Every finding on record at Community Nursing Home of Anaconda

Based on interviews and record review, the facility failed to ensure the QAPI team identified, reported, investigated, and documented the development, implementation, and evaluation of corrective actions for performance improvement projects related to known activities department deficient practices for 2 (#s 2 and 6) of 14 sampled residents, and this failure increased the risk of all residents being affected due to the lack of necessary or preferred activities. Findings include:During the survey from 12/15/25-12/17/25, the facility failed to provide activities to meet the interests and preferences of residents who remained in their rooms for resident #s 2 and 6. (See F0679)During an interview on 12/16/25 at 9:50 a.m., staff member A stated there had been a struggle to get activities to take charge and work the activities programs. Staff member A stated she was aware the one-to-one visits and activities the activities staff should be doing were not being done. During an interview on 12/17/25 at 11:07 a.m., staff member A stated she interviewed staff after surveyors questioned the one-to-one visits and had found the activities staff were falsifying documentation on one-to-one visits, documenting the residents refused, were sleeping, or the staff were kicked out of the room when they had not attempted to complete the required one-to-one visit. Staff member A stated she had not been auditing the activities department's completion of one-to-one visits. Staff member A stated the facility only did one performance improvement plan per year, and the QAPI team chose to work on ambulation-based data review. Staff member A stated that no other performance improvement activities were completed since the previous survey. Staff member A stated the QAPI team had not considered a performance improvement plan for the activity department concerns, even though she was aware of the deficient practices in the activity department.Review of the facility's Quarterly QAPI minutes, dated 1/2020 - 10/2025, reflected no information for the activity department concerns, the lack of provision of activities, falsification of documentation, or concerns related to the well-being of residents who were not receiving activities. The facility QAPI committee failed to identify, address, and or attempt to correct the quality deficient practices for the activity department and staff involved, which affected all residents. Review of the facility policy, QAPI Program/Plan, Disclosure/Good Faith Attempt, dated 10/22, reflected:- Quality Assurance and Performance Improvement (QAPI) is a data driven, proactive approach to improving the quality of life, care, and services in nursing homes. The activities of QAPI involve members at all levels of the organization to: identify opportunities for improvement; address gaps in systems or processes; develop and implement an improvement or corrective plan; and continuously monitor effectiveness of interventions.

Based on observation, interview, and record review, the facility failed to ensure the required personal protective equipment, i.e. N95 respirator, was available to staff and visitors. upon entry to the facility during a COVID-19 outbreak; failed to ensure staff properly wore N95 respirators during a COVID-19 outbreak; and failed to ensure staff wore faceshield/masks while in residents' rooms who had tested positive for COVID-19 for 4 (#s 6, 9, 12, and 16) of 4 confirmed COVID-19 positive residents, which remained on contact and droplet precautions. These failures likely contributed to the spread of COVID-19 and could affect all residents, staff, or visitors at the facility. Findings include:1. Entrance Personal Protective Equipment During an observation when entering the facility on 12/15/25 at 9:00 a.m., a sign was posted on the outside window beside the entrance door, which showed the facility was in outbreak status for COVID-19. Inside the entrance door was a small vestibule, which had a desk with a notebook to sign in as a visitor and screening for signs and symptoms of COVID-19, including a thermometer to screen for an increased body temperature. On the door to enter the facility, a sign was posted with a picture of a paper mask required to enter the facility, and handwritten on the sign was N95. Also in the vestibule, there was a stand which had paper masks available for visitors, but no N95 masks were available to wear. During an observation on 12/15/25 at 4:01 p.m., staff member A's elementary aged son arrived at the facility and walked through the building to staff member A's office without an isolation mask on, as to protect himself, residents, or staff. Staff member A was in her office without a mask on, with the door open. During an observation and interview on 12/17/25 at 9:30 a.m., NF2 was in resident #6's room with a paper mask on doing a blood draw on resident #6. Resident #6 was on EBP and airborne precautions for active COVID-19. NF2 stated she did not see the signage on the door because it was too small, and the sign on the front entry only showed a picture of a paper mask. NF2 stated she did not see the small print above the picture that showed N95, and only paper masks were provided at the entry. NF2 stated she called ahead, and no one mentioned N95 masks or COVID-19 restrictions for resident #6. The facility failed to provide or make available N95 masks upon entrance into the facility when there were confirmed cases of COVID-19. Review of the facility's procedure titled, COVID-19 Outbreak, last revised 7/28/22, showed: - . 5. Visitors must be screened for Covid s/s before entering the building. If cleared to come in they need to wear a mask, wash hands upon arrival and before leaving - All staff need to provide the education and reminders, and - 6. Ensure face masks are available at the front door. [sic] 2. Properly Worn N95 Masks During an observation on 12/16/25 at 9:50 a.m., staff member A was in her office, with the door open, talking to another staff member with no isolation mask on. During an observation on 12/17/25 at 7:26 a.m., staff member B was preparing medications at the medication cart, wearing an N95 mask. Staff member B had not secured the top strap of the mask and was holding the mask on her face with her hand. During an observation on 12/17/25 at 7:26 a.m., staff member H was standing in a resident's doorway, wearing an N95 mask with the top of the mask resting below his nose. During an observation on 12/17/25 at 7:39 a.m., staff member C was wearing an N95 mask without the upper strap of the respirator over her head. The top strap was hanging on the front of her mask, over her nose, not creating a proper mask seal. During an observation on 12/17/25 at 7:40 a.m., staff member B was standing at the medication cart, wearing an N95 mask, with the mask top strap hanging in front of her face. During an observation on 12/17/25 at 7:44 a.m., staff member H was wearing an N95 mask, the mask was sitting below his nose. During an interview on 12/17/25 at 7:47 a.m., staff member H stated he recently had training on the proper use of N95 masks. Staff member H stated he could not breathe with the top strap of the N95 mask over his head, as required. Staff member H stated he would wear the mask with the top strap down until he was around a resident. During an observation on 12/17/25 at 9:23 a.m., staff member E was in the activities room with her mask pulled down, with a resident within inches of her face, and she was talking loudly, asking if she wanted a donut. During an interview on 12/17/25 at 9:38 a.m., staff member A stated N95 masks should be worn properly to be effective. Review of the CDC referenced instruction sheet titled, Sequence For Putting On Personal Protective Equipment (PPE), undated, showed: - . 2. Mask or Respirator, - Secure ties or elastic bands at middle of head and neck, - Fit flexible band to nose bridge, - Fit snug to face and below chin, and - Fit-check respirator. 3. Face Shields/Goggles Review of an infection control spreadsheet listing, dated 12/16/25, of the last four residents who tested positive for COVID-19 showed: - Residents #6 and #12 were confirmed positive on 12/9/25, - Resident #9 was confirmed positive on 12/11/25, and - Resident #16 was confirmed positive on 12/16/25. This listing showed the COVID-19 virus continued to spread to other residents. During an observation on 12/16/25 at 8:02 a.m., staff member B was passing medications to resident #12 in his room. Resident #12 had tested positive for COVID-19 on 12/9/25. Staff member B was not wearing a face shield or protective eyewear. During an observation on 12/17/25 at 7:40 a.m., staff member B was passing medications to resident #9 in her room. Resident #9 had tested positive for COVID-19 on 12/11/25. Staff member B was not wearing a face shield or protective eyewear. During an observation on 12/17/25 at 8:13 a.m., a droplet precautions sign was posted on the door frame of resident #9's and #12's room. The signage showed a gown and gloves were to be worn for entry, and Mask/face shield is indicated for those who come within 3 feet of patient/resident. During an observation on 12/17/25 at 8:14 a.m., staff member C was assisting resident #9 with her morning meal. Staff member C was not wearing any form of face shield or goggles. During an observation on 12/17/25 at 8:15 a.m., none of the PPE carts located outside or directly inside the rooms of residents #6, #9, #12, and #16 had any form of face shield or goggles in the carts. During an interview on 12/17/25 at 9:38 a.m., staff member A stated all staff were to wear protective eyewear/face shields when entering into a COVID-19 positive resident's room with contact and droplet precautions posted. Staff member A stated the staff had PPE available to them, and staff knew they were to wear the proper PPE during a COVID-19 outbreak. Review of the facility's procedure titled, COVID-19 Outbreak, last revised 7/28/22, showed: - . Staff adhere to strict PPE (Personal Protective Equipment) use, including: N95 mask, protective eyewear such as goggles or facemask, gown, gloves and continue to perform proper hand hygiene when performing direct care. All staff use N95 masks and protective eyewear to limit exposure risk. Contact isolation precautions include contact, airborne and droplet when working with Covid-19 residents. [sic] Review of the State of Montana Epidemiology and Scientific Support Bureau outbreak tracking, provided to the State Survey Agency, and dated for 12/12/25 and 12/18/25, showed the COVID-19 outbreak began at the facility on 12/2/25. As of 12/18/25, there were a total of 11 cases: three residents and eight staff. When surveyors were onsite at the facility, there were four resident cases identified, as resident #16 was confirmed positive for COVID-19 during the survey, which reflected the facility staff were not proactively or successfully preventing the spread of COVID-19.

Based on interview and record review, the facility failed to submit mandatory payroll-based data to CMS. This deficient practice prevented CMS review of the level of staff, employee turnover, and tenure to ensure safe staffing levels. Findings include:Review of the PBJ Staffing Data Report, dated 12/9/25, for quarter four (7/1/25-9/30/25) reflected the facility failed to submit data for the quarter. During an interview on 12/15/25 at 9:15 a.m., staff member A stated the facility did not submit the PBJ for the fourth quarter of 2025 and once the facility realized the data had not been submitted, it was too late to submit the data.

Based on observation and interview, the facility failed to have a designated registered nurse to serve as the director of nursing on a full-time basis. This deficient practice resulted in a failure of clinical oversight for all residents residing in the facility. Findings include: During an observation on 12/15/25 at 9:00 a.m., the Director of Nursing was not present at the facility. During an interview on 12/15/25 at 9:15 a.m., staff member A stated the Director of Nursing resigned on 12/2/25, and a new Director of Nursing would start on 12/29/25. Staff member A stated she did not assign an interim Director of Nursing because she knew the new Director of Nursing would be starting soon. Review of a facility provided document, Survey Information, dated 8/18/25, reflected that the Director of Nursing resigned on 12/2/25, and a new Director of Nursing would start on 12/29/25. Review of a facility policy, Nursing Services, with a revision date of 10/2022, reflected: - . 3. b. Except when waived the facility must designate a registered nurse to serve as the director of nursing on a full-time basis. Review of an email communication, sent to the State Survey Agency, dated 12/4/25, related to the Director of Nursing Hourly Requirements, showed staff member A requested clarification on the regulatory requirement for the DON hours and coverage of the position duties. The communication showed staff member A was aware of the DON designation requirement(s) prior to the survey.

