Every finding on record at Livingston Health & Rehabilitation Center

Based on observation, interview and record review, the facility staff failed to assess, measure, document, and implement necessary interventions for the treatment of pressure ulcers for 1 (#11) of 7 sampled residents. The resident had one Stage ll pressure ulcer on his midline gluteal fold and one deep tissue injury on his left buttocks. The deep tissue injury was purple in color with intact skin. The facility failed to initiate treatment for the pressure ulcers upon admission, which placed resident #11 at risk of deterioration of both pressure ulcers or more developing. Findings include: Review of resident #1's medical record showed he was admitted on [DATE], with a diagnosis of pressure injury, metastatic prostate cancer, vertebral bodies with extradural mass, pulmonary nodules and spinal cord compression (not all inclusive).Review of resident #1's EHR showed the following related to pressure ulcers/care: A review of resident #11's nursing progress notes dated 6/26/26 at 12:37 p.m. showed resident #11 was admitted to the facility following a hospital stay which resulted in surgical interventions to remove a cancerous mass causing spinal cord compression.A review of resident #11's admission skin assessment dated [DATE] at 3:20 p.m. showed resident #11 had a 1.5 cm by 0.4 cm by 0.2 cm deep Stage II pressure ulcer to the left gluteal fold. Resident #11 also had a Stage II pressure injury to his left buttocks which measured 5.8 cm by 3.4 cm, and the depth could not be determined because the wound bed was necrotic.A Review of resident #11's June 2026 treatment record showed no treatments were being provided for the two Stage II pressure ulcers.Review of resident #11's electronic health record failed to show the assessment and measurements of the deep tissue injury and the pressure ulcer to the center gluteal fold from admission, until 10 days later, when the pressure ulcers were observed and assessed by the wound doctor.A review of resident #11's July 2026 treatment record showed treatment for the pressure ulcers was not started until the wound physician assessed the resident on 7/7/26.Review of resident #11's nursing documentation, from admission on [DATE] through 7/6/26, showed no documentation of wounds, the sizes of wounds, any treatments, or the need for repositioning or any changes in the wounds. Review of resident #11's 7/6/26 Wound Assessment Report, completed by the facility wound doctor, showed the resident's left buttock wound was Unstageable (severity) and measured 12.0 cm by 6.5 cm and was 1.0 cm deep. This was the first wound assessment following resident #11's admission to the facility 10 days prior. From June 26 - 7/6/26, resident #11 received no wound care for the two pressure ulcers. The 7/6/26 wound assessment showed the treatment ordered was for nursing staff to wash the wound with normal saline or wound cleanser, apply Betadine, and change daily. The treatment plan did not identify the dressing type that was to be changed daily. Review of resident #11's baseline care plan for skin integrity, initiated seven days after his admission, dated 7/3/26, showed resident #11 had actual impaired skin integrity with pressure ulcers. The care plan directed the staff to administer treatments as ordered, even though there were no physician orders for pressure ulcer treatments. The care plan directed staff to frequently reposition resident #11. Review of resident #11's nutritional evaluation form dated 7/6/26 showed resident #11 had wounds, and the resident was to be getting a protein supplement [Name] 30 ml twice a day. After resident #11 refused to drink the protein supplement, no other protein alternative was offered for nutrition and wound healing.Review of resident #11's physician progress note dated 7/21/26 showed the physician recommended an airbed to offload pressure to the resident's body and help with frequent position changes. The air mattress was not applied until 8/19/26.During observation and interview on 8/17/26 at 2:18 p.m., resident #11 stated I did not know this when I was admitted , but the staff should have been turning me every two hours to get me off (pressure relief) my butt. Resident #11 stated his wounds have gotten really bad because he did not get any treatments on his butt, and he said he did not get turned and repositioned. Resident #11 said the night shift staff told him that he could call them to have them come turn him. Resident #11 said he did not stay awake watching the clock, so he could remind the staff to do their job. Resident #11 said there was a care plan meeting after he was re-admitted . Resident #11 said the Ombudsman was at the facility to advocate for him when he was re-admitted . An air mattress was discussed to help heal the pressure ulcer and to prevent more wounds from developing. Resident #11 had physician orders dated 8/14/26 for an air mattress to be applied to his bed day and night. Resident #11 stated he had very specific eating habits, discussing what he would eat and what he was not going to eat. Resident #11 stated the food at the facility was not healthy for his lifestyle. Resident #11 said he does not routinely eat sweets, carbohydrates, white bread, pasta, potatoes, and rice. Resident #11 said he had not been eating much while a resident there. Resident #11 was lying on a regular mattress, not the air mattress as ordered by the physician. Resident #11 did not contribute any of his pain to the pressure ulcer. During an interview on 8/17/26 at 8:30 p.m. staff member G said when resident #11 first came to the facility, the nurse would wash the resident's wound with wound spray and pack the wound with loose gauze. When asked, staff member G was unable to find the wound orders for that treatment or show the documentation of those treatments. Staff member G said resident #11's wound had increased in size and depth. Staff member G said the current wound vacuum order was incomplete, and she asked for the order to be fixed since he was readmitted on [DATE]. Four days later, the wound vacuum order was still incomplete, as there were no orders for the wound wash or which sponge type was to be used for the wound dressing (for the wound vac). Staff member G said she would ask for clarification again. During an interview on 8/17/26 at 8:50 p.m. staff member H said there had been one less certified nurse assistant lately, and he was not going to lie, and stated, We don't get the residents turned every hour. I try and prioritize to get resident #11 turned, but it doesn't always happen on schedule.During an observation and interview on 8/18/26 at 10:05 a.m., resident #11's pressure ulcer was observed during the wound vacuum dressing change to the ulcer. The wound had already been measured and washed. The wound extended into the resident's skin and muscle. Staff member I said the wound was difficult to measure because the skin could be moved and stretched, causing inaccurate wound measurements. During an interview and observation on 8/18/26 at 12:38 p.m., resident #11's lunch tray was sitting on the overbed table. The meal consisted of a large portion of spaghetti with meat sauce, which was untouched. Resident #11 said he would have to get a snack because he doesn't eat pasta. Resident #11 said the staff did not offer him an alternative meal. Resident #11 said he had a protein drink at the hospital that was tolerable, but the little cup of protein liquid the facility provided was foul, and he could not drink it. Due to this, the facility was asked to reweigh resident #11. During an interview on 8/18/26 at 4:59 p.m., NF1 said resident #11 told her that he did not get out of bed for the first 11 days he was at the facility. NF1 said resident #11 was transferred to the local hospital on 7/21/26. Upon admission to the hospital, NF1 said his wounds had deteriorated and became one large Stage IV 10 cm pressure ulcer, which was almost extending to the anus. The wound was infected. A scraping was done at the hospital to see if resident #11 had osteomyelitis (infection). NF1 said she could not remember the results of the culture, but resident #11's wound caused him to receive intravenous antibiotics while in the hospital. NF1 said this wound is potentially fatal for him. During an observation and interview on 8/19/26 at 12:40 p.m., resident #11 had an air mattress placed on his bed, which was not there the prior day during the observation. Review of the resident's record showed there was a 5-day delay in providing the air mattress to resident #11's bed. Resident #11 said the mattress was just placed today, and he said he didn't know if he liked it yet, but it was there for helping to heal the wounds.During an interview on 8/19/26 at 1:03 p.m., NF6 said resident #11's wound definitely deteriorated when he was at the facility. NF6 said she was aware resident #11 failed to have any treatments completed from admission until 7/6/26, which is when I saw the resident and the wound for the first time. NF6 said she was able to restage (determine severity) and measure the wound after removing the eschar from it.During an interview on 8/19/26 at 5:30 p.m., staff member P said NF6 had discussed issues regarding the facility's inability to manage some of their systems, and NF6 told staff member P the correct wound dressings were not available, and the nursing staff would use whatever they could find for a dressing. The wound care was not being completed per physician orders. Staff member P said he and NF6 discussed the corporation making decisions, and the facility being micromanaged, and the facility was unable to get the wound dressings and treatments the physician ordered. Staff member P said the wound management system was just one of the many issues at the facility. A review of the facility's Policy and Procedure titled Skin Integrity, which was dated March 2026, showed:2. Upon admission, the licensed nurse (LN) establishes a plan of care based on risk factors or presence of wound.3. Ongoing evaluation continues weekly with the LN completing a full body skin audit, Completion of the skin audit is documented on the treatment administration record with their initials.4. b. The following skin integrity issues are evaluated and documented weekly on the Weekly Wound Evaluation. i. Pressure injuryii. Surgical wounds.d. Notifies the medical provider and, if needed, obtains a treatment order and documents on the TAR after order is implemented.g. Implements interventions and documents on the resident's care plan and, as appropriate the Kardex.Based on the policy, the review of resident #1's medical record reflected that the policy was not followed, as resident #11's Stage II pressure ulcer and the deep tissue pressure injury did not have treatment orders, and the wound had been present since admission. There were no progress notes showing the nurses assessed the wound(s) as needed, implemented preventative interventions timely, or requested treatments timely.

Based on observation, interview, and record review, the facility failed to routinely monitor and document a resident's weight in the resident's record, failed to ensure comprehensive nutritional assessments were completed timely to analyze and evaluate related factors for a severe weight loss, and failed to revise a resident's care plan to prevent an avoidable weight loss for 1 (#11) of 7 sampled residents. Resident #11 had a severe 13.5% weight loss in the last two months, and 12.6% in the last month. Findings include: During an observation, interview, and record review on 8/17/26 at 2:18 p.m., resident #11 was lying in bed with his lunch tray on his overbed table. Resident #11 said he believed that sugar feeds cancer, so he attempted to avoid sugar, white bread, potatoes, pasta, and desserts. The food remaining on his tray included 100% of his spinach, bun, and cake; 20% of his pork roast; and 80% of fried potatoes. The resident ate roughly 25 percent of his meal. When checked later, the staff failed to document any meal consumption for resident #11's noon meal in the medical record.During an observation and interview on 8/18/26 at 12:38 p.m., resident #11 had a plate of spaghetti and meat sauce, untouched, on his overbed table. Resident #11 said he did not eat pasta. Resident #11 said the staff did not offer him anything else to eat for lunch. Staff documentation showed resident #11 ate 51-75% of his meal, even though it was observed that he did not eat the meal. Resident #11 said his friends brought him some snacks he could eat if he was hungry. During an interview on 8/19/26 at 2:40 p.m., staff member K said she did not bring resident #11 his lunch tray yesterday or today, but knew he did not eat any lunch yesterday. Staff member K said the meal that day was chicken and a biscuit, which he did not eat. Staff member K said she did not offer him anything else (alternative) from the kitchen, even though other food was available. Staff member K said she thought a friend might have brought him some food. During an interview on 8/19/26 at 2:58 p.m., staff member M stated she did not offer resident #11 anything else to eat when he did not eat the food from the kitchen. Staff member M said resident #11 had some food at his bedside that his friends brought him.During an interview on 8/19/26 at 2:58 p.m., staff member M said she would not be surprised if resident #11 had lost weight. Staff member M said resident #11 did not eat much. Staff member M said she did not offer him a substitute for the spaghetti meal he did not eat, but she knows he had snacks and food in his room.Review of resident #11's meal documentation showed he ate 50% of his lunch on 8/18/26; however, surveyor observation and an interview with staff member M showed resident #11 did not eat any lunch on 8/18/26. For the six days of meal documentation between 8/13/26 and 8/18/26, the percentage of meals documented showed the resident's average intake was 51 to 75% of his meals. During an interview on 8/19/26 at 5:30 p.m., staff member P said he was very concerned about the residents not being weighed at the facility. Staff member P said he had discussed residents not being weighed with facility management, but it seemed like it was still not getting done. Staff member P said nothing had been done to correct the issues with weights or weight loss prevention. When interviewed on it, staff member P stated a lack of awareness of resident #11's thirty-six-pound (13.5%) severe weight loss, due to a lack of facility notification. Review of resident #11's vital sign weight sheet, which was current as of 8/19/26, showed resident #11 was admitted weighing 271 pounds. On 7/7/26, resident #11 weighed 268.2 pounds. When resident #11 was re-admitted to the facility on [DATE], the resident was not reweighed. Due to the amount of food observed uneaten by the resident, his comments, and staff comments, a reweight was requested by the surveyor. The reweight results showed resident #11 weighed 234.4 pounds, which was a severe loss of 36.6 pounds. Review of resident #11's Nutrition Evaluation Form dated 7/6/26 showed the weight changes were not assessed and completed. The note showed there was a potential weight loss history. Even though resident #11 was alert and oriented, the questions the resident could answer were not completed. The form was unmarked for cultural or religious food preferences. During the interview on 8/17/26 at 2:18 p.m., resident #11 was very quick to share his food preferences, and he believed what he ate affected his cancer, but this was not reflected on the evaluation. No nutrition, hydration problems, or interventions were checked. The resident's care plan for nutrition would have been generated from the 7/6/26 nutrition assessment form after it was signed.During an interview on 8/20/26 at 11:00, staff member B said the dietitian had not reassessed resident #11 for weight loss because his assessment was not due for the MDS to be completed yet, even though the resident had an identified severe loss.

Based on interview and record review, the facility staff neglected to provide the necessary services to ensure residents were free from emotional or verbal abuse or neglect of care for 2 (#7 and 50) of 7 residents. Both residents had ongoing emotional distress from the care the facility staff provided/did not provide. Findings include:1. During an interview on 8/18/26 at 5:30 p.m., resident #7 stated the following concerns to the surveyor related to neglect of care and emotional abuse:a. She had been at the facility for three long days. Resident #7 said she begged her family and the facility to send her to the hospital because she felt like she was neglected at the facility. Resident #7 said she was admitted to the facility from a local hospital and was to be given oxygen at 2 liters per minute. Resident #7 said the facility brought in two oxygen machines, and both machines made a terrible screeching noise. There was no working oxygen machine, and the resident had to go without oxygen for the day. NF2 said the staff did not assess her oxygen level while she was not using the oxygen. NF2 said it was the next day before the facility supplied oxygen to fulfill the physician's order. Review of resident #7's medication administration record and treatment administration record for August 2026 showed an order for oxygen from 0-5 liters per minute via nasal cannula to keep saturations over 90 percent, as needed, for shortness of breath. There was no documentation on the treatment record showing the resident's oxygen was administered.A review of resident #7's nurse's progress note, on admission, with a date of 8/1/26 at 11:33 p.m., showed the reason for admission and skilled services was nephrolithiasis, urinary tract infection, ureteral stent placement, and sepsis. The note showed a physician order for oxygen at 0 to 5 liters per minute to maintain saturation over 90%. Resident #7 voiced shortness of breath when lying flat.b. Resident #7 said she rang her call light to use the bathroom. She said the CNA who got her into the bathroom rudely told her it was a busy time because the food trays had to be passed to the other residents. NF2 said she thought she would be nice to the staff, so she sat in the bathroom for a long time so staff could get the meals passed for the other residents. NF2 said the second aide who got her out of the bathroom was also nasty (in the way she was treated) as well. NF2 said she sat on the bed and cried after that.c. Resident #7 said she wanted to use her call light to have the staff assist her. Resident #7 said she could not find the call light. The call light was draped on the chair across the room, and the push button end was stuck between the chair cushions. Resident #7 said she used her cell phone to call her sister to try to get help. Resident #7 said her sister called the facility but was unable to reach anyone via telephone. Resident #7's sister ended up coming to the facility to check on resident #7 to ensure she was safe.d. Resident #7 said she asked if she could go onto Hospice care, because she would rather not live than be at the facility where she felt neglected and abused. Resident #7 said one night she went to the bathroom and her legs gave out. NF2 said she did not fall all the way to the floor; however, she leaned against the wall in a squatting position. Resident #7 said the male CNA assisted her up by physically lifting her and then argued with her, telling her she did not fall.e. Resident #7 had voiced being scared at the facility. Resident #7 said a nurse came into her room and said, You don't remember telling me last night that you were not scared? NF2 said I did not tell anyone that, because I was still scared. NF2 said she cried and told her sister she was afraid the facility was going to kill her. Resident #7 said she also received orange juice on her tray, and she was allergic to citrus.f. During this interview, resident #7 was sobbing. Resident #7 said she would rather be dead than live there. Resident #7 said she had PTSD from being in the facility. Resident #7 said she still cried frequently and woke up in the middle of the night with nightmares. Resident #7 said she was trying to find a counselor who would do home visits to help her deal with the PTSD, related to her stay.During an interview on 8/18/26 at 6:00 p.m., NF3 said he talked to resident #7 on the telephone one night while she was a resident at the facility. NF3 said resident #7 was crying hysterically and was frantic about going onto Hospice care to get out of the facility. NF3 said he and his family were very concerned. Resident #7's fear and anxiety prompted NF3 to make an immediate trip to Montana to ensure resident #7 was safe.During an interview on 6/18/26 at 6:15 p.m., NF4 said the facility staff yelled at resident #7, and neglected her. NF4 said the facility staff promised anything (to her) to calm resident #7 down but backed out of their deal. NF4 said resident #7 had severe nightmares since her return home, causing her emotional distress and lack of quality sleep. NF4 said he was working with Adult Protective Services to try and find a counselor that could see resident #7 at her home due to her being homebound and her ongoing distress. During an interview on 8/18/26 at 10:26 a.m., NF2 stated she had seen resident #7 a couple of times and had talked with her and her family. NF2 said she thought resident #7 still showed signs of PTSD, she cried and continued having nightmares due to her stay. NF2 said she gave the resident's family contact information for several therapists who may be able to do home visits or video calls with the resident. NF2 said she was very worried about resident #7's emotional and physical health, as resident #7 needs quite a bit of nursing-type care.During an interview on 8/19/26 at 5:30 p.m., staff member P said resident #7 had been a patient in the clinic for about seven years. Staff member P stated, I asked the facility to look into what was going on at the facility and who had been mean to resident #7. Staff member P said he had not heard anything back from the facility. Staff member P said resident #7 does not have any dementia, and she told me the events of what happened, and she had no reason to not tell the truth when I asked. Staff member P said resident #7 told him she fell against the wall into a squatting-like position, and the staff member argued with her about the incident. Staff member P said resident #7 told him she changed planes (level/position of her body) and that it would be considered a fall. Staff member P said the resident is not new to healthcare due to her illnesses. Resident #7 told staff member P she was afraid for her life and for herself at the facility. Staff member P said resident #7 was one of the nicest people you would ever meet and would be very reasonable about her care. Review of resident #7's MDS, with an ARD of 8/2/26, showed the resident had a BIMS score of 14; cognitively intact. Review of resident #7's mood interview showed she had feeling of hopelessness and feeling down. Resident #7 also reported she had little energy, had a poor appetite, and spoke or moved so slow that others would have noticed. The score on the mood interview (PHQ-9, Patient Health Questionnaire) was a 12, reflecting that resident #7 had a severity score of moderate depression. Review of resident #7's nursing progress note dated 8/2/26 at 7:04 p.m. showed the resident and her daughter voiced concerns about the resident not being treated well by the day shift staff and that her call light was not placed where she could reach it. The nurse offered resident #7 and her daughter a grievance form. Resident #7 and the daughter said no; they would not fill out the form because they did not want retaliation to occur against them. Review of the facility's investigation documentation for the 8/1/26 Facility-Reported Incident, which was reported to the State Survey Agency, showed the facility communicated with resident #7's family, and the consensus was that the family was satisfied with the care being provided. The facility spent time clarifying the resident's/family's preconceived expectations. No information was included on the report about the resident's fall in the bathroom.2. During an interview on 8/17/26 at 2:00 p.m., staff member C said the staff must do cares in pairs with resident #50 because none of the staff wanted to get into trouble because resident #50 might say something that, We would need a witness to. Staff member C said resident #50 was mad at her because she thought, I called her fat. Staff member C said she told resident #50 she was too heavy (in weight) for her to reposition. However, there were three staff members in the room at the time, and as a team, the resident was lifted and repositioned with a mechanical lift. Staff member C said she could have used kinder words and could have been nicer to resident #50. During an interview on 8/17/26 at 3:25 p.m., staff member E said resident #50 received care in pairs (two staff assisting) even when her call light was answered. Staff member E said she heard staff member C tell the resident that she could not pull her up in bed and stated, Do you know how much you weigh? Staff member E said staff member C told resident #50 that lifting her legs was like moving cinder blocks.During an interview on 8/17/26 at 3:50 p.m., resident #50 said staff member C said some mean and hurtful things to her. Resident #50 said she did not even report all the times staff member C said mean things about her. Resident #50 said staff member C said, If you were not so heavy, you could have met a man and got married, and things would have been different for you. Resident #50 said she had anxiety, and this made her more anxious. Resident #50 said none of the other staff treat her like that. Resident #50 said she felt verbally abused, and it caused her hurt feelings. Resident #50 said she thinks about the encounter quite often, and it made her anxiety worse.A review of the facility's investigation documentation for the Facility-Reported Incident dated 8/1/26 for resident #50, showed the facility investigated the allegations of verbal/emotional abuse. The staff member admitted to saying insensitive words about resident #50's weight, but reported she did not mean for it to hurt the resident's feelings.

