Every finding on record at Intermountain Health Holy Rosary Hospital

Based on interview and record review, the facility neglected to ensure resident-specific care plan interventions were implemented requiring use of a gait belt and continuous physical support during transfers. for 1 (#1) of 3 residents sampled for falls. The failure resulted in the resident sustaining an uncontrolled fall with increased pain requiring emergency department evaluation and subsequent transition to palliative care for pain management. Findings include:Review of a Facility-Reported Incident, submitted to the State Survey Agency on 5/11/26, showed resident #1 experienced a witnessed fall on 5/3/26 while staff assisted the resident from her room to a recliner in the sitting area. Resident #1 used a four-wheeled walker and did not have a gait belt in place for safety or staff assistance. Upon arrival at the recliner, the staff member stepped in front of the resident to adjust a chair pad. Resident #1 lost her balance and fell backward, landing on her buttocks. The staff member was unable to prevent the fall because she was no longer maintaining physical support of resident #1, and no gait belt was in use at the time for safety.During an interview on 7/27/26 at 3:40 p.m., staff member A stated resident #1 had a history of spinal compression fractures with chronic pain. Staff member A stated resident #1 did not initially report pain following the fall but developed worsening pain beginning the following morning. Staff member A stated the family declined radiology testing after the fall. Staff member A stated resident #1 transitioned to palliative care on 5/8/26 for pain management.During an interview on 7/27/26 at 1: 28 p.m., staff member D stated resident #1 had been receiving restorative services, but had been having a little more trouble with pain and balance . During a telephone interview on 7/28/26 at 9:20 a.m., NF1 stated resident #1 had chronic back pain related to compression fractures and did not experience increased pain until after the fall on 5/3/26. NF1 stated she did not want to subject resident #1 to additional testing because of the resident's advanced age and chronic pain. NF1 stated the facility was unable to adequately control resident #1's pain following the fall and palliative care was initiated for comfort-focused pain management. NF1 stated the facility could have monitored resident #1 more closely during transfers and stated, When she fell, nobody was holding onto her (the resident).Review of resident #1's diagnosis list showed diagnoses including dementia, osteoporosis, vertebral compression fractures, and history of falls.Review of resident #1's care plan showed an intervention initiated on 12/15/25 for safety during transfers, and the plan was directing staff to assist resident #1 and to use a gait belt during transfers and ambulation. The intervention remained in effect on 5/3/26 and had not been discontinued or revised. The staff member assisting resident #1 when the fall occurred did not follow the care plan intervention(s) for safety. Review of resident #1's nursing progress notes showed the resident experienced previous falls on 4/23/26 and 5/1/26. During those events, staff used a gait belt and controlled resident #1's descent to the floor. The progress notes did not show increased pain following those falls, and chronic pain remained managed without changes to the resident's pain management regimen.Review of resident #1's nursing progress note dated 5/4/26 at 10:20 a.m. showed, Noted [Resident #1] . in obvious pain-moaning, gasping in pain and unable to sit still. Multiple residents noting her pain and asking staff to do something for her . attempted to give her pain medication crushed in applesauce and she was unable to swallow it. [sic]Review of resident #1's post-fall note dated 5/4/26 at 11:34 a.m. showed resident #1 exhibited substantial pain with facial grimacing and moaning and was transferred to the emergency department for evaluation.Review of resident #1's emergency department record, dated 5/4/26 at 11:50 a.m., showed: . CHIEF COMPLAINT: Fall and Back Pain . History of Present Illness: Pt presents to the ED after having multiple falls over the last couple of days . Pt fell again yesterday and since then increased pain and difficult to manage the patients pain . [sic]Review of resident #1's nursing progress notes dated 5/5/26 through 5/8/26 showed ongoing, escalating pain despite administration of as-needed pain medications, including Norco, tramadol, lidocaine patches, and ibuprofen, with limited relief. Documentation described persistent grimacing, moaning, vocal expressions of pain, and increased distress during movement and care.Review of a facility document titled Residential Living Statement Form, dated 5/3/26 at 5:00 a.m., showed staff member H's summary of resident #1's fall as follows:- I went to switch the incontinence pad off the chair. Patient was walking with front wheel walker and became unsteady. Patient couldnt catch her balance and I wasn't immediately behind her. Patient started to fall back and her bottom hit the floor before I was able to get behind her and hold her on to her upper body. [sic] - The document further showed the question: What could have been done to prevent this incident? Describe: Staff member H wrote the following:Being in closer proximity to the patient, being immediately behind her and properly using gait belt, or using other devices like wheelchairs, since patient has been in pain and unsteady lately.A request was made for a telephone interview with staff member H via voicemail on 7/27/26 at 2:30 p.m. No return call was received by the end of the survey.Review of a facility document titled, Holy Rosary Residential Living Standards of Care, undated, showed: . TRANSFERS . Gait belts are to be used for all one-to-two-person assist transfers . review the resident's care plan for ambulation/transfer assist .Review of a facility policy titled, Fall Prevention, dated 4/21/26, showed: . Have a gait belt readily available at the patient's bedside (if necessary) for use during ambulation or transfer .

Based on interview and record review, the facility failed to ensure an allegation of possible neglect involving 1 (#1) of 3 residents sampled for abuse and neglect was reported to the State Survey Agency within the required timeframe. The facility's failure delayed notification to the State Survey Agency and the agency's ability to determine whether additional oversight or investigation was warranted. Findings include:Review of a Facility Reported Incident submitted to the State Survey Agency on 5/11/26 showed resident #1 sustained a fall on 5/3/26 during an assisted transfer. The investigation showed the facility determined staff neglected to use the resident's required gait belt and walked away from the resident to adjust a chair pad, leaving the resident without continuous support. Resident #1 fell backward to the floor. The resident subsequently developed increased back pain, was transferred to the emergency department for evaluation, later transitioned to comfort-focused care, and passed away on 5/8/26. The documentation showed the neglect incident became known to the facility on 5/3/26. The incident was not electronically submitted to the State Survey Agency until 5/11/26, seven days after the neglect incident occurred. Refer to F689 Accidents and Hazards for information related to the resident's fall. During an interview on 7/27/26 at 4:22 p.m., staff member A stated she was responsible for submitting the facility-reported incidents to the State Survey Agency through the Bounds (electronic reporting) system. Staff member A stated she was aware the report had been submitted late, stating she had completed the report on time; however, she inadvertently hit the save button instead of the submit button. The error was not discovered until 5/11/26, when it was then submitted to the State Survey Agency.Review of a facility document titled, Reportable Event Procedure, dated 6/30/25, showed: Purpose: To outline the notification, response, reporting and follow up requirements for Reportable Events . 9. Report to state and/or regulatory agencies if appropriate criteria for reporting are met . initial occurrence reports are due . no later than end of the next . business day .

Based on interview and record review, the facility failed to ensure the medical director or his designee attended and/or participated in the Quality Assurance (QA) program at least quarterly. This deficient practice increased the risk of negative outcomes for residents with respect to quality assessment and assurance activities. The facility reported a census of 54 residents. Findings include:During an interview on 4/20/26 at 3:13 p.m., staff member A stated staff member G was onsite at the facility once a month. She stated when staff member G was onsite at the facility, it did not always correspond with when QA was scheduled to meet. Staff member A stated staff member G was not currently attending the QA meetings quarterly either in person, or via videoconferencing or teleconference calls, and did not have an authorized designee to attend instead. She stated she did review the QA minutes with staff member G but did not have documentation of staff member G's acknowledgement of the provided QA information.Review of the QAPI Agenda and/or Attendance Roster, dated 9/9/25 through 4/24/26, failed to include staff member G as an attendee. There was no evidence staff member G had a designee to attend the QA meetings and/or that a non-required member of the QA committee had communicated the meeting content to staff member G for his acknowledgment. During an interview on 4/23/26 at 8:41 a.m., staff member G stated he currently had not been attending the QA meetings in person or via an electronic means and did not have a designated proxy to attend in his absence. Staff member G acknowledged attendance of the QA meetings was an expectation of his current role.Review of staff member G's Professional Service Agreement, signed 10/25/24, showed:- 3. Contractor's Obligations. Contractor, through Medical Director, shall provide the following services (the Medical Director Services):a. Develop, maintain, and update, as may be reasonably appropriate, clinical quality control programs and protocols that meet the legal requirements of state and federal statutes and regulations applicable to the Unit, including: (a) performance and utilization standards.

Based on interview and record review, the facility failed to provide required effective communication training to all direct care staff. This deficient practice had the potential to affect the care of all residents residing in the facility. Findings include:During an interview on 4/22/26 at 1:30 p.m., staff member A stated the last all staff training which would have included effective communication was last provided on 8/29/24. She stated the next all staff training on effective communication was due 8/29/25. Staff member A stated they did establish a training program, which included effective communication, which they failed to implement by 8/29/25. Staff member A stated it was the expectation for all direct care staff to receive training on effective communication at hire, and annually thereafter.Review of the facility's all staff training for effective communication showed the last training was provided on 8/29/24.A request was submitted to the facility for a policy and procedure on staff education/training requirements for effective communication on 4/22/26 at 4:00 p.m. The facility did not provide additional documentation for the staff training requirements for communication training by the end of the survey on 4/23/26.