Based on observation and interview, the facility failed to ensure medication error rates were not 5 percent or greater by crushing medications administered to residents without a physician's order for 2 (#s 7 and 13) of 5 residents observed for medication administration. The medication error rate was 24 percent. Findings include:During a medication administration observation on 12/16/25 at 8:21 a.m., staff member B prepared resident #7's medications. The following medications were placed into a plastic medication cup, crushed, then added to applesauce:- citalopram hydrobromide 20 milligram tablet, give one tablet,- acetaminophen 500 milligram tablet, give two tablets, and- sennosides-docusate sodium 8.6-50 milligram tablet, give two tablets.Staff member B administered the crushed medications to resident #7. These medications were administered without a physician's order for crushed medications.During a medication administration observation on 12/16/25 at 8:38 a.m., staff member B prepared resident #13's medications. The following medications were placed into a plastic medication cup, crushed, then added to applesauce: - cholecalciferol 1,000 unit tablet, give two tablets,- oxybutynin chloride 5 milligram tablet, give 0.5 tablet,- sennosides-docusate sodium 8.6-50 milligram tablet, give one tablet, and- trazodone hydrochloride 50 milligram tablet, give 0.5 tablet.Staff member B administered the crushed medications to resident #13. These medications were administered crushed without a physician's order for crushed medications.During an interview on 12/16/25 at 12:28 p.m., staff member B stated there were not orders for crushed medications for residents #7 and #13. Staff member B stated she knew which residents' medications to crush from the facility's roster/shift change sheet for nurses.During an interview on 12/16/25 at 12:35 p.m., staff member A stated there were no physician's orders for crushed medication for any of the facility's residents. During an interview on 12/16/25 at 1:15 p.m., staff member D stated she knew some residents were receiving crushed medications but did not know those medications were being administered without a physician's orders for crushed medications.

Based on observation, interview, and record review, the facility failed to ensure staff member B adhered to medication administration best practice by crushing a medication indicated on a Do Not Crush medication listing for 1 (#13) of 5 residents observed for medication administration. Findings include:During a medication administration observation on 12/16/25 at 8:38 a.m., staff member B prepared resident #13's medications. The following medications were placed into a plastic medication cup, crushed, then added to applesauce:- cholecalciferol 1,000 unit tablet, give two tablets,- oxybutynin chloride 5 milligram tablet, give 0.5 tablet,- sennosides-docusate sodium 8.6-50 milligram tablet, give one tablet, and- trazodone hydrochloride 50 milligram tablet, give 0.5 tablet.Staff member B administered the crushed medications to resident #13.During an interview on 12/16/25 at 12:28 p.m., staff member B stated she knew which residents' medications to crush from the facility's roster/shift change sheet for nurses. Staff member B stated there were not any labels on any resident's medication bubble packets which indicated medication was not to be crushed. Staff member B stated she knew not to crush an extended-release medication but otherwise she would not know which medications should not be crushed.During an interview on 12/16/25 at 12:32 p.m., staff member B stated she was unaware trazodone for resident #13 was listed on a DO NOT CRUSH listing of medications.During an interview on 12/16/25 at 12:35 p.m., staff member A stated she did not know trazodone was an indicated DO NOT CRUSH medication.During an interview on 12/16/25 at 1:15 p.m., staff member D stated trazodone was on the DO NOT CRUSH medication listing.During an interview on 12/16/25 at 2:08 p.m., staff member A stated the facility did not have a policy/procedure for crushed medications.Review of a document titled, PharMerica Oral Medications That Should Not Be Crushed or Altered, dated 2/2023, showed trazodone as a medication which should not be crushed.

Based on interviews and record review, the facility failed to maintain collaborative records for medication administration and care plans which aligned with the hospice agency for 2 (#s 2 and 15) of 3 hospice patients sampled. Findings include: 1. Review of resident #2's paper chart and EHR reflected no documents for hospice, including there not being a care plan or medication reconciliation for hospice and the resident. The care plan and medication list were requested from the hospice agency.Review of resident #2's faxed, Hospice Medication Profile, undated, reflected the following items were not listed on the facility medication list:- Alendronate Sodium 70 mg tabs, one time weekly on Tuesday for bone reabsorption,- Cholecalciferol (D3) 50 mcg tabs, one tablet daily for vitamin supplement, - Apixaban 5 mg tabs, one tablet twice per day for anticoagulation,- Escitalopram 10 mg tabs, one tablet daily for depression,- Famotidine 20 mg tab, one tablet daily GERD,- Diflucan 150 mg, one tablet with catheter changes and three days later for yeast infections,- Magnesium Hydroxide 30 mL every 72 hours as needed for constipation, - Melatonin 3 mg tabs, one tablet at bedtime for insomnia,- Potassium Chloride ER 10 MEQ, two tablets twice per day for hypokalemia,- Apoaequorin 20 mg, one tablet per day for memory,- Rosuvastatin Calcium 20 mg daily for CVA, and,- Torsemide 20 mg daily for edema. Review of resident #2's facility comprehensive care plan, dated 7/15/25, did not include information related to the frequency of the hospice staff visits, the hospice goals, or hospice interventions. 2. Review of resident #15's paper chart and EHR reflected no documents for hospice, including no hospice care plan or medication reconciliation. The care plan and medication list were requested from the hospice agency.Review of resident #15's EHR Order Summary, dated 12/17/25, reflected the following items not listed on the faxed Hospice Medication Profile:- Bisacodyl Rectal Suppository 10 mg every 72 hours as needed for constipation,- Guaifenesin Oral Syrup 100 mg/mL, 10mL every six hours as needed for cough,- Milk of Magnesia Oral Suspension 1200 mg/15mL, give 30mL every 72 hours as needed for constipation, and- Polyethylene Glycol 3350 Powder, give 17 grams once daily for constipation.Review of resident #15's facility's comprehensive care plan did not reflect information on the frequency of the hospice staff visits, the hospice goals, or hospice interventions. During an interview on 12/16/25 at 2:40 p.m., staff member A stated the facility was responsible for personal care and room and board for hospice residents. Staff member A stated that hospice visited and assessed residents, did spiritual visits, and the hospice staff attended care plan meetings quarterly. Staff member A stated the facility had Utilization Review meetings weekly, and the facility sent updated care plans to hospice, but had no documentation of the care plans being sent to hospice. Staff member A stated she or the Director of Nursing attended the hospice IDT every other week. Staff member A was not able to explain why the care plan and medication lists between hospice and the facility did not match. During an interview on 12/16/25 at 3:31 p.m., NF1 stated communication was ongoing almost daily with facility and she did not know why the orders and care plans did not align. Review of the [Hospice Name] and [Facility Name] Memorandum of Understanding, dated 5/19/25, reflected:- . [Hospice name] staff will be available 24 hours a day to give guidance and contact primary providers to obtain order changes if necessary to properly address the terminal illness and related symptoms.

Based on observation, interview, and record review, staff member B failed to ensure the security of all medications in a locked storage medication cart, limiting access to unauthorized personnel, and or residents. Findings include: During an observation on 12/17/25 at 7:43 a.m., staff member B was in a resident's room passing medications. The medication cart was parked outside of the room, in the hallway. The medication cart was not locked.During an interview on 12/17/25 at 10:54 a.m., staff member B stated the medication cart should be locked when a nurse was not by the cart. She stated she left her medication cart unlocked in the hallway earlier in the morning.Review of the facility's policy titled, Medication Floor Stock, last revised 8/17, showed:- .2. Medications contained in floor stock shall be stored in either locked cabinet or a tamper evident cart. Responsibility for security of the floor stock shall rest with the supervising licensed practitioner or supervising nurse overseeing the unit in which the floor stock is stored.

Based on observations, interviews, and record review, the facility failed to ensure catheter bags were covered for 1 (#6) of 14 sampled residents. This deficient practice resulted in resident #6 feeling embarrassed to have the catheter bag visible to others. Findings include:During an observation and interview on 12/15/25 at 10:40 a.m., resident #6 was in his recliner in his room with the door open. Resident #6 had a catheter bag hanging from the pocket of his recliner filled half full of dark yellow urine. The catheter bag was facing the door and visible to those who walked past his room. Resident #6 stated, It's whatever, when the catheter bag and dignity was discussed. During an observation and interview on 12/16/25 at 9:10 a.m., resident #6's catheter bag was hanging from his right pocket of his recliner, uncovered, and was 1/4 filled with urine. The catheter bag was facing the doorway, and the door was open to the hallway. Resident #6 stated, It's a bit embarrassing, when asked about the catheter bag. During an interview on 12/16/25 at 11:40 a.m., staff member J stated the facility had two catheter bag covers available in the supply closet, and they should be on the catheter bags of residents who used catheters. Staff member J went to staff member A's office and requested that she order more catheter bag covers. During an interview on 12/16/25 at 11:47 a.m., staff member K stated the catheter cover will rip and fall off, but he would go put a catheter cover on resident #6's catheter bag. Review of resident #6's care plan, with a revision date of 10/15/25, reflected resident #6's catheter was to be positioned below the level of the bladder and facing away from the entrance of the room door. During an interview on 12/16/25 at 2:08 p.m., staff member A stated the facility did not have a policy and procedure for covering catheter bags to ensure a resident's dignity is maintained.

Based on observation, interview, and record review, the facility failed to honor a resident's preferences of not being woken up in the morning and given a breakfast tray for 1 (#2) of 14 sampled residents. This deficient practice caused resident #2 frustration and anger leading to behaviors. Findings include:During an observation and interview on 12/15/25 at 10:45 a.m., resident #2 stated she was angry the staff continued to wake her and bring in a breakfast tray every morning even though she repeatedly asked them not to bring in a breakfast tray. Resident #2 stated she had never eaten breakfast and was not going to start. Resident #2 stated it was frustrating the facility would not listen to her wishes. The breakfast tray was sitting on her bedside table uneaten. During an interview on 12/15/25 at 11:45 a.m., staff member J stated resident #2 had not eaten breakfast since she was admitted to the facility. Staff member J stated she was told by the kitchen that resident #2 must receive a tray even if she refuses it. Staff member J stated that resident #2 would become very angry and had a history of throwing her trays at staff. Staff member J stated the resident was not offered breakfast at a later time but was offered a snack before lunch. Review of resident #2's care plan, with a revision date of 11/19/25, reflected resident #2 had a personal history of refusing breakfast.Review of a nurse's progress note, dated 12/16/25 at 9:08 a.m., reflected, Res. was offered her tray twice this a.m. and refused twice. She was offered when it was brought in and later after the CNA fed someone else she came back to resident's room and offered again to help her eat and res. refused again. [sic]During an interview on 12/17/25 at 9:50 a.m., staff member A stated she did not know where the rule came from, but the staff were told to bring her a tray each morning regardless of whether the resident wanted one or not. Staff member A stated she often became very agitated and would hit, throw things, and cursed at the staff. Staff member A stated she did not have a policy showing meal trays must be given regardless of residents' preferences. Staff member A stated she did not have documentation of any resident education offerinng resident #2 an altered meal schedule and she continued to refuse.

Based on observation, interview, and record review, the facility failed to ensure staff member B protected a resident's right to privacy and confidentiality of her medical record for 1 (#9) of 5 residents observed for medication administration. Findings include:During an observation on 12/17/25 at 7:43 a.m., staff member B was in resident #9's room, administering her medications. The medication cart was parked outside resident #9's room. The computer used for medication administration was on top of the medication cart, with the computer screen open to resident #9's medication listing with her picture visible. At the time of the observation, another resident had exited her room and passed directly next to the medication cart.During an interview on 12/17/25 at 10:54 a.m., staff member B stated the computer on the medication cart should be locked each time she (staff member B) stepped away from the cart so a resident's record could not be seen by others.Review of the facility's policy titled, Confidentiality of Information, undated, showed:- .Confidentiality of the patient record shall be maintained at all times by keeping the record closed when not in use. If an electronic health record is used, ensure that no other individual can read the screen and log-off the computer when not in use.