Based on interview and record review, the facility failed to ensure staff had the competencies and skills to identify, assess, document, and apply a wound vacuum for 1 (#11) of 7 sampled residents. This increased the resident's risk of infection and was a contributing factor for his hospitalization. Findings includeA review of resident #11's admission skin assessment dated [DATE] at 3:20 p.m. showed resident #11 had a 1.5 cm by 0.4 cm by 0.2 cm deep Stage II pressure ulcer to the left gluteal fold. Resident #11 also had a deep tissue pressure injury to his left buttocks. The Stage II pressure ulcer measured 5.8 cm by 3.4 cm, and the depth could not be determined because the wound bed was necrotic.Review of resident #11's June 2026 treatment administration record showed no treatments were being done for the two pressure ulcers, one to the left gluteal fold and one to the left buttocks. Review of resident #11's July 2026 treatment administration record showed a treatment for the two pressure ulcers was not started until the wound doctor saw resident #11 on 7/7/26.During an interview on 8/17/26 at 8:30 p.m. staff member G said when resident #11 first came to the facility the nurse would wash the resident's wound with wound spray and pack the wound with loose gauze. When asked, staff member G was unable to find the wound orders for that treatment or show the documentation of treatments. Staff member G said resident #11's wound had increased in size and depth. Staff member G said the current wound vacuum order is incomplete, and she asked for the order to be fixed since he readmitted on [DATE]. Four days later, the wound vacuum order was still incomplete. Refer to F686 for more detail on the resident's wounds and care. Staff member G said she would ask for clarification again. During an interview on 8/18/26 at 4:43 p.m., staff member B said NF6 started a wound education session but did not finish it due to the physician's other obligations. Staff member B said the staff saw the wound vacuum itself, but there was no return demonstration of it's use. During an interview on 8/19/26 at 1:03 p.m., NF6 said she came to the facility once a week to complete wound rounds. NF6 said resident #11's pressure ulcer definitely deteriorated while he was at the facility due to lack of care. NF6 said the resident had not received any wound care from 6/26/26 until 7/6/26 when she assessed and performed wound care. NF6 said the facility failed to get physician orders for wound care when he was admitted on [DATE]. NF6 said usually wound orders are given by the discharging hospital, but in the absence of wound care orders, she would expect the facility nursing staff to call her to initiate treatment. NF6 said the resident told her he had not been repositioned off his back for days after admission. NF6 said the deep tissue injury for resident #11 would evolve, and it would get worse before it got better. NF6 said she repeatedly talked to the director of nursing about the multiple resident wound dressings not being changed and wounds not healing. NF6 stated, There seems to be several patient harm events that the director of nursing does not do anything to correct. NF6 said she is aware of the nursing staff not following orders and putting on whatever dressing they chose, or a wound dressing they were able to find. NF6 said the nurses told her the facility ran out of supplies or they were not able to get specific dressings which were ordered. NF6 said the facility nursing staff were not always able to follow her orders because of supply issues. NF6 said she suggested the facility not take some residents with complicated wound care due to the concerns surrounding wound care. NF6 said resident #11 may not be getting the care he needs because there is a deficit when it comes to the nursing staff's knowledge of wound vacuum dressings/changes. NF6 said she attempted to give an in-service at the facility but did not demonstrate a wound vacuum application. NF6 said the Director of Nursing did not seem to know wound care at all and that bothered NF6 a lot.During an interview on 8/20/26 at 8:43 a.m., resident #11 said the wound vacuum was not working during the night. Resident #11 said the dressing was not sealed, and it would not have any suction. Resident #11 said he told the night shift nurse, staff member O. Resident #11 said staff member O would not fix the dressing. Resident #11 said staff member O said the day shift can fix the wound vacuum and change the dressing when they get there that morning, so the dressing remained in place and not properly placed on the wound. A request was made for licensed nurse competencies for treating wounds with a wound vac on 8/19/26 at 4:05 p.m. for staff members: F, G, I, O, and Q. By 8/20/26 at 11:16 a.m., at the end of the survey, no wound vacuum competencies were provided.

Based on interview and record review, the facility failed to complete a baseline care plan, which provided instructions needed for the provision of personalized resident-centered care for 1 (#11) of 7 sampled residents. The failure to have a baseline care plan placed the resident at risk of not being provided care to meet the increased needs of his pressure wound. Findings include:Review of resident #11's electronic medical record showed an admission date of 6/26/26, and the baseline care plan was not completed within 48 hours of the resident's admission. A review of Resident #11's medical diagnoses showed the resident was admitted with metastatic prostate cancer, post-operative tumor removal with incision, vertebral bodies with extradural mass, pulmonary nodules, pressure injuries, and spinal cord compression. The baseline care plan would be important to ensure the resident's pain, skin, and nutritional interventions were in place for necessary care and services. Review of resident #11's admission skin and wound evaluation dated 6/26/26 at 3:20 p.m. showed three skin concerns. Resident #11 had a surgical wound on the back of his neck, and the sutures were intact. The incision was 10 cm long and 0.4 cm wide. The evaluation showed wound number 2 as a pressure injury to the center/left of resident #11's gluteal fold. The pressure ulcer measured 1.5 cm by 0.4 cm by 0.2 cm deep. The wound was identified as a Stage II pressure ulcer. The note also showed the resident did not like to lie on his right side due to shoulder pain. Resident #7's third wound was identified as a pressure injury on his left buttocks. The wound measured 5.8 cm by 3.4 cm, and the depth could not be determined because of a necrotic wound bed. Review of resident #11's baseline care plan for activities of daily living was initiated on 7/3/26, seven days following his admission to the facility. The care plan identified resident #11 as requiring maximum assistance with turning in bed. The baseline care plan did not include care management details for the surgical incision on resident #11's neck or the limitations necessary to keep his spine in alignment. The care plan failed to identify the need to keep the surgical incision dry until after the sutures were removed and did not direct how often staff should reposition the resident or show what positions should be avoided due to the resident's pressure ulcers. The post-operative care intervention for the spinal surgery had not been added until seven days after the resident's admission. The sutures and incision care were not addressed on the care plan. The resident's pressure ulcers were not addressed on the care plan until 7/3/26, ten days after his admission. The care plan did not identify treatments for the wounds, and it failed to show the resident had shoulder pain and could require medication for pain before repositioning him onto his right side. Lastly, the baseline care plan nutrition section, other than his use of dentures, was not started until 7 days post-admission and failed to identify and direct the staff to encourage extra nutrition needed due to the resident's pressure ulcers. A review of resident #11's medical record showed he was discharged to the local hospital on 7/21/26. Resident #11 returned to the facility on 8/13/26.During an interview on 8/17/26 at 2:18 p.m., resident #11 said the facility used the mechanical lift to transfer him because he could not feel his legs well enough to stand on his own. Resident #11 said he does not use his dentures, and the dentures are not even at the facility. Resident #11 said he had to all but beg to get sent to the hospital in July 2026. Resident #11 said he was admitted to the hospital because the facility ran out of his morphine for pain management. Resident #11 said he had his last scheduled morphine, but there was none available if he had pain during the night, and this was worrisome for him. Review of resident #11's care plan for his re-admission on [DATE] showed the plan had been cancelled. The care plan for enhanced barrier precautions, pressure wound infections, skin integrity, foley catheter care, and psychosocial well-being was not care planned until 5 days after his readmission, on 8/18/26. Due to the indwelling Foley catheter use, and two pressure ulcers, the enhanced barrier precautions would be applicable to help to keep bacteria from the resident's wounds, which were already infected, and prevent staff from infecting others with the bacteria from the infection.Resident #11's care plan did not direct the staff on resident preferences for positioning or repositioning him, and his desire for the staff to not wait for him to ask to be repositioned. Resident #11 did not have the following added to his care plan for five days after his readmission: - A dietary/nutritional care plan, even though he had pressure ulcers and a recent surgical procedure. - The sacral wound and wound infection. - Enhanced Barrier Precautions for the wounds and Foley catheter. During an observation on 8/18/26 at 10:05 a.m., wound care was observed for resident #11's sacral wounds. The three staff members (E, I, and K) in the room caring for the resident failed to use enhanced barrier precautions when in close contact with the resident and when changing the wound vacuum dressing. The readmission baseline care plan had not been initiated at the time of the observation. The enhanced barrier care plan was not added until sometime during the day of 8/18/26. During an interview on 8/18/26 at 4:43 p.m., staff member B said the MDS and care plans are done by the MDS nurse. The care plans can be updated or added to at any time.During an interview on 8/19/26 at 2:58 p.m., staff member M said the staff used a daily cheat sheet form with some resident information on it. Staff member M said, I don't think it is as complete as the care plan. The nurses try to keep the cheat sheet current and do a pretty good job, but the Kardex which is for the CNA's, comes off the care plan but is not always current. Staff member M said they try to keep it current.

Based on interviews, observations, and record review, the facility failed to ensure the food served accommodated the resident's preferences and the options were of similar nutritive value for 1 (#11) of 7 sampled residents. The failure to provide adequate nutrition may contribute to a resident's weight loss and deterioration in wound status. Finding include:During an interview and observation on 8/17/26 at 2:18 p.m., resident #11 discussed his thoughts and beliefs about nutrition and diets, and how they affect the body and his cancer. Resident #11 said he had completed research and found that eating lots of sugar in his diet would negatively affect his cancer, causing the cancer to feed off the sugar, and the cancer would grow. Resident #11 said he tried hard not to eat sugar or refined carbohydrates (pasta, white bread, cakes, desserts, or potatoes). Resident #11 said carbohydrates turn into sugar and feed cancer. Resident #11's meal tray was sitting on his overbed table. The meal consisted of pork roast, fried potatoes, spinach, a white bun, and yellow cake with whipped cream on top. Resident #11 ate approximately 20 percent of his pork and his potatoes. No other substitutes were offered to ensure he received a nutritious meal. During an observation and interview on 8/18/26 at 12:38 p.m., resident #11 was sitting up in bed with his meal tray at his bedside. The meal tray consisted of a large portion of pasta with some marinara and meat sauce. The resident again said he does not eat pasta, but the staff must not pay any attention to his preferences. Resident #11 ate none of his lunch meal.During an interview on 8/19/26 at 2:40 p.m., staff member K said she did not bring resident #11 his lunch tray that day or the day before, but knew he did not eat any lunch yesterday. Staff member M said the meal on 8/19/26 was chicken and a biscuit, which he did not eat. Staff member K said she did not offer him any alternatives from the kitchen. Staff member K said she thought a friend might have brought him some food today.During an interview on 8/19/26 at 2:58 p.m., staff member M stated she did not offer resident #11 anything else to eat when he did not eat the food from the kitchen. Staff member M said resident #11 had some food at his bedside that his friends brought him.Review of resident #11's Food Preferences Record, dated 6/29/26, showed N/A and lettuce for his dislikes, and N/A for dietary goals. The assessment had no additional comment notes, even though resident #11 was very willing to share his dietary preferences and choices with the surveyor during his interview on 8/17/26 at 2:18 p.m. Refer to F692 for the resident's weight loss and nutritional information.

Based on interview and record review, the facility failed to notify a resident's physician of a change in condition related to the resident's significant weight loss for 1 (#11) of 7 sampled residents. This deficient practice resulted in the physician not being provided with timely information or having the opportunity to evaluate and consider nutritional interventions. Findings include:Review of resident #11's vital signs weight sheet, as of 8/19/26, showed resident #11 was admitted weighing 271 pounds. On 7/7/26, resident #11 weighed 268.2 pounds. When resident #11 was re-admitted to the facility on [DATE], the resident was not re-weighed. Due to the limited amount of foods the resident was eating, a reweight was requested by the surveyor. Resident #11 weighed 234.4 pounds, which showed a severe loss of 36.6 pounds. During an interview on 8/19/26 at 5:30 p.m., staff member P said he was very concerned about the facility residents not being weighed routinely. Staff member P said he attended the facility quality assurance and performance improvement meetings. Staff member P said he discussed the process for resident weights and the fact that residents were not being consistently weighed with facility management. Staff member P said even after the discussion with the Director of Nursing and Administrator, residents were still not getting their weights measured routinely. Staff member P said nothing had been done to correct the issues with weights or for weight loss prevention. Staff member P said he had not been made aware of resident #11's thirty-six-pound (13.5%) severe weight loss over the two months and had not reviewed or made any changes in the resident's diet or nutritional plan due to his lack of awareness. Review of resident #11's Nutrition Evaluation Form dated 7/6/26 showed the weight changes were not assessed and marked with a yes or no. The note showed there was a potential weight loss history. Even though resident #11 was alert and oriented, the questions the resident could answer were not completed. The form was unmarked for cultural or religious food preferences. No nutrition, hydration problems, or interventions were checked on the nutrition evaluation form. The resident's care plan for nutrition would have been generated from the 7/6/26 nutrition assessment form after it was signed.During an interview on resident #11 was very quick to share his food preferences, and he believed what he ate affected his cancer.

Based on interview and record review, the facility failed to implement and maintain a water management program for the prevention of waterborne pathogens in accordance with CDC guidance for 1 (#6) of 20 sampled and supplemental residents. Environmental testing identified Legionella bacteria within the facility's water system after resident #6 was diagnosed with Legionnaires' disease. The facility's failure to implement and maintain its water management program placed all residents at increased risk for exposure to waterborne pathogens. During the survey, it was found that the facility had previously identified, investigated, and corrected the non-compliance for the water management system, resulting in findings of Past Non-Compliance. Findings include:During an interview on 6/28/26 at 5:15 p.m., staff member G stated he had worked at the facility for approximately one year and had learned the facility's water management activities on the job. Staff member G stated the facility's Legionella prevention measures included weekly flushing of toilets in unoccupied resident rooms and weekly water temperature monitoring throughout the facility. Staff member G stated a resident became ill in March 2026 and was subsequently diagnosed with Legionnaires' disease.During an interview on 6/29/26 at 7:34 a.m., staff member A stated the facility was notified on 3/18/26 that resident #6 tested positive for Legionella. Staff member A stated the facility had been flushing areas at risk for water stagnation; however, the facility's water management practices were not following public health guidelines. Staff member A stated the facility subsequently contacted the local public health department for guidance.Review of resident #6's provider note, dated 4/1/26, showed resident #6 was hospitalized on [DATE] with acute hypoxic respiratory failure related to Legionnaires' disease. Corrective MeasuresReview of facility's maintenance documentation showed the facility obtained consultation from NF5, NF6, and NF7 between 3/19/26 and 3/31/26 to evaluate the building water system and provide recommendations to reduce the risk of Legionella. The facility revised its water management program based on current public health guidance, implemented ongoing environmental water monitoring, and provided staff education regarding the revised procedures.Review of the facility's QAPI meeting minutes dated 3/25/26 through 5/19/26 showed the committee monitored implementation of the revised water management program, reviewed environmental testing results, and discussed ongoing monitoring activities.Review of the facility's environmental testing records showed follow-up water samples collected through 5/12/26 were negative for Legionella.The surveyor determined the facility completed corrective actions before the survey, implemented its revised water management program, and maintained ongoing environmental monitoring. Follow-up environmental testing remained negative for Legionella, verifying the findings of Past Non-Compliance, as the deficient practice had been corrected prior to the survey.

Based on interview, observation, and taste testing of food served by the facility, the facility failed to provide food at a palatable and appetizing temperature for 5 (#s 14, 28, 40, 48, and 52) of 20 sampled and supplemental residents. This deficient practice affected the residents' nutrition, weight management, and quality of life. Findings include:During an observation and interview on 6/27/26 at 12:31 p.m., resident #52's food was placed uncovered on the dining room table. Resident #52 got to the dining room and began eating at 12:36 p.m. When asked if his food was hot, resident #52 said no, not his French fries. During an observation and interview on 6/27/26 at 12:42 p.m., resident #48 was observed sitting at the dining room table. A staff member was observed bringing resident #48's food tray into the dining room from down the hall toward the E hall nurses station. Resident #48 stated, no, my food was not hot. She was served a Philly cheesesteak sandwich and French fries.During an interview and observation on 6/27/26 at 1:14 p.m., resident #28's food tray was sitting on her bedside table. She had been served French fries and a Philly cheesesteak sandwich. Resident #28, said no, her food wasn't hot today and was often not hot. She said, I eat what I can, but it does prevent me from eating well.During an interview on 6/27/26 at 1:32 p.m. resident #40 stated she knew she could ask for other food or it heated up, but she did not want to inconvenience the staff. Resident #40 said the French fries were cold today and when eggs are served for breakfast, the eggs are always cold.During an interview on 6/27/26 at 2:58 p.m., resident #14 said the food was usually cold by the time it was delivered to her room. Resident #14 said if she doesn't like the food or the food was too cold, she just does not eat it. Resident #14 said she had lost weight in the last six months and she said weight loss was partly due to the food served and partly her choice to lose weight.During observation and an interview on 6/28/26 at 7:32 a.m., the meal cart for the 200 rooms left the kitchen. A meal tray was requested for a sample, with the tray to be the last served from the kitchen and the last delivered off the cart. Between 7:32 a.m. and 8:01 a.m., the food delivery cart was noted to have the doors open and closed many times. The tray was delivered to the conference room at 8:01 a.m. by staff member P. The meal consisted of a bowl of oatmeal with a scoop of brown sugar, one fried egg, and a factory-wrapped blueberry muffin. The oatmeal tasted hot and appetizing. The fried egg was cold and was not appetizing. Staff member P said she was aware some residents had complained about cold food.During an interview on 6/28/26 at 11:25 a.m., staff member H said she was aware there had been some cold food complaints.During an observation and interview on 6/28/26 at 1:06 p.m., staff members K and M brought a sample tray to the conference room. The food was cabbage, pork roast, roasted potatoes, and corn bread. The food was sampled and the temperature of all the food was barely warm to the taste. Both staff members K and M said they have had residents complain of cold food. Staff member M, who routinely worked the day shift, said the residents complained about cold food. Staff member M said getting the food reheated was a lot of trouble as the tray had to go back to the kitchen. Then the kitchen staff had to reheat it and take the food temperature, so residents didn't get burned. Staff member M said the food was only reheated for the residents who asked for their food to be warmed.