Based on interview and record review, the facility failed to provide required dementia training to include management of dementia related behaviors to all staff. This deficient practice had the potential to affect the care of residents with dementia health needs in the facility. Findings include:During an interview on 4/22/26 at 1:30 p.m., staff member A stated the last all staff dementia training occurred on 8/29/24. She stated the next annual dementia training was due 8/29/25. Staff member A stated all staff have not been provided dementia training since 8/29/25. She stated they did establish a training program for dementia which they failed to implement by 8/29/25. Staff member A stated it was the expectation for all staff to receive dementia training to include management of dementia related behaviors at hire and annually thereafter.During an interview on 4/22/26 at 1:56 p.m., staff member V stated the facility used quarterly workday assignments to assign training. Staff member V stated she did not remember doing any specific dementia training. During an interview on 4/22/26 at 3:11 p.m., staff member X stated she had dementia training about two years ago at this facility. Staff member X stated they have not done any training on dementia since then. Review of the facility's all staff training for dementia care showed the last training was provided on 8/29/24. A request was submitted to the facility for a policy and procedure on staff education/training requirements for dementia care and on 4/22/26 at 4:00 p.m. The facility did not provide additional documentation for the staff training requirements for dementia training by the end of the survey on 4/23/26.

Based on interview and record review, the facility failed to report investigation findings to the State Survey Agency (SSA) within the required timeframe of 5 working days for 4 (#s 21, 29, 44, and 62) of 25 sampled and supplemental residents. Findings include:A review of Facility Reported Events showed: 1. Review of the facility's reported incident, dated 1/24/26, showed, Resident (#44) came out of her room and went over to another resident (#62) and kicked her feet. Review of the facility's investigative findings for the incident reported on 1/24/26, between resident #s 44 and 62, was submitted to the SSA on 2/4/26, 11-days after the facility reported the incident. 2. Review of the facility's reported incident, dated 3/20/26, showed, One resident (#29) kicked another resident (#44) in the legs while both were in their wheelchairs. No injuries noted or reported from the resident who was kicked. Immediate interventions were to separate the residents. Review of the facility's investigative findings for the incident reported on 3/20/26 did not show that the facility submitted investigative findings to the SSA. 3. Review of the State Survey Agency reporting site showed the facility made initial reports of elopement for resident #21 on 7/18/25 and 2/1/26. The facility failed to submit the final investigation within the required five working days. There was no final report for the elopement on 7/18/25 and 2/1/26. During an interview on 4/21/26 at 4:01 p.m., staff member A stated that staff member B was responsible for reporting and submitting the investigative findings to the SSA for allegations of abuse. Staff member A stated staff member B was out of the facility the week of the survey. Staff member A stated it was the expectation to report the findings of any allegation of abuse to the SSA within five working days of the initial allegation. Staff member A stated they were not able to provide investigative findings for the incident that occurred on 3/20/26, between residents #s 29 and 44. Review of the facility's policy and procedure titled, Abuse Investigation and Reporting Procedure - Long Term Care, with a review date of 7/15/25, showed: -Procedure: What is to be reported: .The results of all investigations of alleged violations. When: Results of all investigations of alleged violations - within 5 working days of the incident.

Based on interview and record review, the facility failed to thoroughly investigate allegations of abuse, failed to prevent further potential abuse, and failed to report the results of the investigation to the State Survey Agency (SSA) to verify corrective actions were taken for allegations of resident-to-resident abuse for 2 (#s 29 and 44); and the facility failed to document a thorough investigation of multiple elopements and identify the root-cause of the elopements for 3 (#s 21, 61, and 62) of 25 sampled and supplemental residents. These failures had the potential to cause the facility to miss key parts of the investigation and prevent further elopements or injuries to the residents and increased the risk for more than minimal harm by creating an environment that perpetuates a disrespectful situation between residents. Findings include:1. Resident-to-Resident Review of the facility's reported incident, dated 3/20/26, showed, One resident (#29) kicked another resident (#44) in the legs while both were in their wheelchairs. No injuries noted or reported from the resident who was kicked. Immediate interventions were to separate the residents. A. Failure to Investigate: Review of resident #44's Nursing Note, dated 3/20/26, showed, Resident (#44) was kicked multiple times in the lower legs by another resident (#29) while both were in their wheelchairs at the nurses station. No injuries noted. A review of the facility's abuse investigations completed between March 2026 and April 2026, showed the facility failed to complete an investigation related to the reported allegations of resident-to-resident abuse between resident #s 29 and 44, reported on 3/20/26. B. Failure to Protect: Review of resident #29's Nursing Note Addendum, dated 3/22/26, showed at 7:00 p.m. Observed another resident continually attempting to follow, communicate, agitate and argue with [Resident #29]. Staff separated twice. Information communicated to other staff to monitor interactions between her [and] other resident. [sic] Review of resident #44's Nursing Note Addendum, dated 3/22/26, showed at 7:00 p.m. Observed [Resident #44] continually attempting to follow, communicate, agitate and argue with another resident (resident #29). Staff separated twice. Information communicated to other staff to monitor interactions between her [and] other resident. [sic] Review of residents #s 29 and 44's Nursing notes on 3/22/26, showed the facility failed to prevent potential further abuse between the two residents. C. Failure to Report: A review of the facility reported investigative findings for the incident reported on 3/20/26, between residents #s 29 and 44, did not show that investigative findings were reported to the SSA (See F609). During an interview on 4/21/26 at 4:01 p.m., staff member A stated staff member B was responsible for investigating and reporting allegations of abuse. Staff member A stated staff member B took over the reporting and investigating of allegations of abuse after the staff member who was coordinating those investigations left in September of 2025. Staff member A stated staff member B was out of the facility the week of the survey and was not available for an interview. Staff member A stated they were not able to provide the documentation for what was completed during the investigation of the allegation between resident #s 29 and 44, or the investigative findings. Staff member A stated they were not able to verify whether the investigation was completed or that it was reported to the state agency. Staff member A stated it was the expectation to thoroughly investigate allegations of potential abuse, protect the residents, prevent further potential of abuse during the investigation, and report the findings from the investigation to the SSA. 2. Elopements: A. Review of resident #21's elopement investigation dated 7/14/25, showed information about resident #21 exiting the facility. There were no signatures or names of where this information was obtained. An email was included as part of the investigation, but the sender of the email was not identified by title or how the person was involved in the investigation. Review of the state abuse reporting website dated 2/1/26 at 10:00 a.m., showed resident #21 was brought back from Med-Surg by Med-Surg nurse. Resident eloped through back doors either following volunteer or staff taking other resident's to Mass. No alarms were triggered when she got out of RLU. PCP, Administrator, DON, MDS and social worker notified of incident. There was insufficient investigation completed to identify the root-cause of the elopement, and the facility neglected to address the reason or interventions put into place to prevent the elopement. B. Review of the reportable incident submitted to the SSA on 7/24/25 showed resident #61 eloped through the doors leading into the hospital. Review of resident #61's electronic health record showed there were no nurses' notes that were written on 7/24/26 describing the elopement. Review of the nurse's note dated 7/25/26, showed resident #61 attempted to elope twice on 7/24/25, reflecting a lack of oversight. The facility investigation, dated 7/30/25, for resident #61's elopement on 7/24/25, showed an interview involving two staff members. The interview showed that resident #61 left shortly after arrival. He was lost and confused - didn't seem to be exit seeking - just going back through doors he came in - [Nurse Name] found him exiting - door alarms. Second time he followed other residents out patio door by Activities. Alert residents were outside. Another staff member interview stated, RN was bringing him back. She heard alarms and went to doors. She alerted [Nurse Name] for resident #61. Not exit seeking. The facility neglected to interview certified nurse assistants or activity staff to develop a timeline of resident #61's movements at the time of the elopement. The facility neglected to identify the root cause. Review of resident #61's Nursing Note, dated 8/12/25, showed that resident #61 eloped into the hospital on 8/12/25. The alarm sounded alerting the staff resident #61 had left through the exit to the hospital. Review of the facility's investigation, undated, of resident #61's elopement on 8/12/25, included a staff member's handwritten note, which was undated, and it showed People came in RLU looking for someone in hospital. They left unit to go to the M/S and resident #61 followed them out the door. The door alarm was on and working. Resident #61 did come back to the unit. The facility neglected to identify the root cause of the elopement. There was no timeline developed, nor were interviews completed to identify the activities or interventions that had been implemented to determine the effectiveness of elopement prevention. C. Review of the facility's investigations for Facility Reported Incidents of resident #62's elopements showed: - on 5/3/25, resident #62 exited the facility. The facility investigation file contained the bounds report and staff members' statements. - on 6/29/25, resident #62 exited the facility without staff awareness. The facility investigation file contained only a summary of the incident. - on 7/11/25, resident #62 exited the Residential Living Unit and was found wandering in the hospital. The facility investigation file contained an incomplete investigation checklist and a summary of the incident. - on 9/9/25, resident #62 exited the facility. The facility investigation file contained a summary of the incident and an invoice for a wander guard system. - on 9/22/25, resident #62 exited the facility and was brought back by an unknown staff member. The facility investigation file contained a summary of the incident, interventions, and a new process for the wander guard system. The file did not contain a root-cause analysis or assessments. - on 9/26/25, resident #62 exited the facility and was brought in by another resident's family member. The facility investigation file contained the bounds report, a summary of the incident, and interviews with staff. - on 1/4/26, resident #62 made it through the main doors and was stopped between the two doors. The facility investigation file contained a summary of the incident. - on 1/20/26, resident #62 exited the facility by pushing the doors open and closing them. The facility investigation contained the bounds report submitted to the SSA and a summary of the incident. Review of resident #62's electronic health record showed a discharge plan was in place, and resident #62 was discharged to a memory care facility on 2/12/26. The facility failed to identify and document the root causes of resident #62's exit seeking and elopements, which led to a fall with injury (see F689). During an interview on 4/21/26 at 3:46 p.m., staff member A stated NF1 used to conduct the incident investigations and has been gone since October 2025. Staff member A stated, .the expectation on conducting an investigation would be to find the root cause. Why is this happening? . Staff member A stated they would monitor the residents to ensure interventions were being implemented. During an interview on 4/22/26 at 1:56 p.m., staff member V stated that after each elopement, the nurse would file a report to the SSA and update the resident's care plan with new interventions. After they were done with that part, it would go to management for a full investigation to be conducted. During an interview on 4/23/26 at 10:01 a.m., staff member A stated that when a resident eloped, the nurse would enter an occurrence report in the EHR and submit a report to the SSA. Staff member A stated that this was how the staff tracked the elopements. Staff member A stated they monitor interventions by observing them to see if they were being implemented. Staff member A stated that they (staff) talk about the root cause, but have not kept that documentation. Review of the facility's policy and procedure titled, Abuse Investigation and Reporting Procedure - Long Term Care, with a review date of 7/15/25, showed, - Procedure: What is to be reported: . All alleged violations of abuse, neglect, exploitation or mistreatment. - The results of all investigations of alleged violations. - Take steps to prevent any further abuse, neglect, exploitation, or mistreatment while the investigation is happening. If the allegation is confirmed, take the necessary corrective actions.