Based on observations, interviews and record review, the facility failed to provide activities to meet the interests and preferences of residents who remain in their rooms for 2 (#s 2 and 6) of 14 sampled residents. This deficient practice led to boredom for resident #6 and frustration for resident #2. Findings include:1. During an observation and interview on 12/15/25 at 10:45 a.m., resident #2 stated, I'm just laying here playing dead I guess. Resident #2 stated she did not get out of bed anymore and did not have activities in her room. Resident #2 stated she used to quilt and read. Resident #2 stated she liked to read modern romance and adventure books, but they were not offered to her. Resident #2 stated, I guess they just leaving me to play dead.Review of resident #2's care plan, dated 11/10/25, reflected resident #2 had little or no interest in activities. The care plan reflected, . [resident #2] enjoys watching television in her room, visiting in her room with friends and family and going on outings with her family as able.Review of resident #2's Kardex, dated 12/16/25, reflected activities to include donuts and news, one-to-one activity, arts and crafts, ball toss/beanbag toss, barber, bingo, cooking, educational presentations, exercise, family involvement, gardening, holiday party, jazzercise, manicures, morning stretches, movie, music event, out of facility, parade, pet therapy, picnic, television in her room, reflections, religious services, reminiscing basket, resident council, self-directed activity, social hour, van ride, visitors, walking outside, wheelchair yoga, women's luncheon, youth visitors and games.Review of resident #2's activity assessment, date 11/12/25 reflected resident #2's preferences included pets, TV/movies, and youth visits.2. During an observation and interview on 12/15/25 at 10:40 a.m., resident #6 was in his recliner resting with the television on. Resident #6 stated, I really don't do much but sleep in this chair. I'm not tired really but watch TV and sleep. No activities, not really sure about what they have for me. Resident #6 stated he did not come out of his room and did not have any visits from the activities department except to drop off a schedule of group stuff and sometimes coloring stuff. Resident #6 stated he was not getting his newspaper in the mornings anymore. Resident #6 stated he did not know why he was not receiving the newspapers.Review of resident #6's care plan, dated 10/15/25, reflected, . Provide peasant diversional activities such as conversation, newspapers, TV and structured group activities to decrease exit seeking behavior and promote safety. [Resident #6] enjoys reading the paper with coffee and watching the news. [sic]During an interview on 12/16/25 at 9:17 a.m., with staff members J, K, and L, staff members J and K stated the facility did not receive the newspaper for a long time except the [newspaper name] a couple of times a month. Staff members J, K, and L stated they were not aware resident #6's care plan showed he enjoyed the newspaper with coffee. Staff member J and K stated the CNAs only had access to the Kardex. Staff member K stated resident #6 did not leave his recliner and did not participate in group activities. Staff member J stated resident #6 told her he hated Bingo and did not participate in Bingo. Staff member J stated the Kardex, and the care plan did not reflect resident #6's activity preferences since he did not want to leave his chair for the last few months. Staff member J stated resident #2 did not get out of bed anymore so her Kardex and care plan also did not reflect her current status for activities. Staff members J, K, and L stated activities were not done for residents who did not leave their rooms. Staff member K stated they had not seen any one-to-one activity visits completed in the facility in a long time, at least months if not longer.Review of resident #6's Kardex, 12/16/25, reflected resident #6's activities were to include donuts and news, one-to-one activity, arts and crafts, ball toss/beanbag toss, barber, bingo, cooking, drumming circle, educational presentations, exercise, and games. Review of resident #6's activity assessment, dated 10/14/25, reflected resident #6 preferences included arts and crafts, church service, exercise, games, music, news, pets, social, television and movies.During an interview on 12/16/25 at 8:45 a.m., staff member E stated the activities department used the activities assessment done quarterly to determine activities needs.During an interview on 12/16/25 at 9:50 a.m., staff member A stated the facility had been a struggle to get activities to take charge and work the activities programs. Staff member A stated she was aware the one-to-one visits and activities they should be doing were not being done but could not seem to get activities staff to work on the program. Staff member A stated, I guess we need to take a deficiency and write a Plan of Correction to get them moving. Staff member A stated she added all the activities to every Kardex regardless of preferences listed on the activities assessment findings. Staff member A stated the CNAs use the Kardex as their care plan. During an interview on 12/16/25 at 10:02 a.m., staff member E stated, We need to do more for the residents who stay in their rooms.During an interview on 12/17/25 at 9:10 a.m., staff member A stated she had a conversation with activities and determined the one-to-one charting was being falsified. Staff member A stated the staff were putting down residents were refusing, sleeping, or unavailable when they had not attempted the one-to-one activities. Review of the facility policy, Activities Meet Interest/Needs of Each Resident, dated 2/2023, reflected:- The facility must provide, based on the comprehensive assessment and care plan and the preferences of each resident: 1. An ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities designed to meet the interest of and support the physical, mental and psychosocial well-being of each resident, encouraging both independence and interaction in the community.

Based on observations, interviews and record review, the facility failed to develop a comprehensive person-centered care plan, including the residents' preferences, for 2 (#s 2 and 6) of 14 sampled residents. This deficient practice resulted in resident #s 2 and 6 not having activities to meet their preferences. Findings include: 1. During an observation and interview on 12/15/25 at 10:45 a.m., resident #2 stated she did not get out of bed anymore and did not have activities available in her room. She discussed her activities of interest, to include reading and quilting, but these things were not offered to her.Review of resident #2's care plan, dated 11/10/25, reflected resident #2 had little or no interest in activities. The care plan reflected, . [Resident name] enjoys watching television in her room, visiting in her room with friends and family, and going on outings with her family as able. The care plan did not include information related to the interest's resident #2 relayed during the interview. Review of resident #2's Kardex, dated 12/16/25, reflected a variety of activities, such as 1:1 activity, arts and crafts, ball toss/beanbag toss, barber, bingo and others. These activities were not noted on the resident's comprehensive care plan. Review of resident #2's activity assessment, date 11/12/25, reflected that resident #2's preferences included pets, tv/movies, and youth visits. Although the activity assessment identified activities she was interested in, these were not reflected in her comprehensive care plan.2. During an observation and interview on 12/15/25 at 10:40 a.m., resident #6 was in his recliner resting with the television on, and stated he did not come out of his room and did not have any visits from the activity staff, except for them to drop off a schedule of group activities. Resident #6 stated he was not receiving his newspaper in the mornings either. Review of resident #6's comprehensive care plan, dated 10/15/25, reflected, . Provide peasant diversional activities such as conversation, newspapers, TV and structured group activities to decrease exit seeking behavior and promote safety. [Resident #6] enjoys reading the paper with coffee and watching the news. [sic]During an interview on 12/16/25 at 9:17 a.m., with staff members J, K, and L, staff members J, K, and L stated they were not aware that resident #6's care plan showed he enjoyed the newspaper with coffee, and the facility did not always receive a newspaper. Staff members J and K stated that the CNAs could not see the resident's care plan, which should show identified activities of interest. Staff member J stated the Kardex and care plan did not reflect resident #6's preferences, as he did not want to leave his chair, and many of those activities listed, he had never done. Staff member J stated resident #2 did not get out of bed anymore, so her Kardex and comprehensive care plan also did not reflect her current status for activities. During an interview on 12/16/25 at 9:50 a.m., staff member A stated there was no activity care plan for resident #6.During an interview on 12/16/25 at 8:45 a.m., staff member E stated she did not use the care plan and did not enter anything for resident activities on the care plan. Staff member E stated that staff member A must be creating the activities care plan, but the activities department did not use that care plan. Staff member E stated the activities department used the activities assessments, which were done quarterly, to determine the residents' activity needs. During an interview on 12/16/25 at 9:50 a.m., staff member A stated she added all the activities to every Kardex, regardless of resident preferences, and stated the CNAs use the Kardex as the resident care plan.During an interview on 12/16/25 at 10:02 a.m., staff member E stated she could see there was a disconnect between the resident care plans staff member A created, the Kardex used by CNAs, and the assessments used by the activities department.Review of the facility policy, Resident Centered Care Plan, dated 10/2022, reflected:- . Each resident will have a person-centered comprehensive care plan developed and implemented to meet his preferences and goals, and address the resident's medical, physical, mental and psychosocial needs.

Based on interview and record review, the facility failed to ensure an agency staff member, who was contracted with the facility for over 12 months, had an annual performance review completed. Findings include:During an interview on 9/22/25 at 1:15 p.m., staff member A stated she did not have performance reviews for agency staff.During an interview on 9/22/25 at 1:57 p.m., staff member B stated the facility did not conduct performance reviews for agency staff. Staff member A said staff member C had contracted with the facility for over 12 months. Staff member A said she thought staff member C had been contracted with the facility since COVID.During an interview on 9/22/25 at 2:08 p.m., staff member E stated, My agency does not do performance reviews; They just tell me when a facility compliments my work. Staff member E stated she does not receive annual education based on her performance reviews.Review of the staffing contract for staff member C with the facility showed, .Contract will commence on 01/22/22.A request was made for performance reviews for staff member C on 9/22/25 at 1:30 p.m., no evaluation was provided by the end of survey.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive care plan based on resident activity preferences and physical abilities, for 4 (#s 4, 10, 14, and 15) of 10 sampled residents. Findings include: 1. During an observation on 8/26/24 at 11:13 a.m., resident #15 was sitting in her wheelchair in her room. The room was quiet, and she was facing the wall, looking forward. During an interview on 8/28/24 at 3:56 p.m., NF2 stated, It would be nice if there were more for (resident #15) to do. I understand it is hard because she really can't communicate, though. Review of resident #15's care conference review, dated 7/29/24, showed on the Activities Summary: Problems/Needs (resident #15), . She spends the majority of her time in her room watching TV, napping, and 1:1 visit with family and staff. Evaluation/Goals: Continue to invite and encourage (resident #15) to attend group activities of her choice 3-4 X per week . Review of resident #15's care plan dated 7/31/24 showed, provide a program of activities that accommodates (resident #15's) abilities. Engage (resident #15) in simple, structured activities that avoid overly demanding tasks. 2. During an interview on 8/26/24 at 2:34 p.m., NF1 stated, Most of the time when exercises are on the activity calendar, residents are just in the recreation room putting together puzzles, watching TV, or sleeping. I would like to see more options for activitities for [resident #14]. Review of resident #14's most recent activity assessment, with a date of 3/24/22, showed activity preference: independent activities. Review of resident #14's Annual MDS, dated [DATE], section GG, showed the resident is dependent on staff for all care areas. Review of resident #14's care conference review, dated 7/8/24, showed, Activities Summary: Problems/needs: (resident #14) attends group activities 2-3 X per week. 3. During an observation on 8/27/24 at 9:13 a.m., resident #4 was in his wheelchair in the activities room. Other residents were playing cards, and he was sleeping. Review of resident #4's care conference review, dated 7/15/24, showed, Activities Summary: Problems/needs: (resident #4) attends group activities 2-3 X per week . 4. During an observation and interview on 8/26/24 at 10:42 a.m., resident #10 was sitting in her room with music playing. Resident #10 stated, I wish there was more to do. We used to go on outings, but I haven't been out of the facility in a long time. I know the van is broken down, but it would be nice to go for a walk outside or something. Review of resident #10's care conference review, dated 6/24/24, showed, Activities Summary: Problems/needs: (resident #10) attends group activities 2-3 times a week. She likes playing bingo, puzzles, church, and arts and crafts. She spends the majority of time in her room self-directing with word puzzles, TV, music, and a 1:1 visit with family and staff. During an interview on 8/28/24 at 8:28 a.m., staff member G stated, I add resident information into the resident's care plan. The care plans are generic. I wouldn't say activities are specific to the residents. When a resident gets admitted , we do an intake assessment, and then we do them annually. During an interview on 8/28/24 at 11:13 a.m., staff member A stated, The activity director doesn't normally put anything in the care plan. I add that section's information. We need to work on the care plans being comprehensive, and the revisions to meet the resident needs. We need to work on more activities for dementia residents, such as sensory and meaningful activities.