Based on interview and record review, the facility failed to maintain documentation of the COVID-19 vaccination status (received or refused) for one staff member (staff member M) of 2 sampled staff for COVID-19 vaccination status. Findings include:During an interview on 6/28/26 at 4:57 p.m. staff member M stated the facility offered COVID-19 vaccinations to employees. Staff member M stated she declined the initial COVID-19 vaccination series and did not recall if the facility had offered her the latest booster vaccination. Staff member M stated she did not remember if she signed a declination form for additional booster vaccinations the facility offered.During an interview on 6/29/26 at 7:34 a.m., staff member A stated the facility had a health fair in February or March of 2026 in which COVID-19 vaccinations were offered to all employees. Staff member A stated the facility could not find documentation showing which employees had received or refused the COVID-19 vaccination.A written request was submitted to the facility for staff member M's COVID-19 consent or refusal documentation on 6/28/26 at 1:55 p.m.; no documentation was received from the facility by the end of the survey on 6/29/26.Review of the facility's policy titled Prevention and Management of COVID-19 in Long Term Care, revised 9/6/23, showed: . DOCUMENTING COVID-19 VACCINE:1. The center will maintain documentation for all residents and staff on COVID-19 vaccination and recommended boosters.2. For staff, the information will be documented thru the [Facility name] Consent or Declination maintained in their employee health file. 4. The information to be documented includes:a) The staff, resident, or representative was provided education regarding the benefits and potential risks associated with COVID-19 vaccine.b) Whether the staff, resident, or representative consented to the vaccine.i) If yes:(1) Which vaccine was administered(2) Which dose was administered(3) Date of vaccinationii) If no, reason for refusal:(1) Contraindication(2) Refusal. [sic].

Based on interview and record review, the facility failed to protect the resident's right to be free from neglect for a resident who was dependent upon staff for incontinence care, resulting in the resident not receiving the necessary incontinence care for an extended period. The failure placed the resident at risk for skin breakdown, infection, pain, discomfort, loss of dignity, and psychosocial distress, for 1 (#18) of 7 residents sampled for abuse and neglect. Findings include:Review of a Facility-Reported Incident submitted to the State Survey Agency on 6/2/26 showed an allegation of neglect involving resident #18. The report alleged resident #18 remained soiled throughout an entire shift after required incontinence care was not provided. The facility's investigation findings showed, Although the resident did not voice concerns about the care, nine staff interviewed indicated the employee was not completing assigned duties. The employee provided a statement indicating he did not provide care for the resident. This employee was terminated on 6/5/26.During an interview on 6/27/26 at 2:50 p.m., resident #18 recalled the day staff member NF4 was assigned to provide care, stating, Of course I remember. That guy did not change me once. The last time I was cleaned up was by the night shift before they left . The other CNAs cleaned me up late in the afternoon. What a mess.During an interview on 6/28/26 at 9:33 a.m., staff member A stated resident #18 was hit and miss with using the call light, required care in pairs because of behaviors, and was almost continuously incontinent of urine. Staff member A stated the CNAs all knew resident #18 required changing every one-to-two-hours as she couldn't always tell she was wet, and often wouldn't call for help. Staff member A stated [NF4] did not provide the care for resident #18 as assigned. Staff member A stated NF4's employment was terminated shortly after the incident because of ongoing performance concerns and not exclusively due to the resident neglect. Staff member A stated written documentation of prior performance concerns or corrective actions for NF4 could not be located.During an interview on 6/28/26 at 1:40 p.m., staff member M stated she reported the incident on 6/2/26, after resident #18 pressed the call light and stated she had been left wet since the early morning. Staff member M stated resident #18 . was saturated head to toe. Staff member M stated the facility's CNAs typically made their own assignments and worked in teams and divided the facility into three team assignments. Although staff worked in teams, staff member M stated resident #18 was specifically assigned to NF4. Staff member M stated resident #18 required care in pairs, and another certified nursing assistant would have been required to assist NF4 with the resident's care. Staff member M stated resident #18 depended on staff to recognize and provide incontinence assistance as she had limited awareness of her incontinence at times.During an interview on 6/29/26 at 2:12 p.m., NF4 stated CNA assignments were not always clear, and responsibility for resident care was shared among team members. NF4 stated he was not assigned to resident #18's care on 6/2/26, but he was assisting in her hall. He requested assistance to provide resident #18's required care in pairs; however, the other certified nursing assistants were busy. NF4 stated another team eventually changed resident #18, after which he (the neglect of care) was reported to staff member A and later terminated.During an interview on 6/29/26 at 10:30 a.m., staff member B stated CNAs made their own assignments; some preferred to work individually while others worked in teams, and the current assignment process may have created opportunities for conflicts and missed care.Review of resident #18's care plan intervention, updated 12/3/25, showed, Care in pairs if indicated.Review of resident #18's CNA task list and Kardex showed the resident required care by two staff members as well as checks and incontinence care every one to two hours.Review of resident #18's electronic health record showed incontinence care was documented on 6/2/26 by staff member NF4 during the 9:00 a.m. hour and was not documented again until staff member M documented incontinence care during the 2:00 p.m. hour, despite resident #18's required every one-to-two-hour checks and incontinence care. The documentation contradicted staff member NF4's statement that he had not provided care to resident #18 on 6/2/26.Review of a facility policy titled Prevention of All types of Abuse, Neglect, Mistreatment, Involuntary Seclusion, and Misappropriation of Resident Property, updated October 2022, showed: . e. The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect, such as:i. Verbally abusive behavior .vii. Residents that require extensive nursing care .

Based on interview and record review, the facility failed to ensure thorough investigations of alleged abuse and neglect were completed for 2 (#s 10 and 50) of 7 residents sampled for abuse. This deficient practice could place other residents at risk for abuse and neglect. Findings include:A review of a Facility-Reported Incident submitted to the State Survey Agency on 6/15/26, showed resident #s 10 and 50 made abuse allegations against two different certified nurse assistants.The State Survey Agency event report for resident #50 showed an allegation of abuse and neglect. In the report, resident #50 stated staff member J was mean, rude, and rough when providing perineal care during the night.During an interview on 6/28/26 at 9:15 a.m., resident #50 stated that staff members J and O came into her room to provide care. Resident #50 stated staff member J told her she (the CNA) did not sign up to take care of that kind of mess (incontinent episode). Resident #50 stated staff member O provided care and did a good job. Resident #50 stated she called the certified nursing assistants to her room again at about 5:30 a.m. Resident #50 stated that staff members J and O both responded to the call light. Resident #50 stated staff member J rudely said, This better be your last time tonight (soiling self due to incontinent episode) because I'm clocking out and leaving. Resident #50 stated that these interactions with staff member J made her feel very apprehensive about when help is needed. Review of the facility's investigation file showed the allegation made by resident #50 was not investigated during the facility investigation process, as the complaint was made against staff member J, and staff member J was not interviewed.

Based on interview and record review, the facility failed to notify residents and the residents' representatives in writing, of the reason for the transfer and the required bed hold information for 3 (#s 3, 6, and 56) of 20 sampled and supplemental residents. Findings include:1. Review of resident #56's nursing progress note, dated 5/27/26, showed the resident was transported to the hospital. During an interview on 6/29/26 at 10:20 a.m., staff member B said the nurses completed the initial transfer forms. Staff member B said she was unaware if the discharge or bed hold forms were completed for resident #56. Review of resident #56's electronic medical record failed to contain, and the facility did not produce, a Montana Notice of Bed Hold Policy or the Resident Notice of Transfer or Discharge form. 2. Review of resident #3's Resident Notice of Transfer or Discharge form, dated 3/24/26, showed a verbal acknowledgement was provided to resident #3's guardian on the transfer. The form failed to show which staff member received the verbal acknowledgement and which staff member provided a copy of the notice to the guardian. The Montana Notice of Bed Hold Policy dated 3/24/26 did not have the signature of the facility representative obtaining the verbal consent. Review of resident #3's Resident Notice of Transfer or Discharge form, dated 2/6/26, was missing the name of the staff member who notified the representative regarding discharge. The form showed verbal in the section that was identified as the person receiving a copy of the transfer notice. The form titled Montana Notice of Bed Hold Policy, dated 2/6/26, did not have a resident identified to show which resident was being transferred. The form also did not show the name of the responsible party who had been given the notice. 3. During an interview on 6/29/26 at 1:00 p.m., staff member I stated the nurse was responsible for completing a resident's transfer and bed hold form prior to a resident leaving the facility. Staff member I stated the forms were located at the nurse's station in a white binder. Staff member I stated that a transfer and bed hold form should have been completed for resident #6's transfer on 3/29/26 to an acute care hospital. Review of resident #6's electronic medical record showed that on 3/29/26, the resident was transferred via emergency medical services to an acute hospital due to a productive cough and difficulty breathing. The resident's electronic medical record failed to show that a transfer and bed hold notice had been provided to the resident or a family member at the time the resident was transferred to the acute care hospital. On 6/28/26, a request was made for a copy of resident #6's Notice of Transfer and Bed Hold for the 3/29/26 facility-initiated transfer. No documentation or records were received from the facility by the end of the survey. Review of the facility's policy titled Transfer and Discharge, updated May 2025, showed: POLICY: . 5. When the transfer or discharge is initiated, the resident receives written notice using the Resident Notice of Transfer or Discharge which includes the following items: a. Date notice is given. b. Effective date of the transfer/discharge. c. Reason for the transfer/discharge. d. Where the resident is to be moved. e. Contact information for the State Long-Term Care Ombudsman. Review of the facility's policy titled, Bed Hold, updated May 2025, showed: Policy Statement: The resident and/or resident representative is informed of the Bed Hold Policy in writing upon admission, transfer, or leave of absence (LOA). If unable to provide at the time of transfer or leave of absence, the policy is provided within 24 hours.

Based on interview and record review, the facility failed to ensure prescribed psychotropic medications were administered as ordered for 1 (#51) of 6 residents sampled for medication administration by failing to obtain prescribed medications and failing to notify the physician when the medications could not be administered. The failures placed the resident at risk for increased mental health symptoms and other adverse clinical outcomes associated with interruption of prescribed psychotropic medication therapy. Findings include:Review of a Facility-Reported Incident submitted to the State Survey Agency on 5/7/26 showed resident #51 was admitted on [DATE] with physician orders for psychotropic medications including Lithium ER 300 mg twice daily, Sertraline 25 mg daily, and Quetiapine 100 mg twice daily. The report showed the medications were not administered as ordered due to miscommunication between facility nursing staff and the pharmacy.During a telephone interview on 6/29/26 at 9:00 a.m., staff member R stated she recalled the incident and understood the medications for resident #51 were unavailable because of some confusion with the pharmacy. Staff member R stated she was not sure how to access the list of medications available through the facility's stocked prescription medication dispensing system. Staff member R could not recall whether she had received education regarding the medication dispensing system or the facility's policy for missed medications.During an interview on 6/29/26 at 4:15 p.m., staff member A discussed the facility's investigative documents and stated the facility's investigation determined that miscommunication and misinterpretation of the facility policies and procedures contributed to the deficient practice. Staff member A stated nursing staff did not follow up on medications ordered from the pharmacy, determine whether the medications were available through the facility's stocked prescription medication system, notify the physician when ordered medications could not be administered, or document actions taken to ensure continuity of medication therapy. Staff member A stated the previous Director of Nursing implemented corrective measures and auditing; however, documentation of those actions could not be located.Review of resident #51's medication admission orders showed the resident was prescribed the following psychotropic medications:-Lithium ER 300 mg by mouth twice daily,-Sertraline 25 mg by mouth once daily, and-Quetiapine 100 mg by mouth twice daily.Review of resident #51's Medication Administration Record for May 2026 showed:-Lithium ER 300 mg, scheduled for 8:00 a.m. and 8:00 p.m. daily beginning at 8:00 p.m. on 5/5/26, and this was documented as not administered on 5/5/26, 5/6/26, and 5/7/26, resulting in four missed doses.-Sertraline 25 mg, scheduled for 8:00 a.m. daily beginning on 5/6/26, was documented as not administered on 5/6/26 and 5/7/26, resulting in two missed doses.-Quetiapine 100 mg, scheduled for 8:00 a.m. and 8:00 p.m. daily beginning at 8:00 p.m. on 5/5/26, was documented as not administered on 5/7/26, resulting in one missed dose.Review of resident #51's nursing progress notes for the 48-hour period from 5/5/26 through 5/7/26 corresponding to the missed medication doses showed entries which included, on order, waiting on pharmacy, and waiting on pharmacy to sent. [sic] The nursing progress notes did not show documentation of follow-up with the pharmacy regarding the unavailable medications, attempts to obtain the medications through the facility's stocked prescription medication dispensing system, or notification to the physician after resident #51 missed consecutive doses of prescribed psychotropic medications.Review of a facility policy titled Medication Administration, dated 1/2024, showed, . If two consecutive doses of a vital medication are withheld or refused, the physician is notified.Review of a facility policy titled Psychoactive Medications, dated 6/2025, showed, . It is the policy of this facility that the resident's medication regimen . helps to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being .

Based on interview and record review, the facility failed to complete a baseline care plan which provided instructions needed to provide personalized resident-centered care for 1 (#28) of 20 sampled and supplemental residents. The failure to have a baseline care plan placed the resident at risk of not being provided care to meet their basic needs. Findings include:Review of resident #28's electronic medical record showed an admission date of 6/12/26, and the baseline care plan should have been completed within 48 hours of the resident's admission but was not.A review of Resident #28 medical diagnoses showed the resident was admitted with diagnoses of chronic pain and lumbar region spinal stenosis. The resident also had prior falls. Due to these, a baseline care plan would be important to ensure the resident's pain needs and fall prevention interventions were in place in a timely. Review of resident #28's admission MDS, with an assessment reference date of 6/16/26, showed the resident had frequent severe pain and was receiving nonpharmacological interventions for pain management. Resident #28's pain frequently limited her ability to perform day-to-day activities. The MDS showed resident #28 had falls in the last month and had falls two to six months ago. A review of resident #28's care plan showed the resident's risk for falls, assistance or needs for ambulating, bed mobility, and self-bathing performance, but resident #28 did not have a care plan in place directing the staff on how to assist the resident until 6/15/26. The care plan did not identify triggers for pain or interventions to help manage the pain until 6/15/26. The nonpharmacological interventions for pain management had not been added to the care plan. During an interview on 6/29/26 at 9:31 a.m., staff member D stated the care plans were triggered by the nurse evaluations, which are completed on admission. Staff member D stated the evaluations are reviewed for completion and signature during the daily clinical meeting. The baseline care plans were started and would be dated when the evaluations were done, signed, and locked. Staff member D said that if the resident had known falls before admission, the way the corporate care plans were set up, those falls would not trigger a care plan.

Based on interview and record review, the facility staff failed to complete a thorough investigation and comprehensive corrective action, following a facility-reported event involving neglect allegations related to bowel and bladder care of 5 dependent residents (#s 12, 32, 33, 42 and 112); and staff failed to document physician ordered medication and treatment orders for 23 residents (#s 6, 9,12, 13, 15, 20, 22, 23, 27, 32, 33, 112, 114, 116, 118, 121, 123, 124, 126, 127, 131, 133, and 199) of 24 sampled residents. Findings Include: Review of a Facility-Reported Incident, submitted to the State Survey Agency on 9/26/25, included two separate incidents involving neglect of resident care. The first event occurred on the 12-hour night shift beginning at 6:00 p.m. on 9/19/25. NF3 was working the night shift and was reported by other staff to be missing for extended periods of time with another staff member. Day shift staff reported resident #12, 32, 33, 42, and 112, who were all assigned to NF3's care, were found during the morning rounds heavily saturated in urine and feces. The second event occurred on the 12-hour night shift, beginning at 6:00 p.m. on 9/25/25. On the morning of 9/26/25, resident #20 reported neither she nor her roommate received their morning medication from the night nurse. Resident #20's statement prompted a facility investigation, which revealed NF4 failed to document medications and treatments given for resident #s 6, 9, 12, 13, 15, 20, 22, 23, 27, 32, 33, 112, 114, 116, 118, 121, 123, 124, 126, 127, 131, 133, and 199 during her shift. The facility's investigation and report of findings, dated 10/2/25, included the following corrective actions: Staff were educated on reporting and recognizing abuse and neglect by the Administrator on 10-1-25 and 10-2-25 . DNS will report the licensed nurse (NF4) to the Montana Board of Nursing by 10/3/25 . All licensed staff will be in-serviced by the Director of Nursing Services on med administration and documentation compl . [sic]During an interview on 10/20/25 at 1:11 p.m., staff member J stated she believed she had abuse training through her contract agency and recently had received an abuse policy to review and sign for the facility, but there wasn't really any training with it. Staff member J stated she had not received medication administration and documentation training at the facility within the past two months, as noted to be done in the facility investigation notes. During an interview on 10/20/25 at 1:15 p.m., staff member F stated she had received abuse training review recently, but it did not apply to this neglect issue (being investigated) really. Staff member F stated she did not recall any medication-related training in the past two months. During an interview on 10/20/25 at 1:34 p.m., staff member G stated there was sexual abuse training recently, but staff member G did not recall any training on the identification and reporting of resident neglect. Staff member G stated the education consisted of a review of the abuse policy, sign-off on receipt of the policy, and a short quiz with sexual abuse scenarios. During an interview on 10/20/25 at 1:52 p.m., staff member I stated she could not recall if she had abuse and neglect training recently.During an interview on 10/21/25 at 10:38 a.m., staff member B stated the facility became aware of both incidents on 9/26/25 with NF4. Staff member B reported the incident to staff member A and began investigating the allegations. Staff member B stated her investigation involved pulling medication administration records and the bowel and bladder task reports for all affected residents, interviewing residents, and interviewing staff. During her investigation, staff member B stated she identified 21 residents were negatively affected, and their medication and treatment administration records were left incomplete by NF4 between 9/25/25 at 6:00 p.m. and 9/26/25 at 6:00 a.m., which showed the treatments and medications were not provided. Staff member B stated she reviewed the controlled substance logs for the residents who were prescribed controlled substances to ensure there were no discrepancies in the medication count, but did not confirm the same with the other medications using the facility's blister pack system for medication administration. Staff member B stated, I just never thought to do that. During an interview on 10/21/25 at 1:50 p.m., staff member B stated there was an informal interdisciplinary meeting held on 10/1/25, wherein department heads received updated abuse and neglect training, but it was not a formal QAPI meeting.During an interview on 10/21/25 at 2:12 p.m., staff member C stated there had been no QAPI meeting following the incident on 9/26/25, to identify quality-deficient practices and or needed corrections related to the events and NF4.During an interview on 10/21/25 at 3:40 p.m., staff member A stated he held a focused (adhoc) QAPI meeting after the reportable incident, as part of the facility's plan for correction. Staff member A provided a QAPI committee minutes form with three names listed: the administrator, a corporate regional nurse, and corporate regional administrator. Staff member A stated, Everyone was there, I just haven't gathered the rest of the signatures yet. The report was dated 10/1/25. Staff member A stated the staff had all received refresher training on abuse and neglect. When the sexual abuse quiz questions were reviewed with the surveyor, staff member A stated he could have selected more relevant quiz questions, as the events with NF4 were not related to sexual abuse. Staff member A stated the questions were selected from a standard resource he had available for abuse and neglect training. During an interview on 10/24/25 at 6:33 p.m., staff member D stated he received a summary of the occurrence and investigation with NF4, by phone from staff member B, but had not been notified or invited to a QAPI meeting regarding the event. Staff member D stated he would have attended the meeting as he felt it was an important step for preventing a recurrence in the future, to address a quality-deficient practice.Review of the facility-provided abuse and neglect training document showed a three-page document titled Abuse Prohibition Notification Policy, and it included a 4-question quiz. All questions pertained to sexual abuse of residents, no content was related to neglect of care. On 10/20/25, a request was made for evidence to show NF4 had been reported to the Montana Board of Nursing by 10/3/25, as reflected in the investigation report findings. The board notification documentation was received; however, the document was dated 10/20/25. Staff member C stated at the time of delivery, This was just completed today, as (staff member B) was not sure if Adult Protective Services was going to do the reporting (to the nursing board), therefore, the facility had not reported NF4's actions to the nursing board as documented in the investigation summary. On 10/20/25, a request was made for evidence of the nursing education on medication administration, and the required documentation for medications when administered. No documentation was provided before the end of the survey.

