4 stated she did not know how the injury occurred. I went to sleep as usual, and woke up with it. Resident #4 stated she had no feeling in her legs or feet. Review of resident #4's Nurse Note, dated 6/26/17, showed the right heel was open to air, black in color. Review of resident #4's Nurse Note, dated 6/2717, showed the heel was black in color but intact. Review of resident #4's Nurse Note, dated 7/3/17, showed the heel remained intact, soft in the middle. Review of resident #4's Nurse Note, dated 7/5/17, showed deep purple to black, 5 cm in circum. Review of resident #4's Nurse Note, dated 7/12/17, showed the heel remained black, intact. Review of resident #4's Nurse Note, dated 7/15/17, showed the heel was black and intact. Review of resident #4's Nurse Note, dated 7/18/17, showed the heel was slowly resolving. Review of resident #4's Nurse Note, dated 7/19/17, showed a scab was starting to peel off. During an interview on 10/11/17 at 8:50 a.m., staff member D stated she did not know why the heel opened, because the facility thought the ulcer was improving. She stated they called the wound clinic right away. Review of resident #4's Wound consult, dated 7/20/17, showed dry eschar that has been present for an unknown period on the right heel/ Someplace along the way she has had some pressure on this heel which has caused some skin necrosis which is dry. Review of resident #4's Nurse Note, dated 7/26/17, showed wound on her right heel that is scabbed over, half of the scab fell of today. Review of resident #4's Nurse Note, dated 8/9/17, showed ulcer to right foot heel is a smaller black eschar pad. Review of resident #4's Nurse Note, dated 9/9/17, showed scab getting smaller. Review of resident #4's Nurse Note, dated 10/3/17, showed the scab is off. Review of resident #4's Wound Documentation from the electronic record, dated 10/4/17, showed Scab in place to right heel. During an interview and observation on 10/11/17, at 1:20 p.m., resident #4's heel had a 4 X 2- centimeter dark area. Staff member I stated she was not comfortable staging the pressure area. During an interview on 10/12/17 at 10:10 a.m., staff member R stated the nurses at the facility were not certified for wound care. Review of resident #4's Care Plan, dated 6/26/17, showed no individualized risk factors. Interventions included Prevalon boot in place while in bed. Atmosair Mattress removed because the resident wanted cotton sheets and, Apply [MEDICATION NAME] to stage (sic) II on coccyx and moisture barrier cream to surrounding areas. Review of the facility skin care Policy and Procedure showed an incident report should have been completed upon the discovery of the deep tissue injury. It also showed a deep tissue injury would require a Wound Clinic referral. This referral occurred a month after the injury was identified. Review of resident #4's Wound Documentation from the electronic record showed one wound measurement, on 7/13/17. Review of resident #4's Nutrition at Risk notes showed the resident was eating 100%. Her blood sugars and protein needs related to wound healing were not included in the notes. 2. Review of resident #4's Admission CAA, dated 3/20/17, showed Her skin is intact and has blanchable redness to her coccyx. She is at risk for pressure ulcer due to current skin integrity, requiring assistance with bed mobility, pain with the use of narcotics. She is on a pressure relief mattress and wheelchair cushion. They are assisting with bed mobility and peri-care every two hours and as needed. Heels are bridged. Review of resident #4's Weekly Skin check, dated 4/3/17, showed her buttocks were reddened, blanchable and intact. Review of resident #4's electronic record lacked evidence of interventions implemented for the reddened buttocks. Review of resident #4's incident report dated 4/4/17, showed discovery of a Stage II pressure ulcer on the resident's coccyx. Area cleansed and [MEDICATION NAME] applied. Will continue to monitor until resolved. The pressure ulcer was determined unavoidable due to resident health - refusal to eat periodically, and staying up for extended periods of time. Review of the Manufacturer's directions for the use of [MEDICATION NAME], provided by the facility, showed it was to be used as a moisture barrier on denuded and open skin. It provided temporary relief from skin irritation, itching and discomfort in the perineal area. If improvement is not seen, discontinue after 7 days. Review of resident #4's Wound Documentation showed the facility continued to use [MEDICATION NAME] on the wound for seven months. The documentation lacked evidence of evaluation of the treatment for [REDACTED]. Review of resident #4's Nurse Note, dated 4/6/17, showed the pressure ulcer had increased in size. No measurements of the pressure ulcer were provided from the facility. Review of resident #4's Wound documentation did not show evidence the facility had identified a second pressure ulcer. During an observation on 10/11/17 at 2:30 p.m., resident #4 had two Stage II pressure ulcers, one on each buttock. Review of resident #4's treatment sheets and wound documentation lacked evidence of evaluation for the treatment of [REDACTED]. During an interview on 10/12/17 at 11:00 a.m., staff member B stated the facility did not require a physician order [REDACTED].