Based on observation, interview, and record review, the facility failed to provide residents with group and individual activities to meet their interests and support their physical, mental, and psychosocial well-being for 4 (#s 4, 10, 14, and 15) of 10 sampled residents. 1. During an observation and interview on 8/26/24 at 11:13 a.m., resident #15 was sitting in her wheelchair in her room. The room was quiet, and she was facing the wall, looking forward. Resident #15 had trouble answering questions and was mostly nonverbal, but when asked if she was bored, she nodded her head in an up-and-down motion. During an interview on 8/28/24 at 3:56 p.m., NF2 stated, It would be nice if there were more for [Resident #15] to do. I understand it is hard because she really can't communicate, though. Review of resident #15's task documentation report dated August 2024 showed resident #15 participated in 7 activities out of 28 days. 2. During an interview on 8/26/24 at 2:34 p.m., NF1 stated, I think cartoons are okay if there are animals in them. She (resident #14) enjoys animals. Her favorite shows are any medical shows, as she was an X-ray technician. NF1 stated, I wish the facility offered more exercise or made it fun. Most of the time when exercises are on the activity calendar, residents are just in the recreation room putting together puzzles, watching TV, or sleeping. During an observation and interview on 8/26/24 at 4:13 p.m., resident #14 was sitting in her wheelchair in her room facing the television. The [NAME] and [NAME] cartoon was on television. Resident #14 was asked if she liked cartoons and said no. During an observation on 8/27/24 at 7:26 a.m., resident #14 was sitting in her room in her wheelchair looking at the ground, and there were cartoons on the TV. Review of resident #14's task documentation report, dated August 2024 showed resident #14 participated in four activities out of 28 days. 3. During an observation on 8/26/24 at 10:29 a.m., resident #4 was sitting in his room in his wheelchair; the room was dark, and the television was on. Resident #4 was difficult to understand when he spoke. During an observation on 8/26/24 at 11:10 a.m., resident #4 was still sitting in his wheelchair, sleeping, in his room. During an observation on 8/27/24 at 9:13 a.m., resident #4 was in his wheelchair in the activities room. Other residents were playing cards, and he was sleeping. Review of resident #4's task documentation report, dated August 2024, showed resident #4 participated in six activities out of 28 days. 4. During an observation and interview on 8/26/24 at 10:42 a.m., resident #10 was sitting in her room with music playing. Resident #10 stated, I wish there was more to do. We used to go on outings, but I haven't been out of the facility in a long time. I know the van is broken down, but it would be nice to go for a walk outside or something. Review of resident #10's task documentation report dated August 2024 showed resident #10 participated in five activities out of 28 days. During an interview on 8/28/24 at 8:28 a.m., staff member G stated, I add resident information into the resident's care plan section. The care plans are generic. I wouldn't say activities are specific to the residents. My assistant does all the documentation in PCC. When a resident gets admitted , we do an intake assessment, and then we do them annually to find out what their interests are. I don't document when I spend time with residents one on one, I probably should. During an interview on 8/28/24 at 8:35 a.m., staff member H stated, I've never documented if a resident refuses activities. I only document if they participate. I don't document one-to-one visits either. During an interview on 8/28/24 at 8:57 a.m., staff member G stated, When a resident comes to an activity and they can't participate, we offer them drinks and snacks . If a resident is asleep, they aren't getting anything out of the activity. During an interview on 8/28/24 at 11:13 a.m., staff member A stated, The activity director doesn't normally put anything in the care plan. I add that section's information. I know our activity program is weak, we need a better program. We need to work on the care plans being comprehensive, and the revisions to meet the resident needs. We are working on getting volunteers back in after COVID. We do have a nurse who has been working with activities to assist them with activities to meet the resident's needs. The overall program needs revamping; we need to see more activities for dementia residents, such as sensory and meaningful activities.

Based on observation, interview, and record review, the facility failed to provide dignity for a resident when transferring the resident to the shower room for 1 (#9) of 10 sampled residents. Findings include: During an observation on 8/26/24 at 9:17 a.m., the surveyors entered the facility. Staff member F was wheeling resident #9 in a bath chair to the shower room. Resident #9's upper body was covered by a bath poncho, but the lower body of resident #9 was exposed and visible underneath the shower chair. During an interview on 8/27/24 at 11:25 a.m., staff member C showed the surveyor the bath poncho and how it was used to cover the residents. Staff member C stated staff would use an extra blanket over the resident's lap if needed. Staff member C stated, I usually change them (the residents) in their room and then transfer them to the shower room . The shower rooms are so small that it is hard to get the residents changed in there. Staff member C stated she ensured the residents were covered before moving them out of their room and into the hallway. During an interview on 8/28/24 at 10:04 a.m., staff member D stated the resident's privacy was important, and they made sure the resident's body was covered completely before exiting the resident's room when being transferring for showers. Staff member D stated they would feel very uncomfortable if they were not completely covered and in the resident's position. Review of a facility provided document, titled Resident Rights/Exercise of Rights, with a revision date of 10/17 showed: 1. A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance and or enhancement of his or her quality of life . The facility must protect and promote the rights of the resident. [sic]

Based on interview and record review, the facility failed to consult wound care services consistently to promote wound healing, and failed to sufficiently document the wound measurements, severity (Stage), and characteristics of the wound, for 1 (#6) of 10 sampled residents. This failure resulted in the wound continuing to remain as a Stage II pressure ulcer for four months (4/9/24 to 8/15/24) with little improvement or intervention, and the wound first started approximately a year ago (7/21/23). Findings include: During an interview on 8/28/24 at 9:43 a.m., staff member E stated resident #6 did not usually refuse wound care treatments. Staff member E stated she may have to make multiple attempts, but was always able to get wound care completed daily for resident #6's left buttock wound. During an interview on 8/28/24 at 10:44 a.m., staff member A stated, The wound is kind of at a standstill. Staff member A stated the status of the left buttock wound would get better for some time and then get worse and repeat that cycle. Staff member A stated wound orders were not updated unless the wound status changed. Staff member A stated [wound care services] were consulted as needed and [wound care services] did not follow this wound consistently or for a specific period of time after being consulted. During an interview on 8/28/24 at 11:45 a.m., staff member B stated they thought it would be more beneficial for resident #6's left buttock wound outcomes to have [wound care services] consulted more frequently. Staff member B stated resident #6's left buttock wound first appeared 7/21/23. Review of resident #6's EHR showed two consults to [wound care services] were completed concerning the left buttock pressure ulcer, on 2/2/24 and 7/16/24. Review of resident #6's EHR showed a [wound care service's] note, dated 7/16/24: . Surrounding skin is very red and irritated and there is moderate bloody drainage . Review of resident #6's Left Buttock Wound Assessments, from 3/18/24 - 8/23/24, showed: - 3/18/24 - no Stage or measurements - 4/1/24 - 4.5cm x 1.2cm x 0.1cm - no Stage - 4/9/24 - 3.8cm x 1.2cm x 0.1cm - Stage 2 open area - 4/15/24 - 4.0cm x 1.3cm x 0.1cm Stage 2 . - 6/12/24 - 5.5cm x 2.0cm x 0.1cm - no Stage - pressure - 6/20/24 - 4.0cm x 1.0cm x 0.1cm - shearing slough . - 7/12/24 - 4.5cm x 2.0cm x 0.1cm - no Stage open area - 7/22/24 - 6.0cm x 3.0cm x 0.1cm Stage 2 . - 8/23/24 - 5.0cm x 1.2cm x 0.1cm - no Stage Review of a facility provided document, titled Quality of Care, with a revision date of 10/22 showed: . 2. A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing .

Based on observation and interview, the facility failed to remove expired medical supplies from the medical supply room and the medical supply cart for 1 of 1 sampled the medical room and medical cart. Findings include: During an observation on 8/29/23 at 8:20 a.m., the following expired items were found: - 23 Protexis PI blue with [NAME]-Thera gloves expired 9/2022. - 55 tongue blades expired 8/9/23. - Six 25 gauge 5/8 needles expired 7/31/23. - 27 glucose test strips expired 2/20/23. - Three Luer-Lok 5mL syringes expired 3/31/23. - 50 Sani cloth wipes expired 5/2023. During an interview on 8/29/23 at 8:45 a.m., staff member B stated the night shift nurses were supposed to check for expired medications monthly. Staff member B showed a spreadsheet hanging on the wall with nurses signed off as having completed the medication room and cart audit, through July 2023. Staff memebr B stated this was done at the end of the month, and August had not been done yet. Staff member B stated she could not explain the items that were expired in the medical supply room and cart.

Based on interview and record review, the facility failed to notify the physician of a severe weight loss for 1 (#7) of 2 sampled residents. Findings include: During an interview on 8/29/23 at 12:31 p.m., staff member D stated she attended a meeting with the facility administration every Wednesday to look over resident's weights, and provide interventions if needed. Staff member D stated she did remember resident #7 had severe weight loss, and stated he went from periods of eating his meals to refusing to eat. Staff member D stated the facility was having an issue with their scale not being accurate, but that was just the last couple of weeks. Staff member D stated she did not remember if she put in any interventions for his weight loss, and believed the reason he looked like he lost so much was because of a scale malfunction. Staff member D stated the facility would notify the doctor of a severe or significant weight loss after it was identified in the weekly meeting with administration. Documentation of the notification of resident #7's severe weight loss, to the doctor, was requested on 8/29/23 at 9:37 a.m. and was not provided. Staff member O was called on 8/29/23 at 12:02 p.m., and there was no answer.