Based on interview and record review, a facility nurse failed to ensure nursing services were provided in accordance with professional standards for medication administration and documentation for 23 (#s 6, 9, 12, 13, 15, 20, 22, 23, 27, 32, 33, 112, 114, 116, 118, 121, 123, 124, 126, 127, 131, 133, and 199) residents, of 24 sampled, and the residents medical records did not reflect if the residents received their ordered medications. Findings include:During an interview on 10/20/25 at 3:35 p.m., NF4 stated, . I did everything I was supposed to that night (the night shift between 9/25/25-9/26/25) . and I told the oncoming nurse I was planning to late entry my notes. they reported me to the Board of Nursing . they (facility) hated me. some of the problem was that (the electronic medical record system) was not saving my (entries) . I gave that guy his morphine all night except for one dose, when I couldn't get it into him, because he was restless .During an interview on 10/20/25 at 3:10 p.m., resident #20 stated, . I didn't get my thyroid med that day (9/26/25) and neither did my roommate, although she won't remember. Resident #20 stated she filed a grievance on the concern.During an interview on 10/21/25 at 10:16 a.m., staff member K stated, Residents complain about (NF4) a lot for late meds or no meds. One day recently, a resident told (NF4) that he didn't get his med, and (NF4) told him she was 80% sure she gave it to him already. Staff member K went on to say, 80%, I thought that was weird, referring to NF4 not absolutely knowing if the medication was given. Staff member K stated there was another incident where a resident told the staff member he didn't get his medications, and staff member K stated he told NF4 about it. Staff member K stated he did not want to identify the residents (who didn't get the medications or voiced complaints to him) as he didn't want to get anyone in trouble.During an interview on 10/21/25 at 10:38 a.m., staff member B stated she investigated the events involving NF4 on the night shift ending on 9/26/25, after resident #20 reported she and her roommate (resident #13) had not received their morning thyroid medicine on 9/26/25. Staff member B stated the investigation revealed NF4 had not completed the medication and treatment records for 21 residents during her 12-hour shift, which started at 6:00 p.m. on 9/25/25, and the shift ended at 6:00 a.m. on 9/26/25. Staff member B stated the records were highlighted in red in the EMR, reflecting the monitoring, treatments, or medications not performed, administered, or signed off by NF4. Staff member B reported inconsistencies during her interview, which included statements that everyone received their treatments and medications. Later, staff member B reported everyone received their medication, except resident #20, even though resident #20's Medication Administration Record (MAR) showed she was administered the thyroid medication at 5:35 a.m. Resident #13's thyroid medication was administered at 5:51 a.m., per the MAR. Staff member B stated resident #20 has a BIMS score of 15; cognitively intact, and she is very reliable and makes sure everyone (staff) does their work. The resident also looks out for her roommate, who has a BIMS of 5; severe cognitive impairment. Staff member B stated resident #116 was on hospice and only received one dose of morphine sulfate during NF4's 12-hour shift, and the resident was receiving the morphine pain medication approximately every two hours on prior shifts. Staff member B stated NF4 told her resident #116 had been restless all night. Staff member B stated the facility's narcotic log matched the medication does sign out documentation. Staff member B stated NF4 told her she was planning to come back the next shift and complete all the documentation (as late entries in the medical record) because she had a migraine headache.During an interview on 10/21/25 at 1:30 p.m., staff member E stated she had received a report from NF4 on 9/26/25, and she had not mentioned/noted she had a headache. Staff member E stated NF4 did not report that she didn't finish her charting. Staff member E stated, She seemed fine, just in a hurry to go. She tried to tell me that everyone was fine, and I had to make her go over the report . it was a busy day trying to fix all the issues and getting the residents comfortable .Review of resident MARs for the period of 6:00 p.m. on 9/25/25 through 6:00 a.m. on 9/26/25, showed the following concerns were not addressed by NF4:1. Resident #6: Catheter care, psychotropic side effect monitoring, serotonin syndrome monitoring, Enhanced Barrier Precautions (EBP) monitoring, shortness of breath monitoring, weekly skin evaluation, nighttime left wrist hand splint application, and pain monitoring were not documented as completed.2. Resident #9: The skilled care vital signs every shift, anticoagulation side effect monitoring, shortness of breath monitoring, psychotropic side effect monitoring, oxygen saturation, and the oxygen flow rate were not documented as completed. Dermaseptine ointment to #9's sacrum/coccyx, over blanchable redness, was not documented as administered per the physician's order.3. Resident #12: EBP monitoring, shortness of breath monitoring, pain monitoring, and psychotropic side effect monitoring were not completed. Oxygen saturation checks every shift, and the pillow boot to be applied at night were not documented as completed per the physician's order.4. Resident #13: Levothyroxin Sodium 50 mcg tablet was documented as administered at 5:51 a.m. on 9/26/25, although resident #20 reported it was not given.5. Resident #15: Sleep monitoring, EBP monitoring, pain monitoring, psychotropic side effect monitoring, fentanyl patch monitoring and the witness were not documented as completed. Oxygen saturation checks were not documented as completed per physician's order.6. Resident #20: Levothyroxine Sodium 50 mcg tablet was documented as administered at 5:35 a.m. on 9/26/25, although resident #20 reported it was not given.7. Resident #22: Sertraline 50 mg tab was not documented as administered per physician order.8. Resident #23: The shortness of breath monitoring, pain monitoring, and psychotropic side effect monitoring were not documented as completed.9. Resident #27: The anticoagulation side effect monitoring, shortness of breath monitoring, EBP monitoring, pain monitoring, opioid side effect monitoring, psychotropic side effect monitoring, and Roho (pressure-relieving air cushion) monitoring were not documented as completed.10. Resident #32: Pain monitoring was not documented, oxygen saturation checks not documented as completed per physician order, treatment order for gluteal fold calmoseptine and antifungal cream to gluteal fold not documented as completed per physician order, and lower extremity edema (swelling) monitoring not documented as completed per physician order, and lower extremity cleansing not documented as completed per physician order.11. Resident #33: EBP monitoring, shortness of breath monitoring, pain monitoring, and psychotropic side effect monitoring were not documented as completed.12. Resident #112: Pain monitoring, opioid side effect monitoring, hypnotic side effect monitoring, and psychotropic side effect monitoring were not documented as completed.13. Resident #114: Pain monitoring, psychotropic side effect monitoring, and bowel movement monitoring were not documented as completed.14. Resident #116: EBP monitoring, hospice order monitoring, pain monitoring, and psychotropic side effect monitoring were not documented as completed. Resident was in the end-of life transition, had been receiving prn liquid morphine multiple times per shift in previous shifts, and received one dose of morphine on the 12-hour night shift ending at 6:00 a.m. on 9/26/25. The dose was administered at 5:59 a.m. on 9/26/25. The resident was given no doses of the prn lorazepam, although in statements, NF4 reported the resident was restless, and out of sorts and combative during her shift, which may have been related to pain.15. Resident #118: Shortness of breath monitoring, pain monitoring, and psychotropic side effect monitoring were not documented as completed.16. Resident #121: Pain monitoring, opioid side effect monitoring, and psychotropic side effect monitoring were not documented as completed.17. Resident #123: Anticoagulation side effect monitoring, shortness of breath monitoring, and pain monitoring were not documented as completed. Miconazole cream was not documented as applied per the physician's orders.18. Resident #124: Pain monitoring, shortness of breath monitoring, oxygen monitoring, and opioid side effect monitoring were not documented as completed. Fluorouracil cream to the left clavicle was not documented as applied per the physician's order.19. Resident #126: Pain monitoring, psychotropic side effect monitoring, and oxygen saturation monitoring (due to rapid desaturation history) were not documented as completed.20. Resident #127: Anticoagulation side effect monitoring, pain monitoring, shortness of breath monitoring, and psychotropic side effect monitoring were not documented as completed.21. Resident #131: Psychotropic side effect monitoring and pain monitoring were not documented as completed.22. Resident #133: Pain monitoring and opioid side effect monitoring were not documented as completed. As-needed acetaminophen was not administered, although it had historically been given regularly.23. Resident #199: EBP monitoring, pain monitoring, shortness of breath monitoring, psychotropic side effect monitoring, and opioid side effect monitoring were not documented as completed.Review of the facility's investigation documentation for the Facility-Reported Incident, dated 9/26/25, showed the following undated statement obtained from NF4, via phone: I kept up on all medication administration even with (residents #9 and 116) being out of sorts and combative. in regard to the shift MAR being red, all of the work was completed. I had a migraine, finished the work, and planned to go back into (electric health system) tonight and make sure it was all clicked off.Review of the [NAME] - Nursing Documentation information, dated August 2025, located at nursingworld.org, and accessed 10/30/25, included the following professional standard guidance for the Six Principles of Nursing Documentation which were:The American Nurses Association (ANA) has identified six principles of nursing documentation to provide guidance for producing high quality documentation (ANA, 2021). 1. Documentation Characteristics Accessible Accurate and relevant Auditable Clear, concise, comprehensive, and thoughtful Legible/readable Timely and sequential Aligned with the nursing process Retrievable on a permanent basis

Based on interview and record review, the facility failed to ensure a resident was transferred safely and correctly, and the resident sustained an injury to the left lower extremity with swelling and bruising which the nurse documented as being tennis ball size, and it was identified the injury was caused due to staff manually transferring the resident, which was not the correct transfer status, for 1 (#16) of 2 residents sampled for injury. Findings include: Review of a facility-reported incident, submitted to the State Survey Agency on 8/28/25, showed resident #16 sustained a hematoma of unknown origin to the left lower extremity. The facility's investigation determined the injury likely occurred as a result of a difficult resident transfer from the wheelchair to bed.Review of resident #16's medical record showed on 8/28/2025 at 10:40 a.m., the nurse documented the resident stated there was an accident, and the nurse detailed the assessment of the resident's left lower extremity injury, which was soft tissue swelling just below left knee. Area is the size of a tennis ball .Review of a written statement from staff member Q, dated 8/28/25, showed, Resident was found in her wheelchair with no sling under her and wanted to be transferred to bed. Nurse and [staff member P] attempted to place a sling under her but she was too weak so they had to do a stand pivot transfer with gait belt to get her safely back to bed with 3 staff members present .A verbal request was made on 11/18/25 for the most recent therapy recommendation forms for resident #16. Two forms were received, dated 6/9/25 and 6/20/25. Neither form was related to resident #16's transfer status or ability to transfer.During an interview on 11/17/25 2:02 p.m., staff member L stated, I understand that PT forgot to put a sling underneath her (resident #16), and the CNAs had trouble getting her back to bed with pivot and lift . The CNAs should have been told how to transfer the resident . During an interview on 11/18/25 at 10:40 a.m., staff member B stated resident #16 was supposed to be transferred only using a hoyer lift (full body lift). Staff member B stated the physical therapist had transferred resident #16 earlier in the day from her bed to her wheelchair using a slider board and did not leave a hoyer lift sling underneath her, therefore, the staff had to attempt a stand and pivot transfer with the resident. Staff member B stated resident #16 was very weak, and the transfer was difficult. Staff member B stated physical therapy should have ensured the staff could safely transfer resident #16 back into her bed.During an interview on 11/18/25 at 1:41 p.m., staff member O stated resident #16 had been regressed by nursing staff to hoyer lift transfers due to weakness, and therapy was using a slider board to transfer resident #16. Staff member O stated she believed there was a system problem or communication problem, as the therapists were getting pulled into resident rooms frequently by CNAs to relay a transfer status or instruct staff on transferring residents.Review of resident #16's care plan, dated 5/22/25, showed the resident was able to perform all transfers with one person assisting, and there were no further updates to resident #16's transfer status in the care plan.

Based on interview and record review, licensed nursing staff neglected to provide the necessary services to a resident and assess for and treat pain and anxiety, for 1 (#116) of 2 residents sampled for pain management, and the nurse stated the resident was restless, a symptom of both anxiety and pain. The neglect of care negatively affected the resident's comfort. Findings include:During an interview on 10/21/25 at 10:30 a.m., staff member B reported she investigated a facility-reported incident involving neglect of care on multiple residents. Staff member B reported she was concerned one resident had not received adequate pain and anxiety management from the nurse on duty on the 12-hour night shift between 6:00 p.m. on 9/25/25 and 6:00 a.m. on 9/26/25. Staff member B stated resident #116 was a hospice resident, and the resident was in end-of-life transition. The resident had been receiving as-needed lorazepam for anxiety, twice daily, and morphine several times per shift, due to restlessness and agitation. Staff member B stated on the 12-hour night shift between 6:00 p.m. on 9/25/25 and 6:00 a.m. on 9/26/25, NF4 gave resident #116 one dose of morphine for pain at 5:59 a.m., and no lorazepam for anxiety. Staff member B stated she was able to confirm the one dose of pain medication was given by reviewing the resident's narcotic log and narcotic count.During an interview on 10/20/25 at 3:35 p.m., NF4 stated, . I gave that guy (resident #116) his morphine all night except for one dose when I couldn't get it into him because he was restless. The staff member was inconsistent in her accounting of the events and did not seem to recognize the restlessness could have been pain/anxiety related. Review of the facility's investigation documentation for the Facility-Reported Incident, dated 9/26/25, showed the following undated statement obtained from NF4 via phone: I kept up on all medication administration, even with (residents #9 and #116) being out of sorts, and combative .Review of resident #116's MAR for September 2025, showed that on 9/25/25, resident #116 received morphine at 12:56 a.m., 5:56 a.m., 9:51 a.m., and 12:59 p.m. The next dose was administered on 9/26/25 at 5:59 a.m., and it was 17 hours since the previous dose, which was the only dose given to the resident on NF4's shift.Review of resident #116's nursing progress notes, for September 2025, did not show any nursing entries for the period of 6:00 p.m. on 9/25/25 through 6:00 a.m. on 9/26/25, and why pain or anxiety medications were neglected to be given, or if the resident was assessed for why he was restless and or out of sorts.

Based on interview and record review, facility staff failed to report investigative findings for reportable events, within the required timeframe, for 2 (#s 16 and 123) of 2 residents sampled for injuries. Findings include:1. Review of a facility-reported incident, submitted to the State Survey Agency on 8/28/25, showed resident #16 sustained a hematoma of unknown origin to the left lower extremity. The facility's investigative findings were not reported to the State Survey Agency until 9/9/25; two days after the submission deadline.During an interview on 11/18/25 at 10:42 a.m., staff member A stated he was responsible for submitting the facility's reportable incidents through the incident reporting system. Staff member A stated he accidentally pressed the save button instead of the send button in the reporting system and did not realize it until two days past the deadline.2. Review of a facility-reported incident, submitted to the State Survey Agency on 9/16/25, showed resident #123 sustained swelling and bruising of unknown origin to the right hand. The facility's investigative findings were not reported to the State Survey Agency until 9/25/25; two days after the submission deadline.During an interview on 11/18/25 at 10:42 a.m., staff member A stated he did not think the incident should have been reported, but the facility did report it as an unknown injury. Staff member A did not feel that the late reporting of the incident should be considered deficient practice. As with the incident above, staff member A stated he pressed the save button instead of the send button in the reporting system and did not realize it until two days past the deadline.