Based on interview and record review, the facility failed to provide sufficient supervision and interventions to prevent an elopement for 4 (#s 21, 38, 61, and 62) of 23 sampled residents, which led to a fall with minor injury for resident #62. Findings include:1. During an interview on 4/20/26 at 2:40 p.m., staff member M said the facility got a wander guard alarm for the front door some time before Christmas 2025. Staff member M said the alarm was activated by a bracelet. Staff member M said the bracelet was placed on the resident or on the residents mobility devices. Staff member M said most elopements happened when residents exited through the front door. Staff member M said the other exit doors have (breakaway) alarms which ring if activated. Staff member M said the residents are assessed by the Minimum Date Set (MDS) nurse for risk of elopement on admission and quarterly. Staff member M said if the nurses identified a resident was at risk, the wander guard bracelet could be applied without an assessment. During an interview on 4/21/26 at 9:57 a.m., staff member T said he was not working when any residents eloped. Staff member T said the certified nurse assistants were provided with a piece of paper which had information about each resident included on the paper. Staff member T said the staff were aware of the residents who were at high risk of eloping because the information was noted on the form the brain (mini care plans for each resident). 2. Review of resident #21's current care plan showed, resident #21 was at risk of eloping and had interventions to prevent elopement. Resident #21's care plan showed she was able to self-propel through the facility in her wheelchair and would go to the doors and attempt to open them. The facility failed to prevent resident #21 from eloping by involving her in activities and using redirection. Resident #21's care plan, dated 9/26/24, had an anti-wander device attached to her wheelchair. Resident #21 eloped while the wander guard bracelet was on her chair. During an interview on 4/23/26 at 8:04 a.m., staff member D said the care plans have a certain number of blank spaces and new interventions were added. Staff member D said resident #21's care plan was incorrect as the facility did not have a wander guard door in 2024. The wander guard door alarm was available in late 2025. Staff member D said resident #21 was a wander risk and the staff were aware of her risk. Review of resident #21's nursing note, dated 7/14/25 at 6:44 p.m., showed, This nurse received report from CNA that resident went through the first set of doors, was in the corridor when found by other resident and brought back into main entrance of ECU . The nurses note showed the intervention to prevent further elopements would be to increase monitoring and activities from 3:00 p.m. to 6:00 p.m. Review of the state abuse reporting website dated 2/1/26 at 10:00 a.m., showed resident #21 was brought back from Med-Surg by Med-Surg nurse. Resident eloped through back doors either following volunteer or staff taking other resident's to Mass. No alarms were triggered when she got out of RLU. PCP, Administrator, DON, MDS and social worker notified of incident. Review of resident #21's electronic health record failed to show any nurses note or any documentation of the elopement which occurred on 2/1/26. During an interview on 4/23/26 at 9:22 a.m., staff member F said when the activity department had three staff members, someone from activities stayed until 7:00 p.m. The three staff were available until 1/2/26. Staff member F said the funding for the third employee had been cut from the budget, so the activity staff did not stay late any longer. Staff member F said there were no organized activities after 5 p.m. 3. Resident #38 's Risk of Elopement Wandering Review, dated 3/24/25 showed resident #38 was at risk for eloping or wandering. Review of resident #38's care plan, dated 3/24/25, showed resident #38 was at risk for elopement due to dementia and she had a (BIMS) brief interview for mental status score of three. A BIMS score of zero to seven indicates severe mental impairment. Resident #38's care plan interventions for elopement showed resident #38 will receive re-direction if she attempts to exit the unit, diversional activities will be provided, and staff will assure the door alarms were activated on all exit doors. A sign was posted at the main entrance to remind visitors not to allow residents out behind them. Review of resident #38's nurses notes dated, 7/24/25 at 3:35 p.m., showed, Resident got out in between the sliding front doors presumably as someone was coming in or going out and no one seen her go out. The facility did not follow the care plan which showed the resident would not leave the facility and the staff would redirect the resident if she attempted to elope. 4. Review of resident #61 nurses note, dated 7/24/25, showed resident #61 was admitted to the facility following a hospitalization. The nurses note showed resident #61 repeated questions frequently showing he had problems with his short-term memory. Review of resident #61's nursing note, dated 7/25/26 at 1:33 p.m., showed resident #61 attempted to elope twice. One elopement was out the double door at the end of a hallway, and the other elopement was out the door to the outside of the facility. Both elopements occurred between three and five p.m The intervention to prevent further elopement was to remind resident not to leave the facility, however resident #61 had dementia with short term memory problems. Review of resident #61's Risk of Elopement/Wandering Review, dated 7/25/25 at 8:25 a.m., showed resident #61 was at risk for elopement. Review of resident #61's care plan for elopement interventions showed the care plan and intervention were not initiated until after resident #61 eloped from the facility twice. Review of the SSA abuse submission portal showed resident #61 eloped on 8/12/25. A request was made 4/21/26, requesting the nurse progress notes through 8/30/25. The nurses note regarding the elopement of 8/12/25 was not provided by the end of the survey on 4/23/26. 5. Review of a Facility Reported Incident, with a date of 1/18/26, showed: Resident #62 had been exit seeking throughout the day. Resident #62 exited out of the main entrance to the facility by pushing open the sliding doors and closing them behind her. The resident was in her wheelchair. The facility used camera footage to determine how the resident eloped. Resident #62 was witnessed by an oncoming staff member, falling while trying to walk down the stairs. Resident #62 had an abrasion to the right side of her face and bruising to her right side. Resident #62 was sent to the hospital for evaluation, and the X-rays came back negative. This report showed the resident did have an anti-elopement alarm device on her wheelchair that sounds as she approaches the door. Resident #62 had been near the door, setting the alarm off throughout the day. During an interview on 4/22/26 at 10:03 a.m., staff member W stated resident #62 was very adamant about her independence and sometimes had behaviors toward staff. Staff member W stated some of the interventions in place for resident #62 were 1:1 monitoring, taking her outside, folding laundry, along with other interventions she could not remember. During an interview on 4/22/26 at 1:56 p.m., staff member V stated, She (resident #62) was sweet but hard to manage. She was all over the place. Staff member V stated they (staff) would update the care plan after each elopement with new interventions and submit the report to the state. During an interview on 4/23/26 at 10:01 a.m., staff member A stated they tracked elopements by staff entering occurrence reports in the EHR and the state reports they submitted to the SSA. Staff member A stated, The way we monitor interventions depends on the intervention. The device on the door is monitored by the night shift. Most interventions we would just observe to make sure they were being done, such as putting her (resident #62) in the recliner to relax. We would discuss interventions at the morning huddle meeting and our IDT meetings. The care plan would be updated anytime interventions were changed and after each incident. Staff member A stated they would discuss the root-cause of the elopements, but they did not document them. Review of a facility document titled SBAR & Procedure for Anti-Wandering Door Alarm for Elopement Risk Residents with a date of 9/24/25, showed: .5. Response to alarm: a. If an alarm is triggered, immediately locate all residents to ensure they are in a safe place. c. If an elopement occurs, follow the Elopement Procedure in [NAME]. The facility failed to identify the resident's need for one-on-one monitoring to prevent the resident from exiting the facility unsupervised, failed to respond to an anti-elopement door alarm, and failed to prevent the resident from experiencing a fall with injury.