Based on observation, interview, and record review, the facility failed to identify the direct root causes of falls for implementation of individualized interventions and update resident care plans with the individualized interventions related to fall safety for 4 (#s 11, 16, 17, and 18) of 6 sampled residents; and failed to ensure staff had the necessary training to provide fall prevention interventions for 1 (#18) of 6 sampled residents. Findings include: 1. Review of a facility reported incident, dated 1/10/23, showed resident #11 had been assisted to the toilet following an episode of incontinence. While the CNA was getting clean clothing, resident #11 self-transferred off the toilet and fell when exiting the bathroom. The facility investigation showed, Fall occurred due to resident being incontinent prior to ambulating to bathroom and resident #11's care plan interventions (were) current. Review of a facility reported incident, dated 1/14/23, showed resident #11 fell when transferring from the resident's recliner to a standing position. Resident #11's legs became weak, and she dropped back to the recliner. Slid from recliner to the floor landing on buttocks. Resident #11 was transported to the emergency room for evaluation of low back pain and weakness. Resident #11 sustained no injuries but was found to have a urinary tract infection and cystitis. The facility investigation showed, Care plan updated.Requiring moderate amount of assist with ADL's d/t recent fall. Care plan current. Review of a facility reported incident, dated 3/2/23, showed resident #11 . was found lying on floor next to wheelchair and bedside table face first with blood coming from head. The nursing assessment showed resident #11 had a 4 cm laceration to her forehead with hematoma formation. Resident #11 was transported to the emergency room for evaluation of her head injury. The facility investigation showed, Resident [#11] was assisted up in wheelchair for scheduled hair appointment and was left in wheelchair unsupervised, fell asleep and fell forward out of chair on to bedside table striking head on edge of bottom stand of bedside table. Care plan updated for staff to not leave resident unsupervised in room in wheelchair all other fall interventions remain current. Review of resident #11's EMR, Hospice Note, effective date 3/6/23, showed: .SNF reported patient had fallen out of her recliner on 3/3/23. Patient was taken to ER for evaluation, sutures placed in forehead laceration. No other concerns noted.Hoyer lifts for transfers . During an interview on 3/28/23 at 2:19 p.m., staff member C said the CNAs referred to the Kardex (communication tool for nursing staff showing resident's needs, current status, resident information, and interventions). Staff member C said resident #11 had a decline and was no longer walking in her room with her walker. Resident #11 required full assist with transferring, and the staff was using the Hoyer lift (mechanical lift) for all of resident #11's transfers. Staff member C said he was told resident #11 was no longer allowed to be left in her wheelchair, unattended, after her fall on 3/2/23. Resident #11 fell asleep in her wheelchair, and fell forward, out of her chair. Review or resident #11's MDS, dated [DATE], showed resident #11 had a BIMS (Brief Interview Mental Status) score of 13; cognitively intact. Record review of a facility Kardex document for resident #11, dated 3/28/23, showed: Safety [Resident #11] needs a safe environment .Be sure [Resident #11's] call light is within reach .Encourage [Resident #11] to use bell to call for assistance Ensure [Resident #11] has unobstructed path to the bathroom Ensure [Resident #11] is wearing appropriate footwear when ambulating to mobilizing in w/c .Fall mat at bedside Follow facility fall protocol Frequent visual checks every shift HIGH FALL RISK .Toilet Use: 1 person extensive assist. .Mobility: [Resident #11] is able to walk with one person assistance and use of FWW .Transferring: Limited 1 person assist. Use walker with all transfers Transfers: [Resident #11] requires extensive one person assist with transferring. The Kardex for resident #11 failed to show intervention changes with resident #11's change in mobility, increased need for assistance when transferring, and need for supervision when in her room and seated in her wheelchair. Record review of resident #11's care plan, dated 1/20/23, showed: Focus: [Resident #11] is at high risk or falls. Fall risk is increased d/t poor mobility, medication use (psychotropic /narcotic), O2 use, Arthritis, HX of past falls prior to admit. Date Initiated: 01/20/2023 .Revision on: 01/23/2023 .Goal: Side effects of: psychoactive drugs, anti-hypertensives etc.; contributing to: gait disturbance, balance disturbance and increasing [Resident #11's] fall risk will be reduced by the review date. Date Initiated: 01/10/2023 .Revision on: 02/02/2023 . Interventions: [Resident #11] needs a safe environment with: even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; bed canes as ordered and personal items within reach. Date Initiated: 01/20/2023 .Revision on: 01/23/23 .[Resident #11] needs to be evaluated for, and supplied appropriate adaptive equipment or devices as needed.Walker used with transfers. Date Initiated: 01/20/2023 .Revision on: 01/23/2023 .[Resident #11] may not be left alone in her room when in wheelchair due to increased fall risk. Date Initiated: 03/02/2023 .Be sure [Resident #11's] call light is within reach and encourage [Resident #11] to use it for assistance as needed. [Resident #11] needs prompt response to all requests for assistance. Date Initiated: 01/20/2023 .Revision on: 01/23/2023 .Ensure [Resident #11] is wearing appropriate footwear when ambulating or mobilizing in w/c.Date Initiated: 01/20/2023 .Revision on: 01/23/23 .Follow facility fall protocol. Date Initiated: 01/20/2023 .Revision on: 01/23/2023 .Review information on past falls and attempt to determine cause of falls. Record possible root causes. After remove any potential causes if possible.Date Initiated: 01/20/2023 .Revision on: 01/23/2023 . Resident #11's care plan did not show individualized interventions that reflected the direct root cause determined for each fall, from the resident's transfers when toileting, and from the recliner. 2. Review of a facility reported incident, dated 8/21/22, showed resident #16 was found on the floor in front of her recliner. She had a lump on her forehead with slight bleeding present, and she had lost a tooth. Resident #16 was unable to give a description of the fall incident. Resident #16 was transferred to the emergency room for an evaluation due to the unwitnessed fall and head injury. Resident #16 received two staples to the laceration on her head, with no other injuries noted. The resident's family declined dental treatment for resident #16's tooth. The facility investigation showed, Suspected that resident was playing with the remote to her electric recliner chair at the time of the fall. The remote has since been removed from her reach .she is frequently encouraged to use call light for assistance. Review of resident #16's EMR Nursing Note, effective date 11/1/22, showed: Today and Sat. res. Hollering out when staff went in to see what res. Needed, she was found sitting on the edge of her recliner between the seat and the foot rest. Res. Demanding that she needed to go to the BR even though she was just taken to the toilet.[sic] Review of resident #16's EMR, Fall Note, effective date 11/9/22, showed: Resident was sitting on the floor by her recliner when the nurse entered her room to respond to the call light. Resident stated that she crawled out of bed to get her candy. Assessed for injuries and initiated neuro checks as this was unwitnessed. Resident slid out of bed to the fall mat positioned on left side and crawled over to her recliner looking for her candy. She then pressed her call light for help. Review of a facility reported incident, dated 11/12/22, showed resident #16 was found in her room lying on her left side, near her recliner. Resident #16 had a 2.5 cm x 4 cm skin tear on her left elbow. Resident #16 said, I fell . The facility investigation showed, No complaints noted from this reported fall, skin tear healing properly, neuro checks remain within normal limits. Staff continue to encourage resident to utilize call light system for assistance. Review of a facility reported incident, dated 11/13/22, showed resident #16 was found lying on her right side, beside her bed on her fall mat. Resident #16 was yelling, I did it again. Resident #16 said she was sitting on the side of her bed and slid off and onto the floor. Assessment did not identify any injury to resident #16. She was assisted back to bed and encouraged to use the call light for assistance. The facility investigation showed, No complaints or injuries reported from this fall, neuro checks remain within normal limits, resident is encouraged to utilize call light for assistance, fall mat continues to be in place. Review of resident #16's EMR, Nursing Note, effective date 11/13/22, showed: Resident was noted to be lying on her right side on top of her fall mat. She stated that she was trying to sit on the edge of her bed and slid off.Earlier in the evening, [resident #16] was very anxious, agitated and combative during cares. Administered Trazodone PRN. Review of a facility reported incident, dated 11/21/22, showed resident #16 stated she was trying to get out of her recliner and slid to the floor. Resident #16 is unable to stand/ambulate on her own. It was determined after assessment, resident #16 had no injuries. She was encouraged to use her call light when she needed assistance. The facility investigation showed, .UA and bloodwork ordered, findings within normal limits. Care plans states that resident is not to be left alone in wheelchair and/or bathroom. It is also care planned that she is not to have remote to her recliner due to increased confusion at times and doesn't utilize it correctly. Fall mat remains in place and resident is visually checked on frequently to ensure that needs are met in a timely manner. [sic] Review of resident #16's EMR, Nursing Note, effective date 11/21/22, showed: Resident was heard to be calling out, Help! When nurse entered resident's room, she was noted to be sitting on the floor between her recliner and bedside table. She was sitting in an upright position with her legs extended in front of her. Review of resident #16's EMR, Alert Charting, effective date 11/22/22, showed: Resident was very anxious most of the night and yelled out nonstop until 0100 (1:00 a.m.). Resident tried crawling out of bed numerous times and finally stopped when she fell asleep. Review of resident #16's EMR, Alert Charting, effective date 11/23/22, showed: Resident is agitated and yelling out. She has been observed trying to get out of bed multiple times this evening. Resident remains a high fall risk. [Resident #16 is impulsive and exhibits very poor safety awareness. Review or resident #16's MDS, dated [DATE], showed resident #16 had a BIMS score of nine; moderately impaired cognition. Review of resident #16's care plan, dated 10/3/22, showed: .Focus: [Resident #16] is at risk for falls r/t Gait/balance problems due to Parkinson's disease and psychotherapeutic drug use: Trazodone and Lexapro.Date Initiated: 10/03/2022 .Revision on: 12/23/2022 .Interventions: Anticipate and meet [resident #16's] needs. Keep call light within her reach. Respond asap. Round on her hourly. Date Initiated: 10/03/22 .Revision on: 12/23/22 Be sure [Resident#16's] call light is within reach and encourage [Resident #16] to use it for assistance as needed. [Resident #16] needs prompt response to all requests for assistance. Date Initiated: 10/3/2022 .Revision on 12/23/2022 .[Resident #16] is safe to ambulate to/from bathroom with FWW, gait belt and 2 person assist per PT eval. Staff to ambulate [Resident # 16] to bathroom as requested by [Resident #16]. Date Initiated: 10/03/2022 .Revision on 12/23/2023 .[Resident #16] needs a safe environment with even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; fall mat on floor beside bed. Date initiated: 10/03/2022 .Revision on: 12/23/2022 .Follow facility fall protocol. Date Initiated: 10/03/2022 .Revision on: 12/23/2022 .Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter remove any potential causes if possible.Date Initiated: 10/03/2022 .Revision on 12/23/2023 .When [Resident #16] is sitting in her recliner staff to unplug chair after placing in preferred position d/t history of fall with independent use of chair remote. Date Initiated: 10/03/2023 .Revision on: 12/23/2022 . Resident #16's care plan failed to show a progression in interventions related to resident #16's change in condition, limited cognition, anticipation of needs, and increase of falls with evaluation of the direct root causes. During an interview on 3/28/23 at 3:48 p.m., staff member A said the root cause of each fall is identified but not really documented through the process. Staff member A said it was identified resident #16 was falling due to her decline (in status) and disease process. Resident #16 had a urinary tract infection and pneumonia that added to her confusion. Staff member A said it (identification root cause and process for the evalation of causes), just was not written down. Staff member A said she was new to the position, and it was a learning process. 3. Review of a facility reported incident, dated 9/12/22, showed resident #18 was being assisted by a CNA at his bedside, who was helping him put his pants on, and the resident lost his balance and slid to the floor. Resident #18 needed verbal ques from staff during cares due to blindness. Resident #18 was wearing no skid socks, and his bed was at a low position. He hit his hand on the bed frame and complained of slight tenderness. The facility investigation showed, Resident with no complaints following fall. Denies pain or discomfort, slight purple bruising on 3rd and 4th digits on right hand, ROM within normal limits, no pain reported when performing ROM, no new orders noted from provider. Resident encouraged to not lean too far over while attempting to assist with pulling pants up. Fall mat remains in place. Review of resident #18's EMR, Fall Note, dated 9/12/22, showed: .Fall Huddle: Continue to provide safe environment with check and changes and proper footwear when standing. Review of a facility reported incident, dated 12/7/22, showed resident #18 said he was . trying to get out of recliner and fell on his butt. There were no injuries noted upon assessment. Resident #18 had gripper socks in place and call light within reach. Resident #18 was encouraged to use his call light for assistance. The facility investigation showed, Resident has no complaints of injuries since most recent fall, no pain reported. Fall mat remains present with gripper socks in place, resident encouraged to utilize call light system for assistance. Review of resident #18's EMR, Fall Note, dated 12/7/22, showed: .Fall Huddle: [not completed] Conclusion: Assessed for injury, No injury noted. Neuro checks initiated.2 per (person) extensive assist onto his feet and ambulated with assist to the restroom.Frequent visual checks in place. Was assisted to dining room for breakfast after assistance to the restroom. [sic] During an observation on 3/28/22 at 2:16 p.m., resident #18 was asleep in his bed, lying on his left side. A fall mat was on the floor next to the bed. The bed was pushed up against the wall with the wall to resident #18's back. The resident's bed side table was placed on the fall mat, centered and placed up against the bed. During an interview on 3/28/22 at 2:19 p.m., staff member C stated the resident's bed is to be lowered to the resident's knee level, and any lower would be considered a restraint. Staff member C said the fall mat is placed next to the resident's bed. Staff member C does not usually place the resident's bedside table on the fall mat next to the bed, because if the resident falls out of bed, the resident could hit the bedside table. Staff member C said staff had been educated to always keep the resident's water and personal items within reach so, sometimes staff will put the bedside table right next to the bed, and place it on the fall mat. During an interview on 3/28/23 at 2:30 p.m., staff member D said the beds are not lowered to their lowest level for fall interventions, because it would be considered a restraint. Staff member D also said the bedside table is placed on the fall mat so the resident can have their water and remote nearby. The resident needs to be able to reach their water, so the water needs to be placed right next to the bed. Staff member D said if a resident has an unwitnessed fall, the resident would be assessed, and it would be determined if they have an injury. For any resident fall, fall paperwork would be filled out, a fall huddle would be done, and the needed people would be notified of the fall. Staff member D said the DON and ADON would meet and do an investigation on the possible cause(s) of the fall and come up with intervention ideas to prevent it from happening again. Staff member D said the information was then shared with the staff. Staff member D said fall interventions for each resident would be found on the care plan. During an interview on 3/28/23 at 2:53 p.m., staff member B said beds need to be lowered to their lowest setting, and a fall mat placed next to the resident's bed. The bedside table should not be next to the bed because, if the resident should fall, they could hit the table and it would cause an injury. Staff member B was not aware of the bed being lowered below the resident's knees to be considered a restraint. Staff member B said, We definitely need to do some re-education on some items. During an interview on 3/28/23 at 3:48 p.m., staff member A said beds are to be lowered to the lowest position. Staff member A said, I think there needs to be some conversations and some training to clear the confusion. We have had difficulty with staff attending the annual inservice and most staff will just sign off on the policies. Staff member A said staff education was identified as an issue and was one of the process improvement projects. The facility was staffed with a lot of travelers, and they were finding the travelers were challenging the CNA testing. Staff member A said some travel staff would arrive and have no idea what they were being asked to do, shave a resident, or provide peri care. Review or resident #18's MDS, dated [DATE], showed resident #18 had a BIMS score of six; severely impaired cognition. Record review of a facility Kardex document for resident #18, dated 3/28/23, showed: Safety Be sure [Resident #18's] call light is within reach and encourage [Resident #18] to use it for assistance as needed. [Resident #18] needs prompt response to all requests for assistance Encourage [Resident #18] to use bell to call for assistance Ensure [Resident #18] has unobstructed path to the bathroom. Requires assistance from staff to toilet[Resident #18] will attempt to ambulate and transfer to toilet on own, history of falls Ensure [Resident #18] is wearing appropriate footwear .Fall mat at bedside Follow facility fall protocol Frequent visual checks Q shift .Toileting .Toilet use- 1-2 person extensive assist .Transferring Transfer: [Resident #18] requires extensive 1-2 person assist from with transferring. Use gait belt, provide verbal and directional cues during transfers due to sight deficit Transferring- 1-2 person extensive assist .Mobility Bed mobility- extensive 2 person assist BED MOBILITY: [Resident #18] requires extensive 1-2 person assist, cuing, and weight bearing assistance, to turn and reposition. Use verbal and directional cues during cares d/t blindness .Dressing Dressing- Extensive 1-2 person extensive assist. Review of resident #18's care plan, dated 2/3/23, showed: .[Resident #18] is a high risk for falls r/t blindness in both eyes, poor mobility, unsteady gait and history of falls prior to NH admit. Date Initiated: 02/02/2023 .Revision on: 02/06/2023 .Anticipate and meet [Resident #18's] needs. Date Initiated: 02/03/2023 .Revision on: 02/06/2023 .Be sure [Resident #18's] call light is within reach and encourage [Resident #18] to use it for assistance as needed. [Resident #18] needs prompt response to all requests for assistance. Date Initiated: 02/03/2023 .Revision on: 02/06/2023 .[Resident #18] needs a safe environment with: even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night and personal items within reach. Date Initiated: 02/03/2023 .Revision on: 02/06/2023 .Ensure [Resident #18] is wearing appropriate footwear such as non-skid socks or shoes when ambulating or mobilizing in w/c. Date Initiated: 02/03/2023 .Revision on: 02/06/2023 .Fall mat at bedside. Date Initiated: 02/03/2023 .Revision on: 02/06/2023 .Follow facility fall protocol. Date Initiated: 02/03/2023 .Revision on: 02/06/2023 .Frequent visual checks Q shift. Date Initiated: 02/03/2023 .Revision on: 02/06/2023 .Place walker within reach at all times when in room. Review of resident #18's care plan failed to show a progression in interventions related to resident #18's falls with dressing, to include with staff assistance, and when safely exiting the recliner, and the plan did not show what individualized resident needs were identified, in an attempt to show staff what needs may be anticipated for the resident for his safety. 4. Review of a facility reported incident, dated 8/18/22, showed resident #17 was found on her knees next to the bed, on the floor. Staff had repositioned resident #17 on her back just prior to the incident. No injuries occurred with the fall. The facility investigation showed, It is suspected the resident used bed cane to pull herself out of bed. Resident unable to verbalize what happened. Resident #17's POA asked the facility to use bed rails and was informed that the facility considers the use of bed rails as a restraint. The facility had concerns for resident safety, and the resident pulling herself out of bed. It was decided to remove the bed cane. Review of resident #17's EMR, Fall Note, dated 8/18/22, showed: Description: at 0130 (1:30 a.m.) resident found on knees, wedge between legs, holding onto bed rail on ground. Resident was repositioned at 0120 (1:20 a.m.) facing east/doorway. Resident pulled self out of bed. No injuries noted. .Fall Huddle: Resident uses side rail to pull self around in bed. Resident last several nocs (nights) chewing at gown/blanket wide awake .Conclusion: Resident seems anxious at night and prefers to chew/grab blanket or nightgown. The facility failed to identify the root causes of the falls or risks associated with them, and document these in the fall documentation. Review of a facility reported incident, dated 8/24/22, showed resident #17 was found on the floor next to her bed. Resident #17 was checked on by the nurse 30 minutes prior to the incident, and resident #17 was lying in bed. The fall mat was in place by the bed, but resident #17's head was resting against the wall. Resident #17 identified her head hurt but no other injuries were found. Resident #17's POA declined resident transport to the ER for an evaluation. The facility investigation showed that resident #17 was unable to verbalize what had happened, and it was suspected she had rolled out of bed. The POA and physician did not want the bed cane placed back on the bed. The fall mat was present, and the staff were encouraged to perform more frequent visual checks. Review of resident #17's EMR, Fall Note, dated 8/24/22, showed: Description: Resident was found by CNA at 2140 (9:40 p.m.) on the floor next to her bed with most of her body on the mat, but her head wedged up against the wall in her room. Resident was on her abdomen. Resident was facing East and lying on her (L) [left] side the last time this narrator saw her which was approximately 30 minutes before incident. .Fall Huddle: Completed. Suggested by CNA and other CNA's as well that resident have the cane bar replaced in her bed. Conclusion: Resident is nervous and afraid. She is lying on her (R) [right] side at this time facing the window. She does calm down when she is talked to quietly. During an observation and interview on 3/28/23 at 11:47 a.m., NF1 said resident #17 had a few falls when she first arrived at the facility. Resident #17 was not ambulatory, was reliant on staff for full assistance, and the Hoyer lift was used for transfers. NF1 said he was in the facility almost daily to sit with the resident, and to assist her as needed. Resident #17 was seated in a chair with the Hoyer lift sheet beneath her. She would make eye contact with her husband and with this surveyor. Resident #17 was nonverbal. NF1 reminded resident #17 to chew and swallow the chocolate she was eating. Resident #17 would stare at him but provided no response. Review of resident #17's MDS, dated [DATE], showed resident #16 had no BIMS score. Record review of a facility Kardex document for resident #17, dated 3/28/23, showed: Safety Be sure [Resident #17's] call light is within reach and encourage [Resident #17] to use it for assistance as needed. [Resident #17] needs prompt response to all requests for assistance Fall mat: Staff to place fall mat at bedside when in bed Follow facility fall protocol Frequent Visual check Q shift .Transferring Transfers: [Resident #17] is dependent on staff for transfers. MANDATORY HOYER FOR ALL TRANSFERS. .Communication Anticipate and meet [Resident #17's] needs. [Resident #17] is aphasic and cannot verbalize needs. Review of resident #17's care plan, dated 2/13/23, showed: .Focus: [Resident #17] is a high risk for falls r/t poor mobility, cognitive impairment (frontal temporal dementia), and psychotropic medication use (trazodone) Date Initiated: 2/13/23 .Interventions: .Anticipate and meet [Resident #17's] needs. [Resident #17] is aphasic and cannot verbalize needs. Date Initiated: 2/13/23 .Be sure [Resident #17's] call light is within reach and encourage [Resident #17] to use it for assistance as needed. [Resident #17] needs prompt response to all requests for assistance. Date Initiated: 2/13/23 .Fall mat at bedside. Date Initiated 2/13/23 .Perform hourly visual checks each shift. Date Initiated 2/13/23 .Review information on past falls and attempt to determine cause of falls, Record possible root causes. Alter remove any potential causes if possible.Date Initiated: 2/13/23 .Staff to assist [Resident #17] to change position while in bed alternating form Rt (right) side to back at least every 2 hours while in bed. Make sure heels are elevated and pillow is placed between knees to reduce pressure. Date Initiated: 2/13/23 . Review of resident #17's care plan failed to show a progression in interventions related to resident #17's falls or increased anxiety, specific identification of needs to anticipate, barriers to her cognition, or how this may relate to her understanding of encouragement with use of interventions. During an interview on 3/28/23 at 2:53 p.m., staff member B said when a resident has an unwitnessed fall, they look at different things to determine how the fall occurred. The staff look at the environment for hazards, check charting to see when the resident was last rounded and checked, and check for any underlying factors that may have caused the fall. Staff member B gave an example of resident #17's falls. Resident #17 had a cane next to her bed and would grab the cane and pull herself out of the bed. The facility removed the cane and resident #17 has had no further falls. Staff member B was unable to answer why resident #17 was using the cane to pull herself out of bed. Staff member B said they may need to have more discussion and look further into why residents are getting up and falling. Staff member B said the CNA staff had a Kardex they referenced for each resident that showed the individualized fall interventions that were in place. During an interview on 3/28/23 at 1:10 p.m., staff member A said all falls were reviewed at a weekly UR (Utilization Review) committee meeting. Safety committee meets quarterly at the hospital, and falls were also discussed. Staff member A said the facility had previously had a process improvement project for falls but it had not been identified as an issue recently, and the facility may need to initiate it again. Staff member A said the facility policy was to go completely restraint free. This took away a lot of the tools or options the facility used for fall prevention. Most of the falls were identified as falling out of bed and onto a fall mat, or from a recliner while getting up without assistance, and not using or remembering to use the call light. The facility no longer used scooped mattresses or any type of sensor alarm. Staff member A said the staff do frequent rounding, and the four P's program (pain, positioning, potty, and possessions). Staff member A said the facility was limited on what could be done. She educates the staff on the four P's and to check the resident frequently, not just every hour. Staff member A said the facility does not perform safety evaluations on residents.