Based on observation, interview, and record review, the facility nursing staff failed to assess and manage a resident's pain, and proceeded with the provision of care when the resident voiced pain, and showed other indicators of pain, to include crying and calling out and in pain, and refusing ADL care, for 1 (#71) of 11 sampled residents. Findings include: Resident #71 was admitted to the facility on [DATE], with a diagnosis of wedge compression fracture of T7-T8, subsequent encounter for fracture with routine healing, pain in left wrist, age related osteoporosis, and chronic pain. Review of resident #71's MAR for October 2024 showed resident #71 had pain interventions of: - Lidocaine patch placed on her mid back daily for 12 hours. - Diclofenac topical applied to the lower back topically two times a day for pain related to the wedge compression. - Acetaminophen 1000 mg by mouth three times a day. - Methocarbamol 750 mg three times a day for pain - Hydromorphone 2 mg every four hours as needed for pain. - Methocarbamol 500 mg every 8 hours as needed for pain. This medication was started 10/22/24 and discontinued 10/31/24 Review of resident #71's MAR for November 2024 showed: - Lidocaine patch was discontinued 11/4/24. - Diclofenac was discontinued on 11/4/24. - Acetaminophen 1000 mg by mouth three times a day. - Methocarbamol 750 mg by mouth three times a day, discontinued 11/4/24. - Methocarbamol 750 mg by mouth on 11/9/24. - Methocarbamol 750 mg by mouth three times a day from 11/5/24 to 11/8/24. - Methocarbamol 1500 mg by mouth three times a day. - Acetaminophen with Codeine 300-30 mg every eight hours as needed for pain. Review of resident #71's December MAR showed the resident was to take the following medications: - Acetaminophen (325mg/10.15 ml) give 17 ml by mouth three times a day, starting 12/31/24. - Acetaminophen 1000 mg by mouth three times, and this was discontinued on 12/31/24. - Acetaminophen with Codeine (120-12 mg) give 10 mg by mouth every four hours as needed. This dose was ordered from 12/26 through 12/31/24. - Acetaminophen-Codeine tablet 300-30 mg - one tablet every 8 hours as needed for pain. This medication was given from 11/8/24 through 12/27/24. - Acetaminophen with codeine oral solution (120-12mg/5ml)-give 20 ml by mouth three times a day starting 12/31/24. - Methocarbamol 1500 mg by mouth three times a day, until it was discontinued 12/31/24. - Methocarbamol 1500 mg by mouth four times a day starting 12/31/24. Review of resident #71's pain care plan, initiated on 10/22/24, showed resident #71's pain was controlled at a 3 of 10 with Tylenol, however pain was limiting her ability to get up. The care plan was updated on 10/31/24 to give analgesics prn for pain. The care plan was not updated to show other techniques for managing resident #71's pain. Review of resident #71's MDS with an ARD of 10/28/24, showed the resident had a BIMs of 6 which show resident #71 was severely cognitively impaired. Review of a resident #71's physicians order dated 11/6/24 showed the physician discontinue the hydromorhpone per the residents request. The order was carried out even after identifying the resident was severely cognitively impaired and would not be able to appropriately direct her own care. Review of resident 71's MDS, with an ARD of 12/4/24, showed the resident had pain or was hurting during the last five days. The MDS showed the pain occasionally affected her ability to sleep at night. The MDS showed the pain occasionally limited resident #71's participation in rehabilitation sessions and frequently limited her day-to-day activities. Resident #71 also had a BIMS score of 7. A BIMS of 7 showed the resident had severe cognitive impairment, which may prohibit her from requesting pain medication when needed. Review of resident #71's MAR/TAR on the pain monitoring section, for December 2024, showed resident #71 had pain only six times on the day shift and six times on the night shift, throughout the month. The December 2024 MAR medication administration for Acemaninophen with codeine showed resident #71 needed pain medication administered 24 times for her pain which resident #71 said ranaged from a 3 to a 10. During an observation on 12/30/24 at 3:00 p.m., resident #71 could be heard from across the hallway and with the resident's door pulled closed. Resident #71 was crying and yelling Oh I hurt, I hurt, and no one cares. This crying went on for over 45 minutes. Review of the December MAR/TAR, showed resident #71's pain level for the day shift on 12/30/24 was a 0, however resident #71 was heard crying out in pain at 3:00 p.m. During an interview on 12/30/24 at 1220 p.m., staff member E said when resident #71 was first admitted she would get out of bed and into a chair. Staff member E said resident #71 has declined because of the pain, and now she doesn't get out of bed and hardly eats. Staff member E said the CNA's try to reposition her, but resident #71 usually just layed on her back. The staff try and put a pillow under resident #71's back to attempt to repositon her, but resident #71 does not tolerate lying on her side because of the pain. Staff member E said sometimes resident #71 yells and is combative with cares because of the pain. During an interview on 12/30/24 at 3:00 p.m., resident #21 said resident #71 cries out often, but she directed this surveyor to the nurse. During the interview, resident #71 quieted for a while. Resident #21 said #71's medication must be working, as the nurse was in earlier to give her medication. Resident #21 said it did bother her, the resident crying out, because the roommate was in pain. During an observation on 12/30/24 at 5:30 p.m., resident #71 was heard from the hallway crying in pain. Resident #71 was unable to be interviewed due to crying and having pain. During an observation on 12/30/24 at 6:15 p.m., resident #71 was still crying in pain. NF2 approached the surveyor and asked if pain medication could be provided. NF2 was directed to the facility staff. During an interview on 12/31/24 at 8:45 a.m., NF2 said the call light was on over 1/2 hour, and he then had to go find someone to get pain medication for the resident. NF2 said resident #71 does not always remember, or able to call the nurses consistently, when she has pain. NF2 said resident #71 rarely gets repositioned in the bed, and she was bed bound as she cannot get up using the lifts, because of the pain they cause. NF2 said today (12/31) was the first time he has ever heard resident #71 state she wanted to just give up and be done. NF2 said he feels like the staff have given up on her, and they just close the door and forget her.

Based on observation, interview, and record review, the facility failed to identify resident's with weight loss, implement weight loss interventions timely, and failed to monitor the effectiveness of weight loss interventions, for 2 (#s 47 & 71) of 11 sampled residents. Resident #47 had a severe 17% weight loss in 42 days, and #71 had a severe weight loss of 12.1% of her body weight in 63 days. Findings include: 1. Review of resident #47's Weights and Vitals summary form showed resident #47 was admitted on [DATE] and his weight was 150 pounds. The resident was not weighed again until 8/20/24. Resident #47 lost 21.4 pounds or 14.1% of his body weight during the first 28 days after admission. This was a severe weight loss. Review of #47's physician orders, dated 7/23/24, showed the resident was on a regular diet. Review of resident #47's nursing notes, dated 8/9/24, showed the skin, weight and nutrition meeting was held with the RD. The note showed the medications, diet, and intake were reviewed. No new supplements or diet changes were made. There were no weights documented in the chart from 7/23/24 to 8/12/24. Review of resident #47's care plan, initiated on 8/13/24, failed to have any dietary or nutritional interventions for resident #47. Review of resident #47's weights and vitals summary, dated 8/20/24, showed resident #47 weighed 128.6 pounds, for a loss of 21 pounds, or 14.3% of his body weight, in 28 days. Review of resident # 47's weight dated 9/3/24, showed resident #47's weight continued to decline to 124 pounds. Resident #47 had a severe weight loss, and lost 26 pounds, or 17% of his body weight. Review of resident #47's discharge recapitulation form showed resident #47's discharge weight was 124 pounds, and his weight was stable. However, according to the weights and vitals report, resident #47 had a severe weight loss of 26 pounds and 17% of his body weight, and he was continuing to decline throughout his stay at the facility. 2. Review of resident #71's weight and vital summary form, dated 10/22/24, showed resident #71's admission weight was 142.2 pounds. Review of resident #71's care plan, dated 10/22/24, showed resident #71 was on a heart healthy mechanical soft diet. Resident #71's care plan was then updated on 11/2/24. The updated care plan showed resident #71's diet was continued on a heart healthy mechanical soft diet, but the diet per MD orders was added to the care plan. The care plan did not include calorie dense medication pass three times a day. Review of #71's nutritional evaluation, dated 11/3/24, showed the resident was admitted on an 1800 calorie dysphasia mechanical soft low fat low cholesterol diet, with a calorie dense medication pass of 237 cc three times a day. This evaluation did not show the root cause of the weight loss was resident #71's failure to eat. The resident's pain was not documented as being evaluated related to the lack of meal intakes or nutritional needs. The dietitian notes showed the following: - There was no indication of the need for the calorie-controlled diet or the fat and cholesterol limitation. - The high volume of Cal Dense could be negatively impacting meal intake. - Diet changed to regular dysphasia mechanical soft and change the Cal Dense to 60 cc tid (three times a day) between meals. Review of #71's Medication administration record, dated November 2024, showed resident #71 was to receive 120 cc of Calorie Dense Medication Pass, three times a day. The orders did not follow the dietitian recommendations. Review of resident #71's weight and vital summary form, dated 11/5/24, showed a weight of 133.4 pounds. This was a 6.2% weight change in 14 days. Review of a physician order for #71, dated 12/23/24, showed the resident's diet was changed to match the dietitian's recommendation from 11/3/24. There was a delay of 50 days before the diet was changed to meet the resident's nutritional needs. A review of resident #71's care plan showed it was not updated on 12/23/24, to show the resident's diet was changed to a regular dysphasia diet, with fortified foods. Review of the nutritional hydration skin committee review form, dated 12/13/24, showed the significant weight loss for #71 was not identified from admission through 12/13/24. The form showed the resident's admission weight as 142.2 lbs, and a weight on 11/5/24 was 133.4 lbs. The staff checked on the form that there was not a 5% or more weight loss from 10/22/24 through 11/5/24, however, this was a significant 8.8 pound, or a 6.2% weight loss. The dietitian note showed, Resident reviewed, inadequate intake suspected, increased CDMP supplement to 120 cc TID. Will continue to monitor. There was no documentation to show why the resident was eating minimal amounts of food. The severe weight loss was not addressed as needed. Review of the resident #71's weights and vitals summary, showed resident #71 continues to lose weight, even after the supplement was added. Review of resident #71's weight and vital summary form, dated 12/24/24, showed resident #71 weighed 125 pounds. This was severe loss of 12.1% weight loss in 63 days. During observation on 12/30/24 at 6:45 p.m., resident #71 was receiving her meal, which was scheduled to be served at 5:30 p.m. The doctors order for resident #71 was for the diet to be fortified. The doctors orders were not folloed whe resident #71 was served her sauerkraut, pickles, and cheddar cheese. There was no other food served to attempt to increase the resident's nutrition or caloric intake. The facility only provided her preferred meal with no other option. During an interview on 12/31/24 at 2:53 p.m., staff member G said the interim DON who was here in the past deleted all the weight loss alerts. If activated, the weight loss alerts could be generated onto a report which would give the dietitian a list of residents with significant weight loss. The dietitian could then assess and put interventions in place timely. Staff member G said some of the interventions were late because the dietitian was unaware of weight loss, and the new assessments were not done timely.

Based on interview and record review, the facility failed to consistently document the status of a pressure injury or the resident's response to treatment for 1 (#182) of 21 sampled residents. Findings include: During an interview on 3/28/21 at 2:40 p.m., NF1 stated she came in to visit resident #182 during lunch on 3/13/21. NF1 stated she believed resident #182 was in pain because every time the aide reached across resident #182's body, touching her right arm, resident #182 jerked away as if in pain. NF1 stated she noticed red, purple, and black bruising above and below a dressing on resident #182's right elbow. NF1 stated she was originally made aware of a small ulcer on resident #182's elbow in late January 2021. NF1 stated she was very upset because she had not been notified regarding changes in resident #182's right elbow wound since the original notification in late January. After leaving the facility on 3/13/21, NF1 stated she called staff member I at about 4:30 p.m. to see what was being done about resident #182's elbow, including management of her pain. NF1 stated staff member I got upset with her and said, What do you want me to do? If you want her to go to the ER, we can send her. NF1 stated she wanted resident #182 to be sent to the emergency room , and she would meet her there. NF1 stated she was able to see the right elbow when the dressing was taken off in the emergency room . NF1 stated she was told by the emergency room physician the wound was infected and they would be starting resident #182 on antibiotics and pain medication. During an interview on 3/29/21 at 9:45 a.m., staff member B, a member of nursing administration with the responsibility of wound care oversight, stated she was not sure where the wound care protocol was located. Staff member B looked at the nursing station, at multiple binders on the shelves, and in a filing cabinet. Staff member B suggested checking with staff member C who had been at the facility longer than she (staff member B) had. A review of the facility's protocol titled Wound Care Protocols, dated 7/2014, showed the following best practice guidelines: -Evaluate wound bed, wound edges, periwound, and document status, including patient response to treatment every visit. -Measure wound(s) weekly & PRN using wound gauge measurement tool and document length, width, and depth. -Document & Coordinate with MD any worsening/changes in wound status such as S/S of infections, advance in stage, increased necrosis, non-adherence to treatment, etc. A review of resident #182's physician notes, nursing progress notes and weekly skin evaluations showed inconsistent documentation of the wound bed, wound edges, surrounding tissue appearance of the resident's right elbow wound, the resident's response to treatment, weekly measurements of the wound or physician involvement as expected per facility's wound care protocol: -1/28/21, nursing progress note and weekly skin evaluation showed, Wound/skin opening observed at right elbow, reddish in color . wound measures 5 cm X 5 cm circular in shape. Foul smelling. Purulent discharge, moderate to heavy in amount observed in the dressing. PCP informed, ED informed. DNS informed. The note failed to identify the type of wound. -1/28/21, physician clinic note, showed a final assessment of, . decubitus ulcers of the right elbow with associated allergic [CONDITION(S)] and no evidence of infection. -2/7/21, nursing progress note showed, Area still presents as red. Area also seemed more tender today than last as evidenced by resident wincing at application of cream to site. The note failed to show any measurements of the wound or MD notification of increased pain. -2/12/21, nursing progress note and weekly skin evaluation, showed the wound re-opened with a skin tear and measured 2 cm X 4 cm, oblong in shape. The note showed the physician was notified via fax. There was no evidence of the physician's acknowledgement of the notification or any new wound care orders. -2/19/21, weekly skin evaluation, dated 2/19/21, showed a Stage 2 pressure ulcer, measuring 5 cm long by 5 cm wide by .25 cm deep, with a yellow wound bed. The note failed to show notification of physician regarding presence of a pressure ulcer or any new treatment orders. -2/20/21 to 3/9/21, no wound measurements, status of healing, or resident's response was found in the nursing documentation. -3/10/21, nursing progress note, showed, . a very red and deep purple the area on the elbow is open again 1.2x1.2x.5 cm . The note failed to show physician notification of the worsening of the wound. -3/12/21, weekly skin evaluation, showed, showed an abrasion which included two areas of open skin on the bony aspect of the right elbow, measuring 2 cm long by 2 cm wide, with dark red/purple color of surrounding tissue. The documentation showed an increase in size and a change from a pressure ulcer to an abrasion, and no documentation of physician notification of the status of the wound. -3/13/21, hospital emergency room physician note, showed, . redness and swelling to the right elbow with a couple of ulcerative pressure ulcers. The note showed an assessment of right elbow [CONDITION(S)].

Based on observation, interview, and record review, the facility nursing staff failed to follow up and ensure interventions, a mobile xray and physician order for [REDACTED]. During an observation on 10/6/2020 at 2:35 p.m. resident #1 had been placed in bed with assistance of one staff for an afternoon nap. Resident #1 had a splint on her left arm. When resident #1 was asked about her left arm, she could only repeat one word yes. Resident #1 was diagnosed with [REDACTED]. During an interview on 10/7/2020 at 8:27 a.m., NF2 said, (Resident) waited quite a while before being sent to the emergency room . The resident had a fall on 8/26/2020 in the morning. NF2 said, the night nurse saw the bruising on the resident's arm and sent her to the emergency room around 9:00 p.m. During an interview on 10/7/2020 at 9:05 a.m., staff member H said she had been the nurse on the day resident #1 had fallen. Resident #1 was found on the floor, in her room, that morning. Staff member H said she had the right arm was sore and red for the resident. Staff member H said she had completed a full assessment, ROM, and neuro checks had been started. Staff member H documented the incident and called the physician. Staff member H stated she had been on the phone with another physician, when the other physician returned her call regarding resident #1's fall. Staff member H said she had wanted to get a portable x-ray for resident #1. Staff member H said that it was not the status quo to delay medical treatment. She said she waited for mobile x-ray and they never came. Staff member H confirmed that the night nurse sent resident #1 to the emergency room . No further follow up occurred. The nurse on duty at the time failed to ensure anternate interventions identified or carried out when the mobile x-ray did not arrive. During an interview on 10/7/2020 at 11:10 a.m., staff member C said she was in the building when resident #1's fall occurred. Staff member C and staff member H had discussed mobile imaging and staff member H was getting that set up. Staff member C did not know what happened after that, as she had to leave. During an interview on 10/7/2020 at 1:10 p.m., staff member I said, Twenty minutes before breakfast resident #1, attempted to transfer self from wheel chair to bed and ended up on the floor. She stated that breakfast was at 7:45 a.m. Staff member I said that resident #1 was assessed for injuries, and vital signs were completed. Staff member I said the resident was assisted off the floor and placed in her wheel chair. Staff member I said the physician and family members were called. She said, family members had talked with resident #1 several times that day. Staff member I said that resident #1 said her wrist was hurting. Staff member I said the two RNs discussed getting a mobile x-ray. During an interview on 10/7/2020 at 3:10 p.m., staff member J said he had returned staff member H's call and she was on another line. Staff member J said when he returned the call, the facility was already considering sending resident #1 to the emergency room . Staff member J said The outcome would not have changed as it was hours not days when discussing the lapse in time from the fall with injuries to the time the resident was sent to the ER. Staff member J said the injury to resident's right arm was non-operative. Review of resident #1's Progress Notes, dated 8/26/2020 at 9:33 a.m., showed the physician, and the family, were notified of resident #1's fall. Review of resident #1's emergency room Report, dated 8/26/2020 at 10:22 p.m., showed a [MEDICAL CONDITION] shoulder, scapula, and wrist. This report also showed these injuries were non-operative. Review of resident #1's Progress Notes, dated 8/27/2020 at midnight, showed On evening assessment at 8:00 p.m., resident (#1) was found to have significant swelling, bruising, and pain of her right upper arm and shoulder with 10/10 pain. Resident #1 was transferred to the hospital for further evaluation and work-up. The facility was notified by the hospital the resident was admitted for the fractures identified. No physician order was found in resident #1's medical record for mobile imaging after her fall, and not as of 10/8/2020.