Based on observation, interviews, and record review, the facility failed to ensure a comprehensive grievance process was operationalized and followed effectively by staff for the resolution of a grievance related to the provision of personal resident care, for 1 (#5) of 23 sampled residents. Findings include:During an interview and observation on 4/22/26 at 11:20 a.m., resident #5 and NF3 said that resident #5 had some concerns with the care he received from the certified nurse assistants. NF3 provided a copy of the grievance dated 3/12/26. NF3 said the resident #5 and his family asked him not to get milk-based supplements. NF3 said resident #5 had a hiatal hernia, which was aggravated by milk. NF3 said the milk-based supplement made resident #5 have more phlegm and mucous, which caused resident #5 to be more congested and increased his cough. Resident #5's lunch tray was observed. The tray included a large glass of milk-based supplement. NF3 said the grievances had not been resolved to the satisfaction of resident #5 or the family.During an interview on 4/22/26 at 4:05 p.m., staff member A said she was aware of a letter of concern that resident #5's family wrote and gave to the facility. Staff member A said the letter was given to staff member B to address the grievance. Staff member A said she did talk to resident #5's daughter about the letter and the concerns. Staff member A said she did not put a copy of the letter into the grievance file, which was given to the surveyors. Staff member A said staff member B spent time with the family working through the concerns, but no documentation could be provided to show the outcome of the concerns.During an interview on 4/23/26 at 9:24 a.m., staff member A said resident #5's grievance was in staff member B's file, and neither the grievance form nor the follow-up could be accessed.Review of a facility document titled Complaint Grievance Policy-Long Term Care, with a review date of 9/16/25, showed: .A resident has the right to voice a complaint or grievance and prompt efforts by the facility to resolve grievances or complaints that the resident may have without worry of reprisal.Efforts to resolve include facility acknowledgement of complaint/grievance and actively working toward the resolution of the complaint/grievance (initial response may be immediate as required or generally within 7 working days).7. After receiving a complaint/grievance, [Facility Name] will actively seek a resolution and keep the patient/resident appropriately apprised of progress toward resolution.7.1 There is generally follow-up within seven (7) working days if possible, and resident will be apprised of progress at least every 30 days for issues requiring comprehensive review or follow up until investigation and response completed.

Based on interview and record review, the facility failed to ensure pain was routinely assessed, and medication was given according to a physician's order for 1 (#3) of 23 sampled residents; this deficient practice had the potential for the resident to experience increased pain. Findings include:Review of resident #3's Quarterly MDS, with an accepted date of 4/21/26, showed: Section J (Health Conditions): .Pain presence Yes.Pain Frequency: 4 - Almost Constantly.Pain Effect on Sleep: 3 - Frequently.Pain Intensity: 3 - Severe.Review of resident #3's electronic health record showed: Physicians' orders: Hydrocodone-acetaminophen (5-325 mg/tab) (Norco) tablet., Dose: 1 tablet 3 times a day, start date of 4/9/26. Admin Instructions: Give with food, Diagnosis: Chronic Pain Syndrome, Time to Peak: oral 40-80 minutes, Duration: 4-8 hours, Route: oral. Additional Documentation. Flowsheets: .Pain Alert Assessment.Review of resident #3's medication administration record showed: Hydrocodone-acetaminophen (5-325 mg/tab) .- 4/14/26 at 1205 (12:05 a.m.) held not given. - 4/15/26 at 751 (7:51 a.m.) held not given, and 1943 (7:43 p.m.) held not given. - 4/16/26 748 (7:48 a.m.) held not given, and 1333 (1:33 p.m.) held not given.- 4/17/26 824 (8:24 a.m.) held not given, and 1318 (1:18 p.m.) held not given.Review of resident #3's electronic health record showed a pain assessment was completed on 4/16/26, which showed: Patient currently in pain. Yes, Pain Score (0-10), 7 -Severe, Pain Onset Ongoing.A pain assessment was completed again on 4/16/26 at 2130 (9:30 p.m.), which showed: Reassessment . Sleeping.No other pain assessments were completed for the dates of 4/14/26 to 4/17/26, when doses of pain medications were not given, which increased the resident's risk of pain.During an interview on 4/21/26 at 4:38 p.m., resident #3 stated her pain medications were recently changed, and she gets them most of the time every six hours.During an interview on 4/23/26 at 8:05 a.m., staff member V stated, We don't do a pain assessment on residents with scheduled pain medication. Staff member V stated if a staff member did do a pain assessment, it would be documented under vitals or in a progress note. Staff member V stated, The computer system automatically pops up a pain assessment even though we aren't required to do them for long-term care residents on scheduled pain medications. I wish they would fix that in the system.During an interview on 4/23/26 at 8:44 a.m., staff member C stated pain assessments should be conducted on each shift for anyone on pain medications. Staff member C stated the only time a pain medication should be held is if a resident is overly sedated and the side effects outweigh the benefits of the medication. Staff member C stated, Staff should always alert the physician if they hold a scheduled pain medication and consult them for further directions. Staff member C looked up resident #3's Medication Administration Record and was unable to identify why the medication was held between 4/14/26 and 4/17/26. Staff member C stated she did not know where the pain assessments were in the computer system and would need assistance locating them.During an interview on 4/23/26 at 9:58 a.m., resident #3 stated she always has pain that was eight out of ten, but she can deal with it when sitting. Resident #3 stated, I usually receive my pain medications as prescribed except when the nurse is too busy.Review of a facility document titled Pain Management Policy with an effective date of 5/9/25, showed: .Purpose: To provide a comprehensive approach to pain management that ensures effective, safe, and patient-centered care for all individuals experiencing pain, recognizing that pain is a vial factor in enhancing patient quality of life and health outcomes.Policy: 1. Pain Assessment: a. Conduct a comprehensive pain assessment for all patients, promptly and effectively, including the use of the enterprise's identified standard pain scales c. Document each pain assessment and reassessment in the patient's medical record.

Based on interview and record review, the facility failed to implement a consistent antibiotic stewardship program, including infection surveillance and mapping, to identify trending of the locations of infections. This deficient practice increased the risk of a negative outcome related to residents taking antibiotics for infections and increased the incidence of adverse events associated with infections throughout the facility. Findings include: During an interview on 2/27/25 at 9:19 a.m., staff member L stated infections and antibiotic use were not tracked for June of 2024. Staff member L said the facility completed the McGreers criteria for tracking infections, but it was not completed in June of 2024. Review of the facility's Infection Control binder showed a lack of infection mapping and line listings for the last year from January of 2024 through January of 2025. Staff member L said, The facility isn't so large that I couldn't just identify if there were trends related to specific infections. Staff member L was unable to identify any areas of infection trends. Staff member L said she just started in December of 2024, and she was just learning what needs to be done.