Based on observation, interview, and record review, the facility failed to prevent the development and worsening of a pressure injury, document wound progression, notify the appropriate physician, and failed to prevent a new pressure injury for 1 (#11) of 2 sampled residents. Findings include: During an observation on 8/16/22 at 12:10 p.m., resident #11 was asleep in his recliner. Both his feet had on thin (1/2 inch) foam heel protectors. His heels appeared to have pressure on them from the recliner foot rest. Staff member B was asked to view his feet on the recliner, and she stated the resident should have had pillows under his feet to float his heels to prevent pressure. She stated the resident's pressure injury started as a blister on his right heel. She was not sure of the root cause of the pressure injury. Staff member B stated the facility had been using the blue foam heel protectors for ten years. Review of resident #11's Nursing notes showed: 5/17/22 - Blister on right heel pressure area was popped this morning sometime. Orders wrote for daily Biatain dressing change, blue foam booties when in bed. 5/17/22 - Right heel has an open area the heel has a large blister like area with a black center. Not soft to the touch. Heels floated. 5/19/22 - Dressing changed on right heel, having a large amount of drainage. 5/24/22 - OT alerted this nurse that resident needed dressing to wound on right heel changed as it was actively bleeding through his slipper sock after walking to the bathroom with OT. The wound measured 3 x 3 cm circular area of eschar type tissue located in center area of heal wound. Provider alerted to changes in wound, PT eval for wound care ordered. 7/19/22 - When changing dressing on right heel, a foul odor was noted and has been noted, slightly for the last couple of days. ADON and charge nurse aware and will have (NP) look at it when he comes on Thursday. 7/21/22 - The NP was here to evaluate resident #11's right heel. The treatment was changed to a piece of promogran and cover with Allevyn. Review of resident #11's Wound Assessment, dated 5/17/22, showed a right heel pressure injury with no measurements, staging (severity), or description. Review of resident #11's Wound Assessment, dated 5/24/22, showed right heel pressure injury, it was Unstagable, with no measurements or description. Review of resident #11's Physical Therapy Note, dated 5/24/22, showed an area of adhered black eschar in the center of the wound that is 20 x 15 mm. Wound is not staged as quality of tissue under eschar is unknown. No further wound care needed by PT at this time. Review of resident #11's Wound Assessment, dated 5/31/22, showed a heel wound 4 x 7 cm with eschar noted in the center of the wound. Review of resident #11's Wound Assessment, dated 6/23/22, showed a right heel wound measuring 4 x 4 x .2 with no description or staging. Continue with daily dressing changes. Review of resident #11's Wound assessment, dated 7/11/22 showed a right heel wound measuring 4.5 x 4.5 x. 2 cm. Eschar noted on lower end of wound beefy red in the middle. Review of resident #11's Physical Therapy Wound Care Evaluation, dated 8/5/22, showed the right heel wound was not improving and may be getting worse as patient has LE edema and tends to dig his heel into the ground. PT is ordered for wound care. The description showed moderate serosanguineous drainage, and a hard reddish black eschar in the center of the wound. An [NAME] boot (protective boot) was prescribed as the treatment. Review of resident #11's Physical Therapy Wound progress note, dated 8/9/22, showed the wound depth was pinpoint at 10 o'clock with tunneling over to 2 o'clock. Wound has 40% red granulation tissue and 60% yellow slough. During an observation and interview on 8/16/22 at 12:50 p.m., staff member E completed wound care on resident's right heel. She stated the wound had improved since the use of the [NAME] boot. She stated the blue foam heel protectors were better than nothing even though they were old. A new intact blister on the left medial heel was also noted, measuring 3 cm x 2.7 cm. Staff member B did not know the cause of the new pressure injury. During an interview on 8/17/22 at 9:05 a.m., staff member B stated it probably should have been the charge nurse's responsibility to notify the NP that resident #11's pressure injury was not healing. She did not know why the NP was not informed sooner than 8 weeks after the wound was identified. Staff member B stated the CNAs' are responsible for daily skin checks for all residents during care. Skin checks prior to the identification of the right heel pressure area were not available because the electronic system saved them for 30 days only.