Based on observation, interview, and record review, the facility failed to ensure 1 (#20) of 20 sampled residents, and all other residents who came in contact with resident #47, or were in his presence when angry, was free from abuse and fear of abuse. Resident #20 sustained a fractured finger during a resident to resident altercation with resident #47, and 6 (#s 6, 7, 10, 26, 28 and 32) filed a Grievance for fear of their safety relating to resident #47. Findings include: Resident #47 was readmitted to the facility on [DATE] and discharged on [DATE] with [DIAGNOSES REDACTED]. During an observation and interview on 5/29/18 at 11:45 a.m., resident #20 stated he was attacked by another resident and had his finger broken. The resident's left ring finger appeared swollen and deformed. The resident was unable to bend his finger. Review of a report filed with the State Survey Agency, dated 4/28/18, showed resident #47 left his table and went over to the table where resident #20 was sitting, grabbed his finger, and bent it which resulted in an injury to resident #20's left ring finger. Review of resident #20's Orthopedic Comprehensive Exam, Final Report, dated 4/30/18, showed a closed, displaced [MEDICAL CONDITION] ring finger. Review of a Grievance Form, dated 5/3/18, showed six residents (#s 6, 7, 10, 26, 28 and 32), filed a grievance which showed they feel it is an unsafe environment in the dining room and hallways, especially at night due to the behaviors of resident #47. Under the investigation and findings, the document showed resident #47 would be, .served his meals in his room if possible, staff nurse to call MD and request DC for safety to psych, 1:1 observation, resident to ER. Review of resident #47's Multi-disciplinary Progress Notes, dated 4/6/18 through 5/7/18 showed the following: -4/6/18; Foul language in dining room, cussing at other residents and staff, threw cup of orange juice across the room. The resident was directed back to his room. -4/7/18 at 6:30 a.m.; The resident ate dinner in his room the previous evening. Was verbally aggressive toward CNAs. -4/7/18 at 3:20 p.m.; The resident was agitated toward CNAs today. He yelled and cussed at the aides. -4/7/18 at 11:00 p.m.; The resident became very agitated at PM meal and threw a heavy glass plate across the floor. -4/9/18 at 11:15 a.m.; The resident was highly agitated in the AM, targeting staff, seeking them out and yelling/cussing at them, threatened violence and attempted to strike them. The resident was poorly redirectable. -4/9/18 at 11:30 a.m.; The resident threw a mug, and was repeatedly yelling/cursing. Multiple staff attempted to redirect and calm, but were ineffective. [MEDICATION NAME] (an antipsychotic) 100 mg given orally. Soon after medication was given the resident began chasing after other staff, cursing and threatening them. -4/9/18 at 5:05 p.m.; [MEDICATION NAME] (an antipsychotic) increased to 100 mg at bedtime. -4/10/18 at 2:30 a.m.; The resident was still cussing and shooing everybody out of his room. -4/10/18 at 6:00 p.m.; The resident was very agitated this AM, throwing cups in the dining room. Backed the nurse up in a corner and kicked her three times. Refused all medications and cares by staff. -4/11/18; Staff avoid the resident to avoid physical or verbal altercations. The resident was verbally or physically aggressive towards staff. Was observed talking to himself. Paperwork was started to send the resident out for evaluation. -4/12/18; Additional paperwork faxed to receiving facility. -4/13/18; The resident refused to allow staff to get him up and change soiled clothing. Reapproached later and allowed staff to assist in changing soiled clothing. The resident cussed at a CNA, at lunch. -4/14/18; The resident was in the dining room at lunch, and was yelling and throwing cups. -4/15/18; The resident was still calling some staff names and was still verbally abusive to staff. -4/16/18; The resident had a moment of verbal exchange with another resident about getting seconds. -4/17/18; The resident was vulgar towards a female CNA. -4/18/18; CNAs report the resident continues to be vulgar towards them. -4/19/18; The resident was cooperative. Refused to allow staff to turn bathroom call light off. -4/21/18; Cooperative with cares. Would not let staff turn off bathroom call light. The resident told staff to get out of his room and called them names. -4/22/18; The resident yelled at the CNA. -4/23/18; Cooperative with cares. -4/24/18; The resident was yelling in dining room at dinner and tossed food and threw a plastic cup at another resident. Resident removed from dining room to his room to finish dinner. -4/25/18; The resident was agitated after lunch, yelling and cursing at people and wandering around the unit. -4/26/18; Cooperative and calm. -4/28/18 at 2:00 a.m.; Threw dinner on floor at dinner time. -4/28/18; Heard loud yelling in dining room and ran down to find that (resident 47) had wheeled over to another resident and attempted to grab him (resident #20) and injured the resident's left ring finger. (Resident #47) was cursing loudly and staff had to pull the resident in wheel chair away from the other resident. The resident was swinging arms and attempting to hit anyone near him. Was able to get the resident out of the dining room and away from the other resident. The resident then attempted to punch staff. [MEDICATION NAME] (an antipsychotic) increased to 150 mg two times daily. The resident sat quietly in room for the rest of the day. -4/29/18; Cooperative. -4/30/18; Non-compliant with cares, refused medications. Refused to let staff turn bathroom call light off. The resident sat in his room with his hands down his pants. Attempted to shut door, but the resident would yell and re-open the door. Staff was finally able to get door closed for privacy. -5/1/18; The resident was agitated at breakfast and threw plate and bowl onto floor and cursed at staff. -5/2/18; The resident refused cares. Appeared heavily soiled. Received new order to increase [MEDICATION NAME] (an antipsychotic), decrease [MEDICATION NAME] (an antidepressant) and add [MEDICATION NAME] (an antidepressant). Becomes aggressive with attempts to turn bathroom call light off. -5/3/18; The staff attempted to draw blood for ordered blood work and the resident became verbally and physically aggressive. 1:1 supervision continues. 1:1 supervision initiated for other residents and staff safety. The resident was sitting in his urine and feces because he was not allowing staff to change him. An order was received for [MEDICATION NAME] (an antipsychotic) 2 mg IM, however staff could not get close enough to administer without getting injured. Resident screaming and throwing things around room at 2:15 p.m. Resident sent to ER for evaluation at 3:00 p.m. Returned from ER at 4:30 p.m. -5/4/18; The resident is on 1:1 care due to danger to staff, self, and other residents. The resident was refusing to eat, drink, or be cared for. Resident in room screaming vulgar language, sticking his hand down his pants, and throwing things around the room. -5/4/18; Order to send out for evaluation. Unable to obtain required lab work. -5/5/18 at 2:30 a.m.; 1:1 supervision when possible. -5/5/18 at 4:00 p.m.; 1:1 staff with resident at all times. -5/7/18 at 10:48 a.m.; The resident was in the hallway, yelling. The resident was observed to be hitting and pulling on staff clothing. The resident was screaming cuss words and attempting to go into other resident's rooms. Staff attempted to get the resident out of other resident rooms, but the resident became angry and started hitting staff again. -5/7/18 at 4:40 p.m.; The resident was yelling, cussing, swinging and hitting staff members. The resident was screaming in the hallways and attempted to go into other resident's rooms. All doors were shut. Police were called. The resident was yelling at the police and swung his hands at the police officer and tried to grab the officer's arm and was cussing at him. Review of resident #47's Quarterly MDS, with an ARD of 3/2/18 showed a BIMS score of 3, which reflected severe cognitive impairment. Review of resident #47's care plan showed the following interventions: -Initiated on 2/19/18; assess and anticipate resident's needs, provide physical and verbal cues to alleviate anxiety, give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff member when agitated, give the resident as many choices as possible about care and activities, monitor and document behavior and attempted interventions in behavior log, notify MD with increased behaviors, and monitor/document/report PRN any signs or symptoms of resident posing danger to self and others. When the resident becomes agitated intervene before agitation escalates, guide away from source of distress, engage calmly in conversation; if response is aggressive, staff to walk calmly away and approach later. -Initiated on 4/30/18; administer medications as ordered, assist the resident to develop more appropriate methods of coping and interacting as able, encourage the resident to express feeling appropriately, caregivers to provide opportunity for positive interaction, attention, stop and talk with him/her as passing by, educate on successful coping and interaction strategies as able, explain all procedures to the resident, discuss behaviors, if reasonable, and intervene as necessary, minimize potential for the resident's disruptive behaviors by offering tasks which divert attention such as playing music in room, and offering food. Monitor behavior episodes and attempt to determine underlying cause. Praise any indication of the resident's progress/improvement in behavior. Provide a program of activities that is of interest and accommodates resident's status. As the resident continued behaviors of aggression, and medications were modified, interventions on the care plan were not evaluated or revised to show steps the facility took steps to further prevent or protect the residents who were either in direct contact with resident #47 or those who had been in his presence, relating to abuse, and for those residents who may have had fear from abuse due to the resident's aggression and behavior, between 2/19/18 and 4/30/18. During an interview on 5/31/18 at 1:45 p.m., staff member B stated she could not recall when resident #47 went on 1:1 monitoring. Staff member B stated when 1:1 was discontinued, staff were to watch the resident closely. Staff member B stated interventions, for resident #47, prior to resident #20's injury included; watching him, contacting the MD, and removing him from the situation. Staff member B stated interventions were ongoing, and included re-directing, and medication adjustment. Staff member B stated when resident #47 was throwing dishes, the facility switched to Styrofoam. Staff member B stated resident #47 would de-escalate, following medication adjustment, for a short time.

Based on observation, interview, and record review, the facility failed to maintain an effective Quality Assurance program to ensure resident care needs were met by utilizing a system that would identify deficient practice areas, or concerns with facility systems or protocols. This failure had the potential to affect all residents at the facility. In addition, the facility specifically failed to identify quality deficient practices which were identified as Immediate Jeopardy deficiencies for Accidents, Hazards and Supervision; Quality of Care and Maintaining the Resident's Highest Well Being; Resident Assessments; Quality Assurance; and Administration which affected 6 (#s 1, 2, 4, 5, 9, and 10) out of 10 sampled and supplemental residents. Findings include: IMMEDIATE JEOPARDY The facility submitted an acceptable plan of abatement for the immediate jeopardy on 9/21/15 at 3:20 p.m. After the immediacy was removed, the scope and severity for this deficiency was determined to be at the level of an H. Refer to F323 - Accidents and Hazards, for further detail on the Immediate Jeopardy Abatement Plan. During an interview on 9/15/15 at 10:00 a.m., staff member A, administrator, stated he participated in the facility's daily clinical meeting. During the meeting resident falls were reviewed and discussed amongst the IDT team. He stated the team would then develop a plan for the resident's future safety. The IDT would look at the causes of the falls, how to prevent the falls, to ensure notifications were made, and to ensure the fall assessments were completed. He stated the nursing duties were reviewed during the meeting to ensure they were managed properly. He stated each resident fall was unique, and with each one the facility looked at what the current interventions were for the resident, and then tried to find an permanent fix. During an interview on 9/16/15 at 6:35 a.m., staff member B, DON, stated the facility received training from the Regional Director of Clinical Operations on fall prevention. This occurred in March or April of 2015. The training included fall risk, contributing factors for falls, fall interventions, care planning and required documentation. Resident #1 was identified as admitting to the facility as a fall risk due to his disease process, cognitive deficits, functional mobility, and behavior. The resident had numerous falls, to include falls with injury, that included one to the head. During his short stay, the facility failed to adequately assess the resident and identify risk factors for the prevention of falls, and failed to adequately develop and implement a comprehensive care plan to meet the resident's needs. Contributing factors for the falls included medications, pain, behavior, inadequate resident assessments, inadequate use of devices and IDT reviews which did not identify causal factors or ensure the implementation of the recommended changes, but also failed to ensure interventions were appropriate for the resident's current status. Resident #2 was identified to have a fall, dated 5/14/15, with significant injury and susequent admission to the hospital on [DATE], for a fracture to the right hip. The facility failed to accurately communicate with the emergency room staff regarding the resident's history of loosening hardware and unstable right hip from a previous fracture. The resident did not have the right hip evaluated when she was sent to the ER following the fall and susequently was placed in a restraint while in the wheel chair. The facility did not receive the ER report until 5/20/15. The facility failed to adequately manage the resident's pain following the fall. The facility failed to follow Occupational Therapy's recommendations regarding behaviors and pain. Resident #4 was identified to have recurrent falls to include one injury to the head. The facility failed to implement effective interventions for the resident who was confused. The interventions identified by the IDT were ineffective due to the resident's cognition, and non-compliance with the interventions. The medical record showed the family voiced concerns with the resident's decreased ADL abilities, as did the CNA staff. The medical record lacked nursing entry progress notes from 7/24/15 to 9/8/15. On 2/13/15, a fall alarm was implemented for the resident, which continued to be in place, and shown to be ineffective for the resident's safety. Resident #5 was identified to have multiple falls including two with head trauma. The facility failed to report abnormal neurological findings to the physician. The facility failed to conduct a comprehensive investigation into each fall and modify/revise the care plan to meet the resident's needs. The IDT failed to carry interventions to the care plan. The facility failed to ensure accurate and detailed documentation was completed. The facility failed to adequately assess behaviors for underlying causes. The facility failed to identify ineffective measures to prevent falls with injury. Resident #9 was identified to have several falls to include one injury to the head. The resident also had a witnessed fall, which was documented in the medical record, but the facility failed to follow up on the fall. The facility failed to implement effective interventions for the resident who was confused. The resident's fall care plan was not accurate and had not been updated with all the interventions identified for use. The medical record lacked documentation for an extended period of time, to include documentation of the fall witnessed by the physician, and during this time was reported to have shown a decrease in functional mobility. The facility IDT met to review the resident's status each week, to include administrative personnel, without effective actions taken to address the resident's falls and behaviors. Resident #10 had two docmented falls and one undocumented fall. The facility failed to accurately document assessments prior to and upon return from the ER. The facility failed to adequately assess the appropriateness of the resident using a public bathroom independently following a fall in the bathroom. The facility failed to ensure documentation was complete and accurate. The facility failed to evaluate and update the care plan with effective interventions. Refer to F281, 309, 323, 490 and 520.

br>Based on observation, record review and interview, the facility failed to maintain Resident Rights for one (#5 ); Resident Behavior and Facility Practices for 1 (#2 ); Resident Assessments 6 (#s 1, 2, 4, 5, 9 and 10 ); Quality of Care for 6 (#s 1, 2, 4, 5, 9 and 10); Dietary Services for 3 (#s 1, 2 and); and Administration for 6 (#s 1, 2, 4, 5, 9 and 10) out of 10 sampled and supplemental residents; specifically, the facility was found to have Immediate Jeopardy deficient practices for Accidents and Hazards, Maintaining the Highest Practicable Well Being, Resident Assessments, Quality Assurance, and Administration, which had the potential to affect all resident's at the facility. Findings include: IMMEDIATE JEOPARDY The facility submitted an acceptable plan of abatement for the immediate jeopardy on 9/21/15 at 3:20 p.m. After the immediacy was removed, the scope and severity for this deficiency was determined to be at the level of an H. Refer to F323 - Accidents and Hazards, for further detail on the Immediate Jeopardy Abatement Plan. F157 Notification of Changes The facility failed to notify the physician of an abnormal neurological status for one (#5) out of 6 sampled residents. For further detail refer to F157. Resident Behavior and Facility Practices F221 Physical Restraints The facility failed to adequately provide evidence that a restraint was the least restrictive device to be used for a confused resident, who displayed behaviors. The facility also failed to adequately assess the resident for the use of the restraint prior to placement, or after placement, or ensure a consent was obtained by the resident/responsible party, for the use of the restraint for one (#2) out of 6 sampled residents. Resident Assessments F279 Comprehensive Care Plans The facility failed to adequately complete, and update, a comprehensive care plan for a resident (#1) who had behaviors which potentially affected his nutrition, medical and safety status. F280 Care Plan Time Frames and Participation The facility failed to update comprehensive care plans for two (#s 4 and 9), specifically, that resident #4 had significant weight variances and skin injuries; and #9 had repeated falls, many from non compliance with care, and behavioral concerns. The facility had implemented a behavior plan which was not reflected on the care plan. F281 Professional Standards The facility failed to ensure nursing staff completed accurate and detailed documentation following falls, failed to provide all pertinent information to the ER for accurate evaluation following a fall for 2 (#s 2 and 10), failed to assess and evaluate the appropriateness of current interventions and implement new interventions to prevent future falls with injury and failed to complete a comprehensive investigation into the root cause of falls for 6 (#s 1, 2, 4, 5, 9 and 10) of 10 sampled and supplemental residents. Quality of Care F309 Quality of Care, Maintaining Highest Practicable Well Being The facility failed to ensure the residents' highest practicable well being was maintained, and ensure services provided met resident care needs for the following: failed to conduct a comprehensive investigation into the root cause of falls, implement interventions based on the findings for future prevention, and document accurate and complete details for the falls for 6 (#s 1, 2, 4, 5, 9 and 10), failed to ensure accurate and detailed documentation for transfers to the ER for 2 (#s 2 and 10), failed to evaluate, identify needs, and revise the care plan and interventions for 6 (#s 1, 2, 4, 5, 9 and 10), failed to accurately communicate a resident's history for continuity of care for 1 (#2), failed to adequately assess, identify, and address weight variances for two (#s 1 and 4), failed to show direct causes, and interventions to prevent skin injuries and show accurate documentation for the healing of skin injuries for one (#4), and failed to show evidence that the physician was notified of medication refusals for one (#1) out of 10 sampled and supplemental residents. Refer to F309 for further detail. F323 Accidents and Supervision The facility failed to ensure an adequate system was in place and utilized, which included the assessment, identification of hazards, monitoring, care planning and prevention of resident falls, with and without injury, for 6 (#s 1, 2, 4, 5, 9 and 10) out of 10 sampled and supplemental residents. F325 Nutritional Status The facility failed to ensure an effective system was in place, and facility weight monitoring documentation was accurate, for the assessment of the resident's nutritional status. Weight discrepancies continued from March to September 2015. The facility failed to timely identify the concern, failed to record why the discrepancies occurred in the individual resident records, and failed to ensure an alternative method was in place for accurately weighing the residents. This failure affected two (#s 1 and 6) out 6 sampled residents. The facility also failed to address, through the nutritional assessment process, how a resident's behaviors, preferences, physical limitations, cognition, and intake affected the resident's nutritional status, or what interventions were implemented to address all of the areas of concern. The resident's nutritional care plans, and care directives, were not updated and current to meet the resident's nutritional needs for two (#s 1 and 6) of 6 sampled residents. F329 Unnecessary Drugs The facility failed to complete a comprehensive assessment into the underlying conditions and behaviors prior to implementing an antipsychotic medication for 2 (#s 2 and 5) out of 6 sampled residents. Dietary Services F369 Assistive Devices The facility failed to identify the need for an adaptive device for the plates used during meal sessions for a resident who had hand/limb limitations, wanted to continued to be independent with eating on his own, and utilized adaptive silverware for one (#6) out of 6 sampled residents. Refer to F369 for more detail. Administration F519 Transfer Agreement The facility failed to maintain, and was unable to provide, a transfer agreement with the local hospital, which was certified for Medicare and Medicaid services, for the provision of healthcare services for those residents needing a higher level of care when their needs could not be met at the facility. This deficient practice had the potential to affect all the residents residing at the facility. For more detail refer to F519. F520 Quality Assurance The facility failed to maintain an effective quality assurance program to identify deficient practices, assess system failures, plan and implement needed changes, and monitor for effectiveness the changes made for the following facility systems, protocols, and/or policies: F156 Facility Must Inform, which pertained to a restraint, implemented after a fall with significant injury, without first assessing the use of the restraint, and identifying what interventions were utilized prior to the placement of the restraint for one (#2) out of 6 sampled residents. Refer to F156 for further detail.