Based on observation, interview, and record review, the facility failed to maintain a safe environment, free from elopements, for 4 (#s 16, 17, 18, and 24), and the facility failed to provide an environment free from accidents and hazards for 1 (#42) of 18 sampled and supplemental residents. This deficient practice had the potential to adversely affect the well-being and safety of all residents in the facility. Findings include: 1. Review of the Facility Reported Incident, dated 8/31/24, showed resident #24 left the Residential Living side of the facility, and the resident eloped into the hospital. The facility identified the alarm between the two areas had not been activated. During an interview on 2/25/25 at 11:17 a.m., staff member B said resident #24 eloped because the alarm on the dining room doors, which led to the hospital, were not activated. Staff member B said staff were educated to ensure the alarm was set to alarm if the door to the hospital was opened. But, no system was put in place to monitor the status of the alarm. Staff member B said if the alarm was not set properly, it increased the risk for residents to elope to the hospital. During an interview on 2/26/25 at 12:35 p.m., staff member B said the facility did not have an elopement assessment for the residents in the Residential Living area and none of the residents had been assessed for elopement risk. Staff member B said the facility was working on developing an elopement assessment for the Residential Living area. Staff member B said resident #s 16, 18, and 24 were at risk for eloping. During an interview and observation on 2/26/25 at 5:24 p.m., staff member I said she did not know how to identify the residents at-risk for elopement. She said, I would think the residents at risk for eloping would be the ones who hang around the door. Staff member I said the only resident she knew of who was an elopement risk was resident #24. Resident #24 was observed near the front exit door during this interview. During an interview on 2/26/25 at 5:28 p.m., staff member J said there were two residents at risk for elopement, resident #s 17 and 24. During an interview on 2/26/25 at 5:40 p.m., staff member K identified two residents who were at risk for wandering and eloping. She identified residents #s 17 and 24. During an interview on 2/27/25 at 7:47 a.m., staff members A and B said the elopement book was not current or updated. Staff member B said it would not surprise her if there were seven residents identified in the elopement binder. Staff member A said the staff should know which residents were at risk for eloping by looking at the care plan or the C.N.A. assignment sheet. 2. During an observation on 2/24/25 at 4:34 p.m., there was an unsecured work bench in the activity room, which was accessible to the residents. On the bench, and within easy reach of residents, were the following items: - Double-edged wood working hand saw, - T-handle screwdriver, - Numerous bottles of paint; and, The work bench contained two easy sliding drawers which contained: - Large tin snips, - [NAME] grips, - Utility knife with a sharp blade, - Wire cutters, - Pipe wrench, - Drill and drill bits - Ball peen hammer, - Hacksaw During an observation and interview on 2/24/25 at 4:30 p.m., resident #42 was sitting in her wheelchair near the work bench in the activity room. Resident #42 stated, That looks like a lethal weapon. Resident #42 was pointing to the double-edged wood saw. During observations on 2/25/25 at 8:30 a.m., and 2/26/25 at 11:50 a.m., the activity room contained a work bench which was not locked. The tools were accessible with some tools on top of the bench and the rest of the tools in the drawers. The tools and paints were not secured, and the drawers were not locked. The activity room was also not locked. During an interview on 2/25/25 at 11:27 a.m., staff member E said when maintenance needs to do repairs in the Residential Living area, the staff bring a tool chest to the area, or a handheld pouch of tools, depending on the size of the job. Staff member E said none of the maintenance tools are left where residents could access them. During an interview on 2/25/25 at 3:19 p.m., staff member G said the activity doors are always open, and all the residents can go in and out any time they want. Staff member G said she was not sure how the safety of the tools was maintained. Staff member G said all the tools could be accessed by any resident right now because the tools were just sitting out on the bench or in the drawers. During an interview and observation on 2/25/25 at 3:31 p.m., staff member A was in the activity room looking at the resident work bench. Staff member A said the tools, which belonged to a resident, were put away and the drawers under the bench were closed when the tools were not in use. During this observation, the screw drivers, the T-handled screwdriver, and the metal ruler were readily accessible. The drawers were closed, however the drawers opened easily, and the listed tools were all accessible to residents.

Based on interview and record review, the facility failed to provide COVID-19 vaccinations for 3 (#s 6, 17, and 35) of 14 sampled residents, and failed to document staff declinations and education regarding the COVID-19 vaccine for 2 (staff members M and N) of 2 sampled staff members. Findings include: During an interview on 2/25/25 at 3:31 p.m., staff member L said the facility pharmacy did not carry the COVID-19 vaccine. Staff member L said the facility could take the residents to the local drug store or the other local clinic, and the residents could get their vaccinations there. Staff member L said keeping the vaccinations at the facility was cost-prohibitive, and would cost the residents over three hundred dollars per vaccine. During an interview on 2/26/25 at 10:29 a.m., staff member H said the facility used to carry COVID-19 vaccines but stopped getting them due to waste. Staff member H said the vaccine could be ordered in pre-filled syringes which would help contain cost for the residents. Staff member H said the cost and billing would be the responsibility of the billing department and was unsure if residents would be able to use their Medicare Part D benefits. Staff member H said billing was not the reason vaccinations were not being given at the facility. During an interview on 2/27/25 at 7:47 a.m., staff member A stated there was no education provided to staff regarding the COVID-19 vaccine. There was also no documentation of consent or declination of the COVID-19 vaccine. Review of a facility document titled, Moderna COVID-19 Vaccine, dated 7/18/24, showed resident #6 requested to receive a Moderna COVID-19 vaccine in July of 2024. Review of resident #6's EHR failed to show the COVID-19 vaccine was provided to the resident as of the start of the survey. Review of resident immunization records for resident #17 and 35 showed the residents were currently waiting to get the COVID (vaccine). IP currently working on getting COVID vaccines. A review of the facility's policy titled,Vaccination Administration Policy, revised 2/24/23, did not address staff requirements for COVID-19 vaccinations. A request was submitted on 2/26/25 for COVID-19 vaccine education and consent or declination documentation for staff members M and N. None were received prior to the end of the survey.

Based on observation, interview, and record review, the facility failed to provide education and information to the residents or responsible party on the risks and benefits of psychotropic medication, so they were able to make an informed decision, and the facility did not have documentation to show the resident/responsible party consented to the use of the medications, for 3 (#s 6, 18, and 39) of 18 sampled and supplemental residents. Findings include: a. During an interview on 2/24/25 at 3:02 p.m., resident #6 stated she was on, . a lot of medicine for my mood and my anger. Review of resident #6's medication orders showed sertraline 25 mg daily, with no associated diagnosis listed. The medical record failed to show education was provided on the use or risks and benefits of the psychotropic medication in order to make an informed decision on the use of it. b. Review of resident #18's medication orders showed citalopram 10 mg daily, with the associated diagnosis of anxiety. The review of the medical record failed to show the resident or the resident's representative received education related to the use or risks, and benefits of the psychotropic medication in order to make an informed decision on the use of it. c. Review of resident #39's medication orders showed trazodone 50 mg daily at bedtime, with the associated diagnosis of insomnia due to other mental disorder. Review of resident #39's medical record failed to show the resident or the resident's representative was provided education related to the use and risks and benefits of the psychotropic medication in order to make an informed decision on the use of the medication. During an interview on 2/26/25 at 9:57 a.m., staff member B stated consents were supposed to be obtained for all psychotropic medications used within the facility, which would show the resident/responsible party was aware of the risks/benefits of the medications. A request was made on 2/26/25 for the written consents for the above listed residents, but none were received by the end of the survey period.

Based on observation, interview, and record review, the facility failed to review the risks and benefits of using a transfer rail, attached to the bed, for the resident and failed to obtain an informed consent prior to the installation of the transfer rail for 1 (#48) of 14 sampled residents. Findings include: During an observation and interview on 2/25/25 at 9:13 a.m., resident #48 stated, I didn't ask for them (bed rail assist bars). One was here when I got here, and they put the other one up. They have been there. They don't bother me, they are just there. Resident #48 stated, There is something on them and maybe I can figure them out later, as she was touching the grab bars and jabbing at them with her fingers. Resident #48 said, The facility does not want us to fall out of bed. Resident #48 was observed turning herself in bed independently without using the grab bars, and then sat straight up in bed without assistance. Resident #48 was able to maintain her unassisted upright position during the 10-minute interview. Review of resident #48's initial Bed Rail/Assist Bar Evaluation, dated 1/23/25, showed the bed rails would be used for positioning, bed mobility, and security. There was no safety assessment to include resident #48's physical ability, strength, and physical size as part of this evaluation. During an interview on 2/26/25 at 12:58 p.m., staff member B said the facility did not have consents for the grab bars for resident #48 or any of the other residents using grab bars. Staff member B said the Bed Rail/Assist Bar Evaluation was used to identify the appropriateness of grab bars and the resident's desire for grab bars. Staff member B said the grab bars were made specifically for each bed and therefore safety assessments were not necessary. Entrapment risk related to her physical ability and her underweight status of 86 pounds was not included on the evaluation form.

Based on observation, interview, and record review, the facility failed to provide written notice of bed-hold information, which included the reserve bed payment amount, for 4 (#s 8, 35, 39, and 151) of 18 sampled and supplemental residents. The notice also failed to five the resident or responsible party the opportunity to select either to pay the reserve bed hold cost or no bed hold. Findings include: 1. During an interview on 2/25/25 at 9:36 a.m., resident #35 said he could not remember why he had been admitted to the hospital in November and December of 2024. Review of resident #35's EHR showed he had been admitted to the hospital on [DATE], with diagnoses of adult failure to thrive, and chronic obstructive pulmonary disease. The resident returned to the facility on [DATE]. The EHR failed to show the resident had been provided bed-hold information at the time of his transfer. Review of resident #35's EHR showed he had been admitted to the hospital on [DATE], with the diagnoses of sepsis and aspiration pneumonitis. The resident returned to the facility on [DATE]. The EHR failed to show the resident had been provided bed-hold information at the time of his transfer. 2. During an observation and attempted interview on 2/26/25 at 7:50 a.m., resident #151 was resting quietly in her bed. Resident #151 did not rouse to her name being spoken in a normal voice. Review of resident #151's EHR showed she had been admitted to the hospital on [DATE] for increased lethargy and a urinary tract infection. Resident #151 returned to the facility on 2/8/25. The EHR failed to show the resident or the resident's representative had been provided the bed-hold information at the time of her transfer. Review of resident #151's EHR showed she returned to the hospital on 2/9/25 with a low blood pressure and septic shock. The resident returned to the facility on 2/14/25. Resident #151 was placed on hospice services upon her return to the facility. The EHR failed to show the resident or the resident's representative had been provided bed-hold information at the time of her transfer to the hospital. 3. During an interview on 2/25/25 at 9:24 a.m., resident #8 stated he was admitted to the hospital, a couple of times. Review of resident #8's medical record showed the resident was transported to the hospital for an acute change in condition on 3/19/24 and 8/13/24. There was no documentation in the medical record to show the resident or his representative was provided or notified of the required written bed-hold notice. 4. During an interview on 2/25/25 at 1:12 p.m., resident #39 stated she had been transferred to the hospital in August of 2024, and did not receive any written documents from the facility on or around the time of transfer. Review of resident #39's nursing progress notes showed resident #39 was transferred to the hospital on 8/31/24 for an acute change in medical condition. There was no documentation in the medical record to show the resident or her representative was provided or notified of the required written bed-hold notice. During an interview on 2/26/25 at 10:12 a.m., staff member D stated she was not aware a written notice of bed-hold was required which showed the resident or resident representative's choice whether to hold his or her bed on transfer from the facility. Staff member D stated the facility would provide a copy of their bed-hold policy on transfer. Staff member D stated, We have had lots of travelers (agency nurses) and we just aren't good about getting it (the bed-hold selection) done. We have just been sending the bed-hold policy to the resident or the representative. Review of a facility document titled, Bed Hold - [Facility Name] (Residential Living), effective 5/22/23, showed, . 2. If available beds are occupied or being held at the time of transfer, then the resident will be expected to pay the full minimum applicable charges during the absence if the resident/resident representative elects to sign a bed hold. If 'no bed hold' is selected, readmission to Residential Living will occur when an appropriate bed is available . The bed-hold policy form did not include a space to show the resident or resident representative's preference regarding whether or not to hold the resident's bed during their absence. A request was made on 2/26/25 for the bed-hold documentation for the above residents. None were received prior to the end of the survey.