Based on interview and record review, the facility failed to assess the resident's safety with transfers, for a resident that experienced [MEDICAL CONDITION] episodes during the transfers, resulting in repeated falls, to include one fall with a [MEDICAL CONDITION], for 1 (#1) and failed to identify the root causes and implement fall prevention interventions for 8 falls for 1 (#2); and failed to adequately assess and treat pain for 17 days after a fall for 1 (#3) of 3 sampled residents. Findings include: 1. Review of resident #1's Progress Note, dated 1/16/19, showed the CNA reported the resident's eyes rolled in the back of his head, and the resident had passed out while being toileted. His vitals were taken, but the physician was not notified. Review of resident #1's Physician Visit Note, dated 1/17/19, showed the facility staff reported he was no longer able to stand on his lower extremities. No transfer assessment was completed for the safety of the sit to stand lift. Review of resident #1's Progress Note, dated 1/23/19, showed the resident had passed out while getting ready to be toileted. Vitals were taken, but the physician was not notified. Review of resident #1's Progress Note, dated 2/5/19, showed it was reported by the CNA that the resident had slumped backwards onto the toilet and was staring off into space, during the transfer. Vitals were taken. No further follow-up assessments were completed for the incident. Review of resident #1's Progress Note, dated 2/18/19, showed the resident was taken into the bathroom on the sit to stand lift, and as he was lowered onto the toilet, and he passed out. The fall intervention implemented was to continue to monitor. Review of resident #1's Progress Note, dated 2/22/19, showed it was reported by the CNA that the resident was being assisted to the bathroom, and became unresponsive for a short time. No assessment was completed for the reason for the unresponsive episode, and the physician was not notified. During an interview on 4/11/19 at 11:00 a.m., staff member D stated the physician should have been notified of the [MEDICAL CONDITION] episodes. She stated she thought the episodes were a vagal response to being up in the sit to stand lift. She was not aware of the reason for the lack of notification to the physician. Review of resident #1's Progress Note, dated 2/24/19, showed Noted brief periods of [MEDICAL CONDITION] during toileting at beginning of shift, less than two minutes. The nurse asked the resident to wear oxygen during the toileting process, and he declined. Review of resident #1's Progress Note, dated 3/8/19, showed While resident was being taken to the restroom per sit to stand lift, the CNA reported that resident lost consciousness and needed to be lowered to the floor but body went limp approximately 12 inches above floor. His vitals were taken and he was assisted to bed with the hoyer lift. Pain was evident when (the resident) rolled on his side by grimacing. The resident refused to go to the hospital for an evaluation. During an interview on 4/11/19 at 2:10 p.m., staff member C stated she was called to the resident's room after the fall. He was on the floor, but kind of sitting up. She said she suspected the resident had broken something when he was put into the bed, and was grimacing. The facility did not have documentation the resident's range of motion was assessed after the fall. Review of resident #1's Fall Huddle note, dated 3/8/19, showed the resident had a fall while [MEDICAL CONDITION] during a sit to stand transfer. The resident was then admitted to the hospital, with a [MEDICAL CONDITION] femur. The interventions for the fall were to Close monitor while in lift. Use 2 people and lift for resident. Review of resident #1's Care Plan showed he was to use the Hoyer Lift for transfers, which was not how the resident was being transferred by staff. During an interview on 4/11/18 at 12:40 p.m., staff member A stated the resident refused to use the Hoyer Lift. The refusals were not documented on the resident's Care Plan. She stated the facility did not have a transfer assessment for resident #1 for the safe use of the sit to stand lift. Review of the Report to the State Survey Agency, dated 3/19/19, showed a refresher inservice on the use of equipment for all staff would be completed. The fracture for resident #1 was not noted on the report. During an interview at 1:15 p.m., staff member A stated the inservice had not been implemented yet. She stated physical therapy would come to the facility in (MONTH) for the training. During an interview on 4/11/19 at 2:25 p.m., staff member B stated he had been aware of resident #1's [MEDICAL CONDITION] episodes, but did not know why the physician had not been notified. Staff member B stated he had no further information regarding the fall with a fracture on 3/8/19. 2. Review of resident #2's Post Fall Huddle reports showed the resident had fallen nine times in the past three months. Review of resident #2's Post-Fall Huddle, dated 1/2/19, showed the resident was found on the floor of her bathroom, with her pants around her legs. The interventions implemented for the fall were to provide frequent checks while the resident was out of bed, and to take the resident to the bathroom more frequently. These interventions were not on resident #2's Care Plan when the plan was reviewed. Review of resident #2's Post-Fall Huddle, dated 1/28/19, showed the resident tried to sit in a chair that had wheels. The chair rolled, and the resident landed on the floor. The intervention for the fall was to watch resident to make sure she only sits in stationary chair. Review of resident #2's Post-Fall Huddle, dated 1/29/19, showed the resident was in the activity room and tried to sit in a chair. She missed the chair and landed on the floor. The intervention for the fall for the prevention of future falls, was to keep close eye on resident and help her sit. This intervention was not on the Care Plan when the plan was reviewed. Review of resident #2's Post-Fall Huddle, dated 2/10/19, showed the resident was found on the floor in the TV room. The intervention implemented for future fall prevention was to provide more frequent check, always watching her when she is out of room. Review of resident #2's Post-Fall Huddle, dated 3/1/19, showed the resident slid out of her wheelchair while in the TV room. No interventions were implemented for the resident's safety with falls. Review of resident #2's Post-Fall Huddle, dated 3/5/19, showed the resident was found on the floor in the TV room. The intervention was for Closer monitoring. Review of resident #2's Post-Fall Huddle, dated 3/6/19, showed the resident slipped out of her wheelchair and landed on the floor. The intervention was Close monitoring. This intervention has been utilized prior, and had shown to be unsuccessful as a safety intervention. Review of resident #2's Post-Fall Huddle, dated 3/13/19, showed the resident was found on the floor of her bathroom. Her feet were bare. The intervention was to keep gripper socks on at all times, and shoes on when up. Review of resident #2's Post-Fall Huddle, dated 3/22/19, showed the resident attempted to transfer from her wheelchair to a chair in the TV room, and fell . The intervention was to keep closer eye on her when she is out of bed. The facility repeatedly failed to identify root causes for the resident's frequent falls, and no evidence was provided to show the facility evaluated the effectiveness of the interventions which were implemented for the repeated falls. 3. Review of resident #3's Post-Fall Huddle, dated 1/31/19, showed the resident was walking the dining room with her four-wheeled walker. Staff heard moaning and found the resident sitting on the floor. She complained of left hip pain, and was sent to the ER for an X-ray, which did not show broken bones. Review of resident #3's Progress Note, dated 2/1/19, showed the resident complained of all over pain and leg pain. She was using her wheelchair for mobility. The note showed, Resident still complains of leg pain with transfers. Review of resident #3's Progress Note, dated 2/2/19, showed the resident required a two person assist with transfers when bearing weight. Has not been able to bear weight without increased pain since start of shift. Resident did not want to go to dining room. Complained of pain in left hip with transfers. Review of resident #3's Progress Note, dated 2/3/19, showed the resident continued to bear minimal weight on the left leg during transfers. Slight swelling and light purple bruising noted in left hip area. Review of resident #3's Progress Note, dated 2/5/19, showed the resident had a visit from the nurse practitioner. Resident has been having extreme pain in her left hip after her fall, did have a CT scan, which showed nothing broken. NP will look at the CT again, in the mean time she will be put on Tylenol #3 every 6 hours. Review of resident #3's Progress Note, dated 2/7/19, showed the resident continued to complain of left hip pain with transfer. Tylenol #3 given per order and resident does seem to obtain some relief. Review of resident #3's Progress Note, dated 2/8/19, showed the resident complained of pain in the left hip when adjusted in bed and during transfers. Tylenol #3 given per order related to left hip pain after fall on 1/31/19. Seems to help with pain, except during transfers and repositioning. Will continue to monitor. Review of resident #3's Progress Note, dated 2/15/19, showed the physician wants the resident to have another hip x-ray on Monday if resident is still not bearing weight on her left hip. Review of resident #3's Progress Note, dated 2/17/19, showed she returned from the ER, with a pathological [MEDICAL CONDITION] illium. A new order for [MEDICATION NAME] was implemented for pain management., which was 18 days after the initial fall.