Based on observation, record review and interview, the facility failed to: adequately assess the resident's for risk factors contributing to falls, to identify injuries from falls, or for what measures could be taken for the prevention of future falls; failed to maintain an accurate and complete medical record for fall assessments/evaluations, interdisciplinary notes, nursing notes, vital signs, or physician/responsible party notifications for falls; failed to update the resident's plan of care or care directive relating to falls and the preventions of falls with and without injury; failed to identify exhibited behaviors that may have contributed to falls; failed to follow identified interventions for the prevention of falls; failed to follow up on recommendations of the IDT Fall Team; failed to notify the physician and/or responsible party for resident falls; and failed to monitor the effectiveness of current interventions, or implement appropriate interventions for fall prevention for residents with and without injury for 6 (#s 1, 2, 4, 5, 9, and 10) of 10 sampled and supplemental residents. Findings include: IMMEDIATE JEOPARDY The facility failed to respond to repeated falls and injuries for 6 identified residents who had falls with and without injury. The facility failed to identify risk factors, and implement interventions for fall prevention and resident safety, to include those interventions recommended by the interdisciplinary fall review team; failed to utilize the residents' fall history to identify causes of falls, or what increased the residents' risk for falls; failed to update the residents' plan of care for identified risks and interventions identified for safety; failed to notify the physician of resident changes in conditions; and failed to adequately and accurately document the residents' status prior to a fall, and after a fall, to include when residents were transferred to a local hospital for a higher level of care. On [DATE] at 11:30 a.m., the facility administrator was notified by the surveyors that an immediate jeopardy situation existed for 6 of the 10 sampled and supplemental residents. PLAN TO ABATE THE IMMEDIATE JEOPARDY The facility submitted an acceptable plan of abatement for the immediate jeopardy on [DATE] at 3:20 p.m. After the immediacy was removed, the scope and severity for this deficiency was determined to be at the level of an H. A summary of the facility's abatement plan to remove the immediate jeopardy was as follows: Resident's #1 and #2 no longer reside at the facility; therefore corrective action cannot be completed. For resident #s 4, 5, 9, and 10, the facility implemented corrective measures for the identification of fall hazards, and implementation of interventions to prevent falls with or without injury. The facility arranged for a medication regimen review for each of the identified residents, to determine if the residents' medications potentially contributed to the falls. The facility identified educational needs for the nursing staff, and completed education with the staff regarding resident assessments, to include those required by facility policy, and the residents' physical and mental status; clinical record documentation requirements; the identification and implementation of fall interventions; duties the nurse must complete when a resident falls; identifying and updating the residents' care plan timely; the need to use good nursing judgment, and consult with other staff for insight into the events surrounding a resident fall, to assist with the prevention of future falls. Further education was identified as needed, which was provided to the facility management team, and corporate management, for the prevention of falls. The facility will utilize the Interdisciplinary Management Team (that includes the administrator, director of nursing, and therapy manager) five days a week at the center's Daily Clinical Meeting with an emphasis on medications, behaviors, environment, functional status, cognitive status, pain status, vital signs, infections, type of assistance received, further assessment, medical tests, interventions or referral to other health care providers as warranted, if interventions are effective, and will ensure interventions were carried to the care plan and care directive. The interdisciplinary team will include a review of the resident's individual history of falls. The facility's fall data will be reviewed by the management team, and regional support staff, monthly. On a quarterly basis the team will meet with the medical director to identify any trends or a concern relating to falls so corrective action can be implemented. During an interview on [DATE] at 10:00 a.m., staff member A, administrator, stated he participated in the facility's daily clinical meeting. During the meeting resident falls were reviewed and discussed amongst the IDT team. He stated the team would then develop a plan for the resident's future safety. The IDT would look at the causes of the falls, how to prevent the falls, to ensure notifications were made, and to ensure the fall assessments were completed. He stated the nursing duties were reviewed during the meeting to ensure they were managed properly. He stated each resident fall was unique, and with each one the facility looked at what the current interventions were for the resident, and then tried to find an permanent fix. During an interview on [DATE] at 6:35 a.m., staff member B, DON, stated the facility received training from the Regional Director of Clinical Operations on fall prevention. This occurred in March or April of 2015. The training included fall risk, contributing factors for falls, fall interventions, care planning and required documentation. 1. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the nursing admission assessment, dated [DATE], reflected resident #2 had a history of [REDACTED]. Review of the Fall Evaluation, dated [DATE], reflected resident #2 had a high potential for falls with a score of 14. Review of therapy recommendations, dated [DATE], reflected resident #2 had extreme level of pain and discomfort in her right leg and was very aware of the pain and any movements made towards her would cause pain and for resident #2, discomfort = striking out, showing she would exhibit behavior when in pain. Review of the initial care plan dated [DATE], reflected PT/OT to evaluate and treat, independent with bed mobility, one person assist with ambulation and independent when in wheel chair. On [DATE], a bed alarm and wheel chair tab alarm were implemented. Review of a nurse's note, dated [DATE] at 2:00 p.m., reflected resident #2 had an unwitnessed fall at 8:00 a.m. on [DATE]. The note reflected the resident was combative when staff attempted to clean her up, but did not address if the behavior was due to pain. The resident's blood pressure at the time of the fall was ,[DATE]. The nurse's note reflected the resident was sent to the ER for evaluation and returned with an order for [REDACTED]. This included whether or not the resident had problems with pain, range of motion, or her cognitive status at the time of the fall. The nurse's note did not reflect the time the resident was sent to the ER, the resident's condition at the time of transfer, who transported the resident to the ER, how the resident was transferred to the ER, what was reported to the ER staff, or an assessment of the resident's condition upon return from the ER. Review of an interdisciplinary note, dated [DATE], reflected resident #2 had a documented fall on [DATE], which required a transfer to the ER for evaluation. The IDT note lacked details relating to the event which were not documented in the nursing notes. Review of the IDT Fall Review form, dated [DATE], reflected resident #2 had a fall on [DATE]. The section, IDT Conclusions, reflected the resident had been ill with diarrhea, increased irritability and combativeness towards staff and resisting care. The resident was to have a lap buddy in place when up in wheel chair. The Fall Review did not address the resident's current medications, effectiveness of current fall interventions and/or interventions related to pain, behavior or toileting needs. Review of the ER report, dated [DATE], faxed to the facility on [DATE], reflected an X-Ray of the LEFT hip. The resident had returned to the facility on [DATE] with an order to place a lap buddy when the resident was up in her wheel chair. Review of nurse's notes from [DATE] through [DATE] reflected the resident was combative towards staff and often refused assistance with cares. Nurse's notes reflected the resident was confused and complained of increased right hip pain with transfers. Review of a physician progress notes [REDACTED]. There was not a re-evaluation of the resident's current pain management regimen until [DATE], which was five days after the fall. Review of a nurse's note, dated [DATE] at 5:00 p.m., reflected resident #2 was admitted to the hospital for a fractured RIGHT hip. Resident #2 did not return to the facility. During an interview on [DATE] at 10:22 a.m., staff member E, RN, stated she completes a pain assessment on each resident every time she had contact with them, at least three times per shift. Staff member E stated the s/s of pain in a confused resident was grimacing, holding a area, change in behavior, change in mobility and anything out of the normal. Staff member E stated she would fax the physician her findings and request changes if the resident's pain regimen was not effective. During an interview on [DATE] at 10:45 a.m., staff member N, RN, stated he completes a pain assessment on each resident at least once per shift. Staff member N stated the s/s of pain in a confused resident were verbal complaints, holding an area, body language, grimacing, clenching jaw, furrowing brow, moaning and screaming. Staff member N stated he would notify the physician immediately if the resident's pain regimen was not effective. The following medication changes were made for resident #2: -[DATE]; Trazodone 50 mg, by mouth at bedtime, -[DATE]; Trazodone 25 mg, by mouth two times daily, -[DATE]; Trazodone 50 mg, by mouth three times daily, -[DATE]; Seroquel 25 mg, by mouth two times daily, -[DATE]; hydrocodone/APAP (acetaminophen) ,[DATE] mg 1 tablet, by mouth two times daily for 30 days, -[DATE]; Discontinue Trazodone, hydrocodone/APAP ,[DATE] mg, by mouth four times daily. Review of a nurse's note, dated [DATE], reflected resident to be a bit more lethargic. CNA reported VS (sic) taken to be low. Bruise to the right leg, unchanged. (Physician's name) here yesterday, N.N.O (sic) r/t puffiness to leg. Noted O2 Sat (sic) to be low, placed on 2L N/C (sic). Tried to reach (physician's name). Opted to send resi (sic) to ER RE (sic) decreased SPO2 et (sic) POA request for X-Ray to be done to right leg. Review of the nurse's notes from [DATE] through [DATE] did not reflect an injury or bruising to the resident's right leg, when the bruising was identified, or how the bruising occurred. During an interview on [DATE] at 9:00 a.m., a family member stated the resident had a fall at the facility on [DATE]. The family member stated she was not aware of the resident's fall, but observed a health deterioration and an increase in the resident's pain level. She stated the resident could not walk, sit in the wheelchair, or lay down in bed without excruciating pain in the right hip. She stated she went to visit the resident on [DATE], and the resident continued to complain of hip pain. The resident was transferred to theER on [DATE], and found to have a fracture of the right hip. The responsible party of the resident told the family member the resident was taken to theER on [DATE], after a fall. She was dropped off by the facility and left unattended. She stated the resident, who had Alzheimer's, told the ER the wrong hip needed x-rayed. The family member reported the resident expired at the hospital on [DATE], and was told by a hospital representative that the resident's last fall (on [DATE]) was the cause of the resident's death. During an interview on [DATE] at 12:15 p.m., staff member B, DON, stated a CNA usually accompanies a resident to the ER, unless the resident is transported by EMS. Staff member B stated the nurse usually calls and gives a verbal report to the ER staff. Staff member B stated a copy of the current MAR, face sheet and POLST are sent with the resident when transferred to the ER. If the ER wants more information, they will call the nurse. Staff member B stated there was no documentation regarding who transferred resident #2 to theER on [DATE] or the time of transfer. Staff member B stated she did not know if the nursing staff made the ER aware of the resident's history regarding an unstable right hip with previous fracture. 2. Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the significant change MDS, with an ARD of [DATE], reflected resident #5 had severely impaired cognitive skills, long and short term memory deficits and required extensive assistance with ADLs. Section N0410 reflected resident #5 received antianxiety, antidepressant and anticoagulant medication. Review of the Fall Evaluation Form, dated [DATE] through [DATE], reflected the resident had a high potential for falls with scores of 18 and above. Review of the facility incident log, IDT Fall Review forms and nurse's notes reflected resident #5 had eight falls between [DATE] and [DATE]. Three of the eight falls had documented injuries. Two of the eight falls reflected head trauma. All eight falls were unwitnessed. Four out of eight falls reflected the physician was notified via fax. Four out of eight falls did not reflect how the physician was notified. Injuries from the falls included: -[DATE]; abrasion to left elbow, -[DATE]; no documented injury, -[DATE]; bruising to right knee, -[DATE]; hematoma to right side, back of head and abrasions to back, buttock, leg and right upper forearm, -[DATE]; no documented injury, -[DATE]; left shoulder ecchymosis, -[DATE]; no documented injury, -[DATE]; found with head wedged between the mattress and nightstand. Abnormal neurological findings. Review of the neurological sheet, dated [DATE] through [DATE], reflected abnormal neurological findings which included sluggish pupils, drowsiness, unable to follow commands and hypotension. The abnormal neurological findings were not reported to the physician. During an interview on [DATE] at 10:22 a.m., staff member E, RN, stated abnormal neurological findings were unequal grip, dilating pupils differ, muscle strength in limbs and indication of pain. Staff member E stated she would notify the physician right away of abnormal neurological findings. Staff member E stated the physician is notified via fax for non-emergent situations and via phone for other than non-emergent situations such as abnormal neurological findings. During an interview on [DATE] at 10:45 a.m., staff member N, RN, stated abnormal neurological finding were uneven hand grasps, drowsiness, not answering questions, how the pupils react to light, not able to move extremities and how they respond to touch and pain. Staff member N stated he would start neurological evaluation and notify the physician if neurological findings were abnormal. Staff member N stated that the physician is notified via phone if it is an emergent situation and via fax if it is non-emergent. Review of resident #5's medication changes reflected the following: -[DATE]; mirtazapine 30 mg (an antidepressant) was discontinued. Haldol 1 mg by mouth at bedtime was started. Lorazepam 1 mg by mouth as needed was started. Order to watch for lethargy and increased fall risk and to notify MD if concerned, -[DATE]; Haldol decreased to 0.5 mg at bedtime and lorazepam decreased to 0.5 mg as needed. Previous orders were discontinued, -[DATE]; Haldol discontinued, -[DATE]; lorazepam increased to 1 mg by mouth at bedtime, [DATE]; lorazepam changed to add 0.5 mg four times daily as needed, -[DATE]; lorazepam discontinued. Trazodone 25 mg at bedtime started. If not effective after 3 days, then increase to 50 mg at bedtime. Start Risperdal 1 mg once daily at 12:00 p.m., [DATE]; decreased Trazodone to 25 mg at bedtime for agitation, [DATE]; decreased Risperdal to 0.5 mg daily at 12:00 p.m., [DATE]; decreased Risperdal to 0.25 mg daily at 12:00 p.m., [DATE]; Ativan 0XXX,[DATE] mg every 8 hours as needed for agitation, [DATE]; Ativan 1 mg 3 times daily as needed for agitation. Review of the care plan for accidents and injury, dated [DATE], and IDT Fall Review Forms did not reflect comprehensive evaluation of interventions related to medications, bowel/bladder status, behaviors or pain and effectiveness of current interventions. 3. Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the facility incident log, nurse's notes and IDT Fall Review Forms reflected resident #10 had 2 falls, one fall on [DATE] with injury to the right shoulder and one fall on [DATE] with a bruise to the forehead. Review of a Care Conference Summary, dated [DATE], reflected a fall on [DATE]. The facility did not provide documentation regarding the fall on [DATE]. Review of the Fall Evaluation Form reflected resident #10 had a high potential for falls with scores of 15 or higher. Review of the IDT Fall Review Form reflected a fall on [DATE] at 5:30 a.m. while the resident was ambulating to the bathroom. Review of the nurse's notes for the fall on [DATE] did not reflect a post fall blood sugar check. The nurse's note reflected the resident complained of pain to the right elbow. The resident was sent to the ER for evaluation; however the note did not reflect what time the resident was transferred to the ER, how he was transferred or what time he returned to the facility. The nurse documented the resident's arm had a muscle strain. Review of a physician progress notes [REDACTED].#10 was doing poorly with his right shoulder. The progress note also reflected the resident's right shoulder has pain with external and internal rotation .has some pain over his upper ribs underneath his arm, which may be causing a lot of his discomfort .some of this may be rib fractures. He also could have a rotator cuff tears that is not going to be seen on x-ray. Review of a PT note, dated [DATE], reflected the resident was advised to rest arm for a few days so has not been walking, using w/c (sic) instead. The facility did not provide nurse's notes for review from [DATE] through [DATE]. Review of the IDT Review Form regarding a fall on [DATE] reflected the resident was using the resident bathroom located next to the nurse's station, lost his balance and fell . IDT conclusion reflected the resident fell while using the bathroom; had been medicated for pain earlier in the morning; morning insulin had been given and blood sugars had been elevated lately. The IDT form did not reflect an assessment of whether the resident was safe to use the bathroom next to the nurse's station. Review of the nurse's notes for the fall on [DATE] reflected the following: -Staff was notified by the visiting pharmacist of yelling from the bathroom. -The resident had fallen in the restroom at 12:10 p.m. and his head was up against the door. -The fire department and EMS to help get the bathroom door open. -At 11:30 a.m., the resident's blood glucose was 315. -The resident was removed from the bathroom and taken to the ER for evaluation. -The resident returned from the ER at 4:30 p.m. -The resident had a bruised forehead. -The nurse's notes did not reflect an assessment upon return from the hospital. -The nurse's notes did not reflect monitoring for 72 hours post fall. Review of the Neurological Evaluation Log reflected an incomplete neurological assessment. During an observation on [DATE] at 3:00 p.m., the resident bathroom located next to the nurse's station had a sign posted on the outside of the door which stated the bathroom cannot be accessed without a key. The observation showed once the resident was in the bathroom, staff could not monitor without opening the door with a key. Review of the facilities Neurological Evaluation Policy reflected the following: 1. In the event that resident has an unwitnessed fall and/or it is suspected or known that the resident has bumped/hit his/her head, initiate neurological evaluations and continue for 24 hours. 2. Place resident on alert charting for 72 hours. 3. The nurse completes the Neurological Evaluation Log according to the following time frames: a. Every 15 minutes for the 1st hour. (If stable and within normal limits for the resident, continue.) b. Every 30 minutes for the 2nd hour after the fall. (If stable and within normal limits for the resident, continue.) c. Every 1 hour for next 3rd and 4th hour after the fall. (If stable and within normal limits for the resident, continue.) d. Every 4 hours for remaining 24 hours. 4. If any of the above evaluation are not within normal limits, immediately notify the physician. When reaching office personnel or an answering service, the nurse indicates that this is an emergency. 5. The nurse prepares resident for transfer to emergency room while awaiting return call from physician. 6. If the attending physician has not returned call within a reasonable time or the resident continues to decline, the nurse emergency transfers the resident to the hospital emergency department, notifies the physician and the Director of Nursing Services of the transfer and documents the evaluation findings leading to transfer. 7. If the resident is transported to the hospital during the evaluation, the nurse resumes Neurological Evaluation Log upon return. 4. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident discharged the facility on [DATE]. Assessment(s) A review of the resident's Admission assessment, with an ARD of [DATE], showed the resident was coded as a three (severely impaired) for cognition, and had short and long term memory deficits. The resident exhibited inattention, disorganized thinking, and had an altered level of consciousness during the assessment period. For mobility, the resident was coded as needing two plus person's physical assistance for bed mobility, transfers and toileting. The resident was coded as frequently incontinent of bowel and bladder. Section J1700 was coded as a 0 showing the resident had no falls in the last six months, and had no falls since his admission. A review of the resident's Fall Evaluation form showed the resident was coded as a 6 on [DATE] and Routine Precautions would be utilized. On [DATE], his Fall Evaluation score increased to a 26 (a score of 13 or above showed fall interventions and review was required) which did not change throughout the remainder of his stay. The medical record lacked evidence for what measures were taken, or what fall interventions were reviewed, due to the increase in the fall evaluation score. A review of the resident's Device Evaluation Form (date not documented) for the alarm in bed failed to show why the device was needed, what measures were attempted prior to the placement of the alarm, the benefits of the interventions in place, or signatures of the parties who evaluated the device. Fall Details A review of the resident's Multi-Disciplinary Progress Notes, and Interdisciplinary Fall Review forms, showed: - The resident had nine falls from [DATE] to [DATE]. The falls occurred on [DATE], [DATE], [DATE] (two falls), [DATE], [DATE], [DATE], [DATE], and [DATE]. - The resident received injuries during three of the falls, which included: complaints of chest and back pain on [DATE], complaints of pain (not specified) on [DATE], a hematoma to the back of the head, and a skin tear to the left shoulder on [DATE]. The medical record lacked evidence to show how the resident's chest pain or back pain was addressed at the time of the fall or what measures were taken to specifically prevent head injuries in the future if the resident were to fall again. - The nurse documented causes of the falls which included sliding or falling out of the wheelchair or recliner, and that he had attempted to ambulate on his own. On [DATE], [DATE], and [DATE], the medical record failed to show evidence for the potential direct causes or status of the resident prior to the falls. The medical record lacked evidence to show the facility utilized the resident's fall details or history to determine why the resident was falling. The medical record lacked evidence to show how some fall contributors were addressed, such as why the resident was sliding from the wheel chair. - The IDT Fall Review forms showed the IDT team reviewed the details for eight of the nine falls, and made recommendations for fall prevention. These recommendations were not all carried over to the resident's care plan or care directive for staff to use. The lack of information on the care plan or care directive, potentially contributed to the resident's fall risk due to the staff being uninformed. Fall Prevention A review of the interventions identified in the nursing progress notes, IDT review notes, care plan or care directive included: - The resident's care plan showed a tab alarm and pressure alarm was in place on [DATE]. The nursing progress note for [DATE] showed only a tab alarm was placed, but failed to specify why the alarm was being used or on what equipment the alarm was placed. - Fall details showed for the first three falls, the interventions included the placement of the tab alarm and increased monitoring/observation. Although the resident had more falls, the interventions were not changed. -The interdisciplinary team recommended the following interventions (not already identified) for the remaining falls: increase in activities, increase in toileting, and notifying the physician of blood pressure concerns or need to change medication. The IDT recommendations were not found to have been carried over to the care plan. Care Plan and Care Directive A review of the resident's Care Directive lacked evidence for interventions implemented in the Safety, Device, Behavior, or Activity sections of the form. The document showed the resident was confused and forgetful. A review of the resident's Care Plan showed the following: - The Behavior care plan lacked evidence of how his behavior may have contributed to the resident's repeated falls. - Neither the ADL Function care plan, nor the Bowel and Bladder care plan, included evidence of the recommended interventions of increased toileting, or risk for falls. - The Accidents and Injury care plan showed the plan was reviewed after several of the resident's falls, but failed to include risk factors, or interventions identified by the IDT team, which included the resident's poor choices/decision making; decreased balance; wandering; potential medication related side effects; history of agitation; unfamiliar surroundings; or his history of falls. The plan interventions failed to show the low bed, need to increase activities, or one to one activities, keeping the resident by the nursing station (for observation); concerns with blood pressure; or the resident's inability to understand the interventions, or safety risks which contributed to his falls. - The Device care plan failed to show the plan was reviewed for the effectiveness of the tab alarm or pressure alarm on the bed throughout the resident's stay. - The Activity care plan failed to show the need for increased activities for fall prevention. Medications A review of the resident's MARs for January, February and March of 2015, showed he was given five medications which may have increased his fall risk, or contributed to his falls. The medications may have caused dizziness, drowsiness, fatigue, muscle cramping, anxiety or restlessness. These medications were: Tramadol HCL for generalized pain; Haldol for behavior management, Metoprolol Succinate for hypertension; Isosorbide Mononitrate for Hypertension; and Sinemet for Parkinsonian features. The MARs for the resident's stay, along with his nursing progress notes, showed the resident refused medications frequently. The medical record lacked evidence for whether or not the physician was aware of the the medication refusals. During an interview on [DATE] at 1:40 p.m., staff member E, RN, stated the resident refused treatments at times and was very independent. She stated he would not listen, or understand his safety issues, and would get up on his own and fall. Staff member E stated the resident refused care and medication. She stated she would report a pattern of medication refusals to the physician, but would not report an individual event, unless the resident had a negative outcome. She did not believe she notified the physician of the resident's refusals. Behavior A review of the resident's Interdisciplinary notes showed the resident had the following behaviors exhibited during this short stay. These included: Restlessness, wandering, refusals of care/medication, crawling on the floor, getting into other's belongings or going into their rooms, physical aggression, refusing to eat, removing his alarms, and self-transferring without assistance. These behaviors were not identified as potentially contributing to the resident's falls. A review of the resident's physician progress notes [REDACTED]. During an interview on [DATE] at 11:20 a.m., staff member B, DON, stated she was assigned to monitor the resident's status, and assist with any concerns that arose either by the resident or family/representative. Staff member B stated the resident had alarms, and was very active. Staff member B reviewed the Care Plan Directive which had the blank areas for Safety, Device, Behavior, and Activity sections on the form, and stated it may have been incomplete because the facility hadn't completed training on fall prevention until the spring of 2015. 5. Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Assessment(s) A review of the resident's Annual assessment, with an ARD of [DATE], showed the resident was coded as having moderately impaired decision making, and short term memory problems. The resident did not display any behaviors, and had a fall prior to the assessment. A review of the Quarterly MDS, with an ARD of [DATE], showed the resident needed two plus person's physical assistance for bed mob