Based on observation, interview, and record review, the facility failed to identify root causes for falls, update care plans with interventions to prevent falls, and to decrease the risk for recurring falls, for 3 (#s 3, 271, and 109) of 5 sampled residents. Findings include. 1. Review of resident #3's nurse progress notes, dated 5/24/23, showed resident #3 frequently slept in his recliner. The nurse progress note also showed resident #3 was found on the floor after an unwitnessed fall. Resident #3 was sent to the emergency room and was diagnosed with a hip fracture. Review of resident #3's nurse progress notes, dated 6/1/24, showed resident #3 was readmitted to the facility following the hip fracture. Review of resident #3's care plan on 6/5/24, showed the care had not been updated with new interventions following his hip fracture and change in status. During an interview on 6/5/24, at 9:42 a.m., staff member C said the facility reviewed the falls every Thursday during the fall meetings. Staff member C said the care plans did not get updated until that meeting. Staff member C said, on 5/24/24 resident #3 got his feet tangled in the blankets, which caused the resident to fall out of bed. Staff member C said resident #3's care plan was updated to include the risk of getting his feet tangled in the blanket. Staff member C was unable to identify the date when the update was made to the care plan regarding the blankets. Staff member C said the update was probably done on 5/30/24 when the fall meeting occurred. Staff member C could not identify what changes had been made to the care plan following resident #3's hip fracture. 2. Review of resident #271's nurses notes showed: - 5/14/24 - Resident #271 was reaching down and fell out of his wheelchair. - 5/17/24 - Resident #271 fell on to his knees while working with the therapy department. - 5/31/24 - Resident #271 was found in his room on the floor. The nurses note showed resident #271 was found on 5/30/24 at 6:24 p.m., by his bed. Resident #271 told the staff that he slid from his wheelchair. During an observation and interview on 6/5/24 at 3:15 p.m., resident #271 said he has had one or two falls. Resident #271 said there was a reacher for him, but he did not use it. Resident #271 said the wheelchair scooted away from him (when transferring). Resident #271 was observed sitting in a regular wheelchair with his left arm in a sling. Resident #271 was observed propelling himself around the facility. The wheelchair brake handles were short and not easily reached by the resident who had his left arm in a sling. Review of resident #271's care plan showed fall interventions dated 4/11/24, with no updates since then to address root causes of the falls on 5/14, 5/17, and 5/31/24. Fall interventions included: - Long reach grabber - Staff to monitor and assist resident to reposition in Broda chair - Resident to work with PT 4/16/24, Occupational Therapy still pending - Staff to provide resident #271 with a puffer call light that is easier to activate - Dycem under and on top of his ROHO cushion in his Broda chair to decrease the chances of slipping out of the chair - Resident to wear sling for left arm to assist with support so he is not leaning to the left in Broda chair - Resident has non-elevating standard footrest with strap at the back to help keep feet in place 3. Review of resident #109's nurses notes, dated 5/31/24, showed resident #109 was found down on the floor. Resident #109 fell out of her Broda chair. Resident #109 was assessed in the emergency room after the fall and returned to the facility. Review of resident #109's post fall huddle, dated 5/31/24, showed the facility identified factors that could have contributed to the fall. The interventions identified were to lay the Broda chair back, so it was not setting upright, place the call light closer to the resident, and the resident would use oxygen. Review of resident #109's care plan showed the last care plan update for falls was done on 5/3/24. The facility failed to update the care plan to include interventions identified on the post fall huddle form. The care plan was not updated after the fall on 5/31/24 to include interventions to reduce the risk for further falls. During an interview on 6/6/24 at 9:47 a.m., staff member B stated the nurses were supposed to complete the post fall huddle every time after a fall to identify the cause of the fall. Staff member B said it was difficult to get the fall system working well due to having interim nurses from an agency. Staff member B said the team mets every Thursday and updated care plans once a week.

Based on observation, interview, and record review, the facility failed to develop and implement comprehensive, person-centered care plans, for 4 (#s 3, 21, 23, and 34) of 23 sampled residents. The failure had the potential to result in inadequate care and a lack of provision of services for the residents identified. Findings include: 1. During an observation on 2/13/24 at 7:36 a.m., resident #23 was eating breakfast, alone, in her room. During an observation on 2/14/24 at 11:49 a.m., resident #23 was eating lunch, alone, in her room. During an interview on 2/15/24 at 7:57 a.m., staff member P stated resident #23 was a known aspiration risk. The resident had failed swallow studies and adamantly refused texture modification or to leave her room for meals. During an interview on 2/15/24 at 8:55 a.m., staff member D stated there was always someone at the nursing station outside of resident #23's room who could hear if the resident was having a choking incident. During an interview on 2/15/24 at 10:17 a.m., staff member I stated she knew resident #23 had to be seated upright for meals to prevent choking. Review of resident #23's Quarterly MDS, with an ARD of 1/16/24, showed the resident had, coughing or choking during meals or when swallowing medications. Review of resident #23's care plan, with an initiation date of 1/11/24, failed to show a problem, goal, or approaches for the resident's aspiration risk or interventions to assist in the prevention of aspiration. 2. During an observation on 2/13/24 at 8:13 a.m., resident #21 was alone, in her room, with a breakfast tray in front of her. She was confused and unable to navigate the utensils from moving the food to her mouth. During an observation on 2/14/24 at 7:45 a.m., resident #21 was asleep in her recliner with a full breakfast tray in front of her. There was no one assisting or cueing the resident to eat. During an observation on 2/14/24 at 10:00 a.m., resident #21 was in the same position observed two hours prior. Her food remained on the tray in front of her, untouched. There was no staff assisting or cueing the resident to eat. There were no observations of staff checking in on the resident to assist with the meal. During an observation on 2/14/24 at 11:38 a.m., resident #21 was asleep in her recliner with her lunch tray in front of her. There was no one assisting or cueing the resident to eat. During an interview on 2/15/24 at 8:55 a.m., staff member D stated resident #21 needed cueing or assistance while eating and staff should be going into her room to help. Review of resident #21's MDS Discharge Assessment - return anticipated, dated 10/9/23, showed under functional abilities and goals, the resident was marked as Setup or clean-up assistance - Helper SETS UP or CLEANS UP; resident completes the activity. Review of resident #21's Quarterly MDS, with an ARD of 12/12/23, showed under functional abilities and goals the resident was marked as Partial/moderate assistance - Helper does LESS THAN HALF the effort. This represented a decrease in the resident's eating ability from the previous assessment. Review of resident #21's care plan, dated 12/12/23, showed, Assist patient with setup of meals and open containers. There were no updates made to the care plan for her increased need of assistance during meals, which was identified on the 12/12/23 MDS assessment. 48268 3. During an interview on 2/12/24 at 4:03 p.m., resident #3 stated his bottom dentures don't stay in place, and he needs to have his food cut up for him. During an interview on 2/13/24 at 2:21 p.m., staff member Q stated she believed resident #3, just doesn't like to wear his dentures, so he leaves them on the table. Review of resident #3's nutrition note, dated 12/19/23, record showed dental problems related to poor fitting dentures. A review of resident #3's MDS assessments, showed an Annual Assessment was completed with an ARD of 12/19/23. Section L200Z showed no concerns related to dental problems. Review of resident #3's current care plan, with no implementation date identified, failed to show any dental or chewing concerns related to poor fitting dentures. 4. During an interview on 2/13/24 at 9:32 a.m., resident #34 stated he was diagnosed with PTSD related to his active military service in Vietnam. Review of resident #34's electronic medical record showed a diagnosis of PTSD. Review of resident #34's Quarterly MDS, with an ARD of 2/1/24, identified PTSD in section I (Active Diagnoses); subsection I6100. Review of resident #34's current care plan, no implementation date identified, failed to identify or show information for resident #34's PTSD, and failed to show any problems, goals or approaches for staff to utilize when assisting resident #34 related to his PTSD.