Based on observation, interview, and record review, the facility failed to provide needed oxygen to a resident on a continuous basis to maintain an adequate saturation level, for 1 (#6) out of 10 sampled residents. Findings include: Resident #6 was admitted to the facility with [DIAGNOSES REDACTED]. During an observation and interview on 2/21/17 at 12:05 p.m., resident #6 was sitting in the dining room eating her lunch meal. Her oxygen tank gauge was observed to be empty, and was set at 5 liters per minute. The resident stated she was not aware her oxygen tank was empty, and asked that the nurse be told immediately. Staff member M was notified, and the staff member then obtained a new oxygen tank for resident #6. During an observation and interview on 2/22/17 at 5:06 p.m., resident #6 was sitting in the dining room eating her supper meal. Her oxygen tank was observed to be close to empty, and was set at 5 liters per minute. Resident #6 continued to stay in the dining room with an empty oxygen tank from 5:06 p.m. until 5:35 p.m. at which time the surveyor asked resident #6 if she was aware her oxygen tank was empty. Resident #6 asked that the nurse be notified immediately to get her a new oxygen tank. Staff member F was notified by the surveyor. Staff member F obtained a new oxygen tank for resident #6. Staff member F assessed the resident's oxygen saturation with a result of 83%. Resident #6's oxygen saturation returned to 92% after she received her oxygen therapy. Staff member F stated she would notify the CNA that the resident's tank was empty. Staff member F stated resident #6 should not have been without oxygen. Review of resident #6's physician orders, dated 4/13/15, reflected oxygen per nasal cannula to keep saturation greater then 92%. Review of resident #6's laboratory results, and physician progress notes [REDACTED].#6's CO2 levels were being monitored, along with a physical assessment of her lung function. Review of resident #6's Treatment Administration record for the month of February 2017, reflected an order started on 6/9/15, for oxygen per nasal cannula to keep saturations greater than 92%, two times a day. Entries of saturation levels were documented for 8:00 a.m. and 8:00 p.m. Staff also documented how many liters per minute were used, ranging from 5-7 liters per minute. Review of resident #6's Care Plan regarding oxygen use, revised on 12/29/16, reflected a goal that the resident would display an optimal breathing pattern daily, and be compliant with oxygen use. Some of the interventions listed reflected that staff would monitor for difficulty in breathing on exertion, and provide oxygen therapy, as ordered, by the physician.

Based on record review, observations and interview, the facility failed to ensure staff, after multiple falls, stayed with one (#14) of 15 sampled residents, to prevent falls and protect the resident from multiple falls. Resident #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's significant change MDS with an ARD of 11/4/14 showed a BIMS of 4, severely impaired cognition and on 11/23/14 showed the resident's BIMS at 9, moderately impaired cognition. Review of the resident's progress notes reflected: - 6/23/14 the resident stated having a fall during the night while trying to transfer self on the toilet. The resident's head, hip, and a skin tear on the right hand were affected. The note reflected the resident was not to be left on the toilet alone and was to have the call light placed in the resident's hand, while using the toilet. "staff is never to leave resident on the toilet alone (sic) this has been care planned for use." -11/17/14 at 6:33 p.m., the resident fell in the bathroom. The "CNA assisted her to the toilet on a commode and she was place on the toilet (sic) CNA stated she was in a up right position on the toilet and turned away for a moment (sic) resident toppled off the commode on the floor on her lt side hitting her head and having a redden small sctatch (sic) to her lt hip (sic) she is nonambulatory using a wheelchair {sic} has an assistive device wheeled by staff having support in her wheelchair (sic) transfer assist of one or two with a gait belt (sic) she has contracture to her lt hand (sic) mobility is poor." The note reflected staff "is never to leave resident on the toilet alone (sic) this has been care planned for use." Review of a fax, dated 11/17/14 at 6:30 p.m., reflected the CNA had assisted the resident to the toilet and then walked away to fold down the resident's bed. The resident fell off the toilet at that time. The resident's temperature was documented as 99.2, blood pressure 96/63, respirations 16, and O2 SATs at room air 91%. Review of a fax sent to the resident's physician, as a FYI, dated 11/17/14 at 6:30 p.m., reflected the "CNA put (resident's name) on toilet and walked away to fold down bed and in that time (resident's name) fell off toilet." - 11/21/14 at 6:45 a.m., showed the CNA had assisted the resident onto the toilet, removed the resident's brief and the CNA turned to the sink to wash her hands. The "resident was leaning and falling forward (sic) she fell on the heating vent hitting her head (sic) her legs turned to the side (sic) she was assisted to back on the toilet (sic)the RN assessed her (sic) she was put in her wheelchair and went down to breakfast (sic) after breakfast resident was put back into her recliner (sic) her rt leg hip appeared different form (sic) her lt (sic)she was sent to the ER per ambulance for evaluation (sic) daughter was notified after resident sent (sic) staff had a huttle (sic) meeting while resident (sic) discussing the concerns and reasons why the fall occurred and a discussion on what happen(sic) prior to the fall and her condition." Recommendations were made by the fall committee and the daughter. The resident was to be moved closer to the nurses' station, review her transfers and "she is be(sic) not be left on the toilet alone (sic) she is to be within arm length", "she (resident) is on a toileting program (sic) resident has contractures to both hands (sic) safety awareness poo (sic)." Review of the physician order, dated 11/21/14 at 9:00 a.m., reflected the facility staff were to send resident #14 to the hospital emergency room for an evaluation related to the fall. Review of the nurse progress note, dated 11/21/14 at 1:25 p.m., showed "new orders for uti. Possible neck fracture so neck brace on and to remain on until Doctor sees resident. Left [MEDICAL CONDITION]. Res. very thirsty {sic} and apple juice with thicken in it. Res. took all of it without choking." Review of three of the local hospital's Imaging Result Reports dated 11/21/14, showed an emergency exam of: XR HIPS BILATERAL W AP PELVIS a. "[MEDICATION NAME] impaction type fracture cervical neck proximal left femur." CT CERVICAL SPINE W CONTRAST: b. "No fracture seen. There is asymmetrical widening of the interspace between the dorsal interspace between the dorsal spinous processes C5 and C6. A ligamentous injury could present similarly. Suggest clinical correlation. No acute cervical spine fracture otherwise noted." CT HEAD WO CONTRAST 9: c. "No acute intracranial abnormality. Suggest clinical correlation." Review of the local emergency room form, Diagnosis, Discharge Instructions and Follow-up, showed: a. The resident's [DIAGNOSES REDACTED]." b. Instructions included, "Recommend higher level of patient's safety and fall risk awareness," and "Recommend the patient be evaluated by their physician as soon as possible-patient's cervical spine has not been medically cleared and patient should wear her cervical collar until a physician deems it safe for removal." c. The resident was given an order of Bactrim DS, 800-160 mg per tablet, take one tablet by mouth two times daily for seven days. Review of the exam report from the local hospital, dictated 11/21/14 at 11:12 a.m., showed resident #14 had a [MEDICATION NAME] impaction type fracture to the left hip. Review of a fax dated 11/21/14 at 4:35 p.m., showed the resident was in pain all over. The physician documented "Apparently pt is "no surgery pt" Neuro to clear pt c-spine Monday. minimize movement of patient/leg/hip d/t FX." Pain medication was increased. A review of a nurse progress note dated 11/22/14 at 9:10 p.m., showed orders were received from the physician which included oxygen to keep sats above 90% and "NS IVF at 60 ml/hr for 48/hr. [MEDICATION NAME] 30 mg SQ-2 doses. INT initiated, veins very fragile and thin." (Resident name) has said a couple times tonight "let me go". (sic) On 11/23/14 at 3:25 p.m. staff documented the resident "answered yes when asked if she was in pain, stated it was over." On 11/25/14 at 10:28 a.m., a nurse documented the resident was "non weight bearing assist of three for transfers using full body lift (sic) a nurse has to assist with transfers (sic) a foley cath is in place (sic) she continues 02 at 9 liters (sic) continues with her low bed that is in low position when staff is not with her (sic) her splints are put in both hands daily she remains at restorative dining table continues with her puree applesauce diet with honey nectar thickening in her fluids to be observed for choking and swallowing(sic) she now is in a room close to the desk and is on frequent visual watches." Review of the resident's care plans, with an initiated date of 6/23/14, showed the resident was not to be left alone in the bathroom at anytime, related to weakness and contractures. The care plan reflected the staff were not to attempt other tasks, when the resident was on the toilet, related to the high fall risk. The care plan showed an intervention with an initiated date of 11/25/14. The interventions reflected the staff was to follow the facility fall protocol: charge nurse should evaluate the resident prior to being moved by CNA staff. During an interview on 1/29/15 at 9:00 a.m., staff member H, LPN, stated the policy of the facility was a nurse needed to assess a fallen resident, before moving the resident. During an interview on 1/28/15 at 3:35 p.m., staff member A, DON, stated the CNA, with resident #14, on 11/21/14 did lift the patient off the floor and back onto the toilet before having the nurse assess the resident. After the nurse assessed the resident, the nurse called the physician who gave the order to send resident #14 to the emergency room . The resident passed away on 12/1/14 at 12:00 a.m.