Based on record review and interview, the facility failed to conduct a comprehensive investigation into the root cause of falls for 6 (#s 1, 2, 4, 5, 9 and 10), failed to ensure accurate and detailed documentation for transfers to the ER for 2 (#s 2 and 10), failed to evaluate and revise care plan interventions for 6 (#s 1, 2, 4, 5, 9 and 10), failed to accurately communicate a resident's history for continuity of care for 1 (#2), failed to adequately assess, identify, and address weight variances for two (#s 1 and 4), failed to show direct causes, and interventions to prevent skin injuries and show accurate documentation for the healing of skin injuries for one (#4), and failed to show evidence that the physician was notified of medication refusals for one (#1) out of 10 sampled and supplemental residents. Findings include: IMMEDIATE JEOPARDY The facility submitted an acceptable plan of abatement for the immediate jeopardy on [DATE] at 3:20 p.m. After the immediacy was removed, the scope and severity for this deficiency was determined to be at the level of an H. Refer to F323 - Accidents and Hazards, for details on the Immediate Jeopardy Abatement Plan. During an interview on [DATE] at 10:00 a.m., staff member A, administrator, stated he participated in the facility's daily clinical meeting. During the meeting resident falls were reviewed and discussed amongst the IDT team. He stated the team would then develop a plan for the resident's future safety. The IDT would look at the causes of the falls, how to prevent the falls, to ensure notifications were made, and to ensure the fall assessments were completed. He stated the nursing duties were reviewed during the meeting to ensure they were managed properly. He stated each resident fall was unique, and with each one the facility looked at what the current interventions were for the resident, and then tried to find an permanent fix. During an interview on [DATE] at 6:35 a.m., staff member B, DON, stated the facility received training from the Regional Director of Clinical Operations on fall prevention. This occurred in March or April of 2015. The training included fall risk, contributing factors for falls, fall interventions, care planning and required documentation. 1. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the nursing admission assessment, dated [DATE], reflected resident #2 had a history of [REDACTED]. Review of the Fall Evaluation, dated [DATE], reflected resident #2 had a high potential for falls with a score of 14. Review of the Care Plan for resident #2 reflected the following: -Alteration in Safety-Devices related to falls, devices, forgetfulness, confusion, restlessness and agitation. Interventions were alarm in bed and wheel chair, and lap buddy when in wheel chair. The care plan did not reflect alternative, less restrictive measures attempted prior to implementing the lap buddy. -ADL Function related to dementia, loose right prosthetic hip and [MEDICAL CONDITION]. Interventions included assist with toileting, bed mobility, transfers, grooming, dressing, eating and mobility. The care plan did not include therapy recommendations regarding combativeness relative to pain. -Accident/Injury related to cognitive losses, impaired judgement, poor choices and loose right hip prosthetic. Interventions included personal alarm on wheel chair and bed, bed against wall and lap buddy when in wheel chair. The care plan did not reflect addressing pain relative to falls. -Actual/Potential Pain related to right hip pain. Non-verbal cues included guarding, agitation, decrease mobility, decreased appetite and resisting care. Interventions included assessment of pain, monitoring effectiveness of pharmacological measures and assessment of cognitively impaired residents for hunger, thirst, toileting needs to rule out pain. Review of the nurse's notes from [DATE] through [DATE] did not reflect non-pharmacological interventions for behaviors or pain, assessment of pain at the time of behavior outbursts, assessment for hunger, thirst, or toileting needs or effectiveness of current interventions. Nurse's notes reflected multiple occurrences of combative behavior and refusal to allow staff to assist with ADLs, however did not reflect an assessment of pain at the time of behaviors. Review of the nurse's notes from [DATE] through [DATE] reflected a pattern of combative behavior when staff attempted to assist the resident with ADLs. Review of the behavior monitoring sheet (did not include the month or year) reflected seven out of 63 scheduled behavior monitoring times had been marked for combative behaviors. The remaining 56 indicated the resident had not displayed combative behaviors. Review of therapy recommendations, dated [DATE], reflected resident #2 had extreme level of pain and discomfort in her right leg and was very aware of the pain and any movements made towards her would cause pain. For resident #2 discomfort = striking out. Review of a nurse's note, dated [DATE] at 2:00 p.m., reflected resident #2 had an unwitnessed fall at 8:00 a.m. on [DATE]. The resident was found on the floor with her pants partially down. The note reflected the resident was combative when staff attempted to clean her up. The resident's blood pressure at the time of the fall was ,[DATE]. The nurse's note reflected the resident was sent to the ER for evaluation and returned with an order for [REDACTED].>The nurse's note did not reflect an assessment of the resident immediately following the fall or how the resident was transferred from the floor. The nurse's note did not reflect the time the resident was sent to the ER, the resident's condition at the time of transfer, who transported the resident to the ER, how the resident was transferred to the ER, what was reported to the ER staff, or an assessment of the resident's condition upon return from the ER. Review of the IDT Fall Review form, dated [DATE], reflected resident #2 had a fall on [DATE]. IDT Conclusions reflected the resident had been ill with diarrhea, increased irritability and combativeness towards staff and resisting care. The resident was to have a lap buddy in place when up in wheel chair. The Fall Review did not address the resident's current medications, effectiveness of current fall interventions and/or interventions related to pain, behavior or toileting needs. Review of the ER report, dated [DATE], faxed to the facility on [DATE], reflected an X-Ray of the LEFT hip. The resident returned to the facility on [DATE] with an order to place a lap buddy when the resident was up in her wheel chair. Review of nurse's notes from [DATE] through [DATE] reflected the resident was combative towards staff and often refused assistance with cares. Nurse's notes reflected the resident was confused and complained of increased right hip pain with transfers. Review of a physician progress notes [REDACTED]. There was no re-evaluation of the resident's current pain management regimen until [DATE]. During an interview on [DATE] at 10:22 a.m., staff member E, RN, stated she completes a pain assessment on each resident every time she had contact with them, which was at least three times per shift. Staff member E stated the s/s of pain in a confused resident were grimacing, holding an area, change in behavior, change in mobility and anything out of the normal. Staff member E stated she would fax the physician her findings and request changes if the resident's pain regimen was not effective. During an interview on [DATE] at 10:45 a.m., staff member N, RN, stated he completes a pain assessment on each resident at least once per shift. Staff member N stated the s/s of pain in a confused resident were verbal complaints, holding an area, body language, grimacing, clenching jaw, furrowing brown, moaning and screaming. Staff member N stated he would notify the physician immediately if the resident's pain regiment was not effective. The following medication changes were made for resident #2, which included medications for pain management: -[DATE]; [MEDICATION NAME] 50 mg, by mouth at bedtime, -[DATE]; [MEDICATION NAME] 25 mg, by mouth two times daily, -[DATE]; [MEDICATION NAME] 50 mg, by mouth three times daily, -[DATE]; [MEDICATION NAME] 25 mg, by mouth two times daily, -[DATE]; [MEDICATION NAME]/APAP ([MEDICATION NAME]) ,[DATE] mg 1 tablet, by mouth two times daily for 30 days, -[DATE]; Discontinue [MEDICATION NAME]/APAP ,[DATE] mg, by mouth four times daily. Review of a nurse's note, dated [DATE], reflected resident to be a bit more lethargic. CNA reported VS (sic) taken to be low. Bruise to the right leg, unchanged. (Physician's name) here yesterday, N.N.O (sic) r/t puffiness to leg. Noted O2 Sat (sic) to be low, placed on 2L N/C (sic). Tried to reach (physician's name). Opted to send resi (sic) to ER RE (sic) decreased SPO2 et (sic) POA request for X-Ray to be done to right leg. Review of the nurse's notes from [DATE] through [DATE] did not reflect an injury or bruising. Review of a nurse's note, dated [DATE] at 5:00 p.m., reflected resident #2 was admitted to the hospital for a fractured RIGHT hip. Resident #2 did not return to the facility. During an interview on [DATE] at 9:00 a.m., a family member stated the resident had a fall at the facility on [DATE]. The family member stated she was not aware of the resident's fall, but observed a health deterioration and increase in the resident's pain level. She stated the resident could not walk, sit in the wheelchair, or lay down in bed without excruciating pain in the right hip. She stated she went to visit the resident on [DATE], and the resident continued to complain of hip pain. The resident was transferred to theER on [DATE], and found to have a [MEDICAL CONDITION] hip. The responsible party of the resident told the family member the resident was taken to theER on [DATE], after a fall. She was dropped off by the facility and left unattended. She stated the resident, who had Alzheimer's, told the ER the wrong hip needed x-rayed. The family member reported the resident expired at the hospital on [DATE], and was told by a hospital representative that the resident's last fall (on [DATE]) was the cause of the resident's death. During an interview on [DATE] at 12:15 p.m., staff member B, DON, stated a CNA usually accompanies a resident to the ER, unless the resident is transported by EMS. Staff member B stated the nurse usually calls and gives a verbal report to the ER staff. Staff member B stated a copy of the current MAR, face sheet and POLST are sent with the resident when transferred to the ER. If the ER wants more information, they will call the nurse. Staff member B stated there was no documentation regarding who transferred resident #2 to theER on [DATE] or the time of transfer. Staff member B stated she did not know if the nursing staff made the ER aware of the resident's history regarding an unstable right hip with previous fracture. 2. Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the significant change MDS, with an ARD of [DATE], reflected resident #5 had severely impaired cognitive skills, long and short term memory deficits and required extensive assistance with ADLs. Section N0410 reflected resident #5 received antianxiety, antidepressant and anticoagulant medication. Review of the Fall Evaluation Form, dated [DATE] through [DATE], reflected the resident had a high potential for falls with scores of 18 and above. Review of the facility incident log, IDT Fall Review forms and nurse's notes reflected resident #5 had eight falls between [DATE] and [DATE]. Three of the eight falls had documented injuries. Two of the eight falls reflected head trauma. All eight falls were unwitnessed. Four out of eight falls reflected the physician was notified via fax. Four out of eight falls did not reflect how the physician was notified. The following injuries occurred during the falls: -[DATE]; abrasion to left elbow, -[DATE]; no documented injury, -[DATE]; bruising to right knee, -[DATE]; hematoma to right side, back of head and abrasions to back, buttock, leg and right upper forearm, -[DATE]; no documented injury, -[DATE]; left shoulder ecchymosis, -[DATE]; no documented injury, -[DATE]; found with head wedged between the mattress and nightstand. Abnormal neurological findings. Review of the neurological sheet, dated [DATE] through [DATE] reflected abnormal neurological findings which included sluggish pupils, drowsiness, unable to follow commands and [MEDICAL CONDITION]. The abnormal neurological findings were not reported to the physician. Review of resident #5's medication changes reflected the following: -[DATE] [MEDICATION NAME] 30 mg (an antidepressant) was discontinued. [MEDICATION NAME] 1 mg by mouth at bedtime was started. [MEDICATION NAME] 1 mg by mouth as needed was started. Order to watch for lethargy and increased fall risk and to notify MD if concerned. -[DATE] [MEDICATION NAME] was decreased to 0.5 mg at bedtime and [MEDICATION NAME] decreased to 0.5 mg as needed. Previous orders were discontinued. -[DATE] [MEDICATION NAME] was discontinued. -[DATE] [MEDICATION NAME] was increased to 1 mg by mouth at bedtime. [DATE] [MEDICATION NAME] was changed to add 0.5 mg four times daily as needed. -[DATE] [MEDICATION NAME] was discontinued. [MEDICATION NAME] 25 mg at bedtime was started. If not effective after 3 days, then it was to increase to 50 mg at bedtime. She start [MEDICATION NAME] 1 mg once daily at 12:00 p.m. [DATE] [MEDICATION NAME] was decreased to 25 mg at bedtime for agitation. [DATE] [MEDICATION NAME] was decreased to 0.5 mg daily at 12:00 p.m. [DATE] [MEDICATION NAME] was decreased to 0.25 mg daily at 12:00 p.m. [DATE] [MEDICATION NAME] was added at 0XXX,[DATE] mg every 8 hours as needed for agitation. [DATE] [MEDICATION NAME] was added at 1 mg 3 times daily as needed for agitation. Review of the care plan for accidents and injuries, dated [DATE], and IDT Fall Review Forms did not reflect comprehensive evaluation of interventions related to medications, bowel/bladder status, behaviors or pain. The care plan did not reflect evaluation of effectiveness of current interventions. During an interview on [DATE] at 10:22 a.m., staff member E, RN, stated abnormal neurological findings were unequal grip, dilating pupils differ, muscle strength in limbs and indication of pain. Staff member E stated she would notify the physician right away of abnormal neurological findings. Staff member E stated the physician is notified via fax for non-emergent situations and via phone for other than non-emergent situations such as abnormal neurological findings. During an interview on [DATE] at 10:45 a.m., staff member N, RN, stated abnormal neurological finding were uneven hand grasps, drowsiness, not answering questions, how the pupils react to light, not able to move extremities and how they respond to touch and pain. Staff member N stated he would start neurological evaluation and notify the physician if neurological findings were abnormal. Staff member N stated that the physician is notified via phone if it is an emergent situation and via fax if it is non-emergent. 3. Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the facility incident log, nurse's notes and IDT Fall Review Forms reflected resident #10 had 2 falls, one fall on [DATE] with injury to the right shoulder and one fall on [DATE] with a bruise to the forehead. Review of the resident's Care Conference Summary, dated [DATE], reflected a fall on [DATE]. The facility did not provide documentation regarding the fall on [DATE]. Review of the Fall Evaluation Form reflected resident #10 had a high potential for falls with scores of 15 or higher. Review of the IDT Fall Review Form reflected a fall on [DATE] at 5:30 a.m. while the resident was ambulating to the bathroom. Review of the nurse's notes for the fall on [DATE] did not reflect a post fall blood sugar check. The nurse's note reflected the resident complained of pain to the right elbow. The resident was sent to the ER for evaluation; however the note did not reflect what time the resident was transferred to the ER, how he was transferred or what time he returned to the facility. It was found the resident strained a muscle in the arm, but did not have a fracture. Review of a physician progress notes [REDACTED].#10 was doing poorly with his right shoulder. The progress note also reflected the resident's right shoulder has pain with external and internal rotation .has some pain over his upper ribs underneath his arm, which may be causing a lot of his discomfort .some of this may be rib fractures. He also could have a rotator cuff tear that is not going to be seen on x-ray. Review of a PT note, dated [DATE], reflected the resident was advised to rest arm for a few days so has not been walking, using w/c (sic) instead. The facility did not provide nurse's notes for review from [DATE] through [DATE]. Review of the IDT Review Form regarding a fall on [DATE] reflected the resident was using the resident bathroom located next to the nurse's station, lost his balance and fell . IDT conclusion reflected the resident fell while using the bathroom, had been medicated for pain earlier in the morning, morning insulin had been given and blood sugars had been elevated lately. The IDT form did not reflect an assessment of whether the resident was safe to use the bathroom next to the nurse's station. Review of the nurse's notes for the fall on [DATE]-3:00 p.m., reflected the following: -Staff was notified by the visiting pharmacist of yelling from the bathroom. -The resident had fallen in the restroom at 12:10 p.m. and his head was up against the door. -The fire department and EMS were called to help get the bathroom door open. -At 11:30 a.m., the resident's blood glucose was 315. -The resident was removed from the bathroom and taken to the ER for evaluation. At 4:35 p.m., the nurse documented the return from the ER, which included that the resident had a bruised forehead. The documentation lacked evidence of the following: -An assessment upon return from the hospital -Monitoring for 72 hours post fall Review of the Neurological Evaluation Log, dated [DATE], reflected the 24 hour neurological assessment was incomplete. During an observation on [DATE] at 3:00 p.m., the resident bathroom located next to the nurse's station had a sign posted on the outside of the door which stated the bathroom cannot be accessed without a key. It was observed that once the resident was in the bathroom, staff could not monitor the resident without opening the door with a key. Review of the facilities Neurological Evaluation Policy reflected the following: 1. In the event that resident has an unwitnessed fall and/or it is suspected or known that the resident has bumped/hit his/her head, initiate neurological evaluations and continue for 24 hours. 2. Place resident on alert charting for 72 hours. 3. The nurse completes the Neurological Evaluation Log according to the following time frames: a. Every 15 minutes for the 1st hour. (If stable and within normal limits for the resident, continue.) b. Every 30 minutes for the 2nd hour after the fall. (If stable and within normal limits for the resident, continue.) c. Every 1 hour for next 3rd and 4th hour after the fall. (If stable and within normal limits for the resident, continue.) d. Every 4 hours for remaining 24 hours. 4. If any of the above evaluation are not within normal limits, immediately notify the physician. When reaching office personnel or an answering service, the nurse indicates that this is an emergency. 5. The nurse prepares resident for transfer to emergency room while awaiting return call from physician. 6. If the attending physician has not returned call within a reasonable time or the resident continues to decline, the nurse emergency transfers the resident to the hospital emergency department, notifies the physician and the Director of Nursing Services of the transfer and documents the evaluation findings leading to transfer. 7. If the resident is transported to the hospital during the evaluation, the nurse resumes Neurological Evaluation Log upon return. 4. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident discharged the facility on [DATE]. Assessment