Based on observation, interview, and record review, the facility failed to ensure staff were adequately trained, and a policy developed and implemented, for staff to follow and adhere to the infection control precautions and processes for the identified residents, for 3 (#s 7, 9 and 46) of 6 sampled residents, with catheters, gastric tubes, or wounds; and, the facility/staff failed to follow CDC recommendations for the precautions implemented by the facility. 1. During an observation on 2/13/24 at 3:19 p.m., staff member E was observed donning an isolation gown prior to entering resident #46's room. Staff member E stated she was planning to turn resident #46 onto his side. During an interview on 2/14/24 at 8:56 a.m., staff member J stated, We gown up for cares on anyone with a stomach tube or catheter because they are at higher risk (for infection). Cares would be changing linens, bathing, showering, turning, and such. When asked if these same precautions were used for resident's with wounds, staff member J stated, Oh, well maybe. I guess I thought it was just for people with a tube, like a catheter or a stomach tube, but maybe for wounds too, that makes sense. During an observation on 2/14/24 at 9:12 a.m., staff members E and R were performing incontinence care and repositioning for resident #46. Neither staff member was wearing an isolation gown. When asked if the staff were provided education on the facility's recommended infection control and isolation precautions, staff member E stated, Training was absolutely not provided, and most importantly no residents were informed. I believe they (isolation precautions) were started on several of the residents last week when they knew they were in their survey window. Some of the residents were very upset. During an interview on 2/14/24 at 2:15 p.m., staff member M stated, Clearly the (precautions) need to be re-evaluated and (the facility needs to) decide if we want to continue it. The expectation is (precautions) for anyone with a line (catheter or feeding tube) or open wound. Staff member M reported the policy was implemented after a resident developed an antibiotic resistant infection, and it was anticipated it would be helpful for the survey process. During an interview on 2/15/24 at 10:40 a.m., staff member M reported the facility doesn't have a specific policy on the current infection control precautions, and stated, We have just been using the CDC guidance. Staff member M stated all nursing staff received PPE education between September and December 2023. Review of a facility document titled, RN/CNA Hand Hygiene Isolation PPE Competency, not dated, included the following CDC information: Wear gown and gloves for the following high contact resident-care activities: - Dressing - Bathing/Showering - Transferring - Changing Linens - Providing Hygiene - Changing briefs or assisting with toileting - Device care or use: central line, urinary catheter, feeding tube, tracheostomy - Wound care: any skin opening requiring a dressing. 46400 2. During an observation and interview on 2/14/24 at 7:57 a.m., staff members F and Q were removing the lift sling from under resident #7. Resident #7 had a feeding tube. They were not wearing isolation gowns. Staff member J pointed to the sign outside the resident's door stating any linen changes or patient contact were included in the (infection control) precautions and required a gown. Staff member F disagreed, and stated removing the sling did not count as a linen change. 49554 3. During an observation on 2/13/24 at 8:10 a.m., a sign outside of resident #9's room read, Stop with a picture of a hand on it. Outside of the room was a set of plastic drawers with isolation gowns in it. During an interview on 2/13/24 at 8:15 a.m., staff member J stated the sign on the wall near resident #9's door was due to an infection control policy that has been in place for about a year, and staff member J stated, We are supposed to wear gowns and gloves during all resident care for residents that have a catheter or wounds. During an interview on 2/13/24 at 2:21 p.m., staff member F stated, I do not know why that sign is up there [on the wall] for transmission-based precautions. We use standard precautions with all catheters and for all resident cares. I will check and get back to you. Staff member F came back and stated, It [the sign] was due to another resident that was susceptible to infections and was resistant to antibiotics. That resident had been discharged , and the sign had not been removed. The facility implemented infection control precautions for designated residents, and failed to develope and implement a policy for it. Staff were neither following, adhering to, nor had sufficient knowledge for the infection control precautions implemented by the facility.

Based on observation, interview, and record review, the facility failed to accurately reflect the dental status on the Annual MDS assessment, for 1 (#3) of 6 sampled residents investigated for nutrition concerns. Findings include: During an observation and interview on 2/12/24 at 4:03 p.m., resident #3 was observed to have bottom dentures sitting on the bedside table. Resident #3 stated, I don't eat much. I need someone to cut it (food) up and my teeth bother me. The bottoms (dentures) don't stay in. Gums are shrinking I guess, and they (the dentures) don't stay in. Review of resident #3's Annual MDS Assessment, with an ARD of 12/19/23, showed no dental concerns in section L (Dental); subsection L0200Z. During an interview on 2/14/24 at 2:14 p.m., staff member B stated, I had no idea that he had denture problems. During an interview on 2/15/24 at 9:18 a.m., staff member D reported she was responsible for the MDS assessments, initial care plans, and updates as needed. Staff member D stated, I didn't know (Resident #3) had dental issues, and he has never mentioned it. The closest dentist that accepts Medicaid is in [Town] and the (Facility) cannot provide transportation, because they would need a non-employee escort. If his gums have shrunk, there's nothing they can do about it. Review of resident #3's nutrition note, dated 12/19/23, showed resident #3 required a mechanically altered diet with chopped meat, due to poorly fitted bottom dentures, and difficulty swallowing. No dental exam notes were located in resident #3's medical record.

Based on interview and record review, the facility failed to prevent the development of two Unstageable pressure areas; failed to obtain physician orders and an OT evaluation timely for the pressure areas; and failed to document the treatment and monitoring for healing of the pressure areas, for 1 (#19) of 3 sampled residents. Findings include: Review of the facility matrix, showed resident #19 had an Unstageable facility acquired pressure area. Review of resident #19's nursing entry note, dated 11/25/22, showed resident #19 was crying, and clearly stated her hands hurt. Review of resident #19's Annual MDS, with the ARD of 1/16/23, showed she had severe cognitive impairment. During an interview on 2/16/23 at 8:10 a.m., staff member R stated she clearly remembered the day she found the black area on resident #19's right index finger. She stated it was the Monday after Thanksgiving, which was 11/28/22, and staff member R had been off for a few days. Resident #19 had severe hand contractures, and used a large 'carrot' to reduce pressure. Staff member R stated the carrot was too large, and caused pressure to resident #19's fingertip. She stated the nurse was notified of the pressure are on the resident's index finger, and an OT evaluation was requested on 12/5/22. Review of resident #19's nursing charting entry, dated 12/2/22, a late entry for 12/1/22, showed the pressure area was reported on 12/1/22. The note showed the left little finger was also starting to breakdown. Review of resident #19's nursing charting entry, dated 12/5/22, showed The patients index finger on the right hand is getting worse. There is an actual hole forming on the tip of the finger. The nurse was notified and she wrapped the left finger. Also the little finger on the right hand is getting worse. Review of resident 19's nursing charting entry, dated 12/5/22, showed the pressure area on the left index finger measured 1.4 cm X .07 cm and approximately 0.1 cm deep. Review of a physician treatment order for the pressure area on resident #19's finger, dated 12/5/22, was four to eight days after the onset of when the pressure areas were identified. Review of resident #19's nursing charting entry, dated 12/5/22, showed the large 'carrot' was exchanged for a smaller carrot, and the nurse documented it may allow hand to be open a bit more and may help with the pressure. Review of #19's OT evaluation showed it was not completed until 12/22/22, more than 20 days after the onset of the pressure areas. During an interview on 2/16/23 at 8:15 a.m., staff member R stated there had been a 'mix up' at the front office, and the OT evaluation was completed late. She stated resident #19 passed away the morning of 2/15/23. During an interview on 2/16/23 at 3:00 p.m., staff member B stated the facility did not have TARs to track measurements of pressure areas, or that treatments have been completed. She stated it was a system the facility was working to improve.

Based on observation, interview and record review, the facility staff failed to provide services that would minimize the spread of infection for 1 (#1) of 11 sampled residents. Specifically, staff lifted a Foley catheter bag and tubing containing urine above the level of the resident's bladder. Findings include: Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. A review of an Admission MDS, with an ARD of 4/4/16, reflected the resident required extensive assistance with activities of daily living, and she had an indwelling Foley catheter. A review of a Quarterly MDS, with an ARD of 9/26/16, reflected the resident required extensive assistance with activities of daily living. The resident's primary mode of transportation was a wheelchair, and she had an indwelling Foley catheter. A review of the nursing notes, dated from 8/1/16 through 11/10/16, reflected the resident had numerous episodes of yelling and crying out, she had visual hallucinations, complained of generalized pain, and had numerous episodes of excessive sleepiness. Notes reflected the resident's physician changed her dose of [MEDICATION NAME] and [MEDICATION NAME] multiple times. A review of nursing notes, dated 11/10/16, reflected the resident had an increase in yelling .threw cups at staff and spit out some morning medication out (sic). Resident has very angry tone to voice and is unable to be calmed by staff. Resident position changed for comfort but does little to calm resident. Lights dimmed but no change in resident's behavior. PRN [MEDICATION NAME] (sic) given and resident absent of visual hallucinations after lunch but is still yelling . A review of nursing notes, dated 11/11/16, reflected the resident continued to have an increase in behaviors, and the staff and family were unable to redirect or calm the resident. The resident was given PRN [MEDICATION NAME] and [MEDICATION NAME]. At 3:50 p.m., nurse's notes reflected a facsimile was sent to the resident's physician and the physician asked that a (urinalysis) be obtained. The nurse's notes read, (Urinalysis) obtained through port in cathater (sic) today at (3:15 p.m.) and sent to lab. awaiting (sic) results. Daughter (name) aware of new orders. A review of nursing notes, dated 11/11/16 at 7:02 p.m., read, (Urinalysis) results faxed to (physician's name). Shows trace blood, positive for [MEDICATION NAME], 1 plus leukocytes, amorphous crystals, and budding yeast. No response at this time. Will encourage fluids with resident. A review of nursing notes, dated 11/12/16 at 00:56 a.m., read, (Resident's name) was hollering and res (sic) was not soiled, but when asked if she hurt, she said yes. Asked where she hurt and she reported 'all over', then said she had to feed those kids cuz they're always hungry after school. Res med (sic) @ (00:20 a.m.) with [MEDICATION NAME] 1 PO for generalized pain. A review of a facsimile sent to the resident's physician, dated 11/14/16, reflected the resident's urine results. The physician wrote a telephone physician's orders [REDACTED]. This was the first time the resident was diagnosed with [REDACTED]. During an observation on 11/15/16 at 5:07 p.m., staff members E and F provided perineal care to resident #1. The resident was lying flat on her back in her bed. A Foley catheter bag and tubing containing yellow fluid was tossed onto the bed between the resident's feet by staff member F. At 5:11 p.m., staff member D entered the resident's room, picked up the catheter tubing and began wiping them down with a cleansing cloth. There was a yellow liquid inside the catheter tubing. Staff member D picked up the catheter bag above the level of the resident's bladder and wiped the bag with the cleansing cloth. The bag was lifted eight inches above the level of the resident's bladder. At 5:19 p.m., staff members E and F put a clean brief on the resident, put her pants back on and assisted the resident to her wheelchair. Staff member F folded the catheter bag in half and passed it through the right leg of the resident's pants while the resident was lying flat in bed. During an interview on 11/15/16 at 5:22 p.m., staff member F stated she always put the catheter bag on the bed during perineal care. The staff member stated there was no easy way to provide perineal care and dressing of residents with a Foley catheter bag. During an interview on 11/15/16 at 5:26 p.m., staff member D stated catheter bags were to remain below the level of the bladder at all times to prevent CAUTI. A review of the facility's Health stream power-point education slides for licensed nurses, page 3, read, Draining a Foley Catheter- Keep drainage bag below the level of the patients (sic) abdomen at all times. A review of the facility's Indwelling urinary catheter care and management policy, page 2 of 6, read, Keep the drainage bag below the level of the patient's (sic) bladder and hips to prevent black flow (sic) of urine into the bladder, with increases the risk of CAUTI.

Based on observation, record review, and interview, the facility failed to ensure one (#2) of 11 sampled residents was free from developing a pressure sore. Findings include: Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the nurse's notes reflected: - On 8/11/15, the nurse documented the resident had previously noted open areas on the buttocks that were now pink and approximated and the nurse continued to use barrier cream. - On 8/11/15 and 8/18/15, the weekly skin checks did not identify skin issues. - On 8/21/15, the resident had developed a pressure area, two open areas close together. The areas measured 1.4 cm x 1.6 cm, medial skin thickness. There was some slough at the edges, but otherwise the ulcer had a pink wound bed. A skin prep was applied around the wound and thin duoderm was applied. The nurse notified the physician with a telephone order for duoderm. The day nurse was to notify the family and a dietary risk referral was sent to the dietary department. -On 8/22/15, the duoderm was intact to the right upper buttock. -On 8/24/15, the wound had worsened and now measured 3.5 cm x 4.5 cm, stage II pressure ulcer with serosanguinous drainage and a slight odor. The nurse cleansed the ulcer with wound cleaner and covered the wound with duoderm. -On 8/24/15, a nutrition note reflected a referral was received regarding skin impairment. On 8/25/15, the resident's wound was measured and a new duoderm was applied. Review of the skin assessments; -On 8/21/15, the resident had a right upper buttock pressure area, medial and lateral. -On 8/25/15, the resident had a right upper buttock pressure area, medial and lateral and measured 3.0 cm x 4.0 cm, skin check completed and no new open areas noted. Review of the physician's recapitulation orders, dated 8/2015, showed the physician had ordered weekly skin checks. Review of the physician's orders [REDACTED]. The physician's orders [REDACTED]. There was no documentation in the resident's medical record of dietary interventions. During an interview on 8/26/15 at 3:00 p.m., staff member A, MDS coordinator, stated she looked in the resident's chart and could not find any documentation regarding the resident's pressure ulcer prior to August 11, 2015. She stated she was not aware of the resident's pressure ulcer prior to 8/21/15. Staff member A stated the nurse's note, dated 8/11/15, that showed the opened area was previously noted, could have been a charting error because the skin and wound assessments and the nurse's notes did not report any open areas. During an interview on 8/26/15 at 3:30 p.m., staff member B, DNS, stated she had documentation on resident #2's pressure ulcer on 8/8/15, 8/9/15 and 8/10/15 from the brain. She stated the brain was a communication tool between the nurses. They received information from the previous nurse about the residents from the brain and the communication tool was updated every night by the shift nurses and was not part of the resident's medical record. Staff member B stated she could not find any documentation from the physician regarding the pressure ulcer or that the physician was notified of the resident's pressure ulcer prior to 8/21/15. She stated it could have gotten missed. During an interview on 8/26/15 at 4:10 p.m., staff member K, RN, stated she could not find any nurse's notes prior to 8/11/15 that documented the resident's pressure ulcer. She stated she heard about the wound in report and did not know that a dietary risk referral was supposed to be sent to the dietician when a pressure ulcer was discovered. During an observation on 8/27/15 at 7:45 a.m., staff member I, RN, removed the duoderm on resident #2's buttocks. The resident had a stage II decubitus area on her right upper buttock.

Based on record review and interview, the facility failed to maintain acceptable parameters of nutritional status. Specifically, the facility failed to identify severe weight loss for one (#2) of 11 sampled residents. Findings include: Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's weight report showed the resident weighed 192 pounds on 3/10/15 and weighed 165.9 pounds on 8/25/15. The resident had a weight loss of 26.1 pounds, which is considered a severe weight loss of 13.6% in less than six months. Review of the nutrition diagnostic statement, dated 5/29/15, showed the resident had been gradually losing weight and was assessed as mildly nutritionally compromised due to a therapeutic diet. During an interview on 8/26/15 at 3:30 p.m., staff member B, DNS, stated she could not find any documentation on the resident's weight loss from March 2015 to August 2015. She stated the dietician should be aware of anyone with a weight loss. Staff member B stated she did not receive any report on the resident's weight loss from the dietician. Review of the registered dietician's nutrition note, dated 8/24/15, showed the resident had a 7.4 pound weight loss in 7 days due to poor intake related to a declining condition. There was no other nutritional documentation in the resident's medical record that reflected the resident's severe weight loss. Review of the physician's nursing home report, dated 5/13/15 and 7/1/15, showed that facility staff noted the resident seemed to be doing well and staff had no concerns about the resident. There was no documentation in the resident's medical records showing the physician had been made aware of the resident's weight loss. During an interview on 8/26/15 at 12:32 p.m., staff member C, RD, stated the resident's family was aware of the weight loss, but the weight loss was not charted and the family was fine with the resident's weight. Staff member C stated she did not know why the resident's weight loss was not addressed or documented and that she would always look at the resident's weight and did not know why she had not addressed or documented her weight loss. She stated if she would have seen that her weight loss was more than 10% she would have marked it. Review of the resident's nurse's notes, dated 8/11/15, showed the resident had a pressure ulcer and by 8/24/15, the ulcer had developed into a stage II decubitus ulcer. During an interview on 8/26/15 at 4:10 p.m., staff member K, RN, stated she could not find any nurse's notes prior to 8/11/15 that documented the resident's pressure ulcer. She stated she heard about the wound in report and did not know that a dietary risk referral was supposed to be sent to the dietician when a pressure ulcer was discovered. There was no documentation in the medical record that showed the physician was notified of the resident's severe weight loss. There was no documentation in the resident's medical record that indicated the dietician was notified or any dietary involvement. The care plan was not updated to reflect the resident's weight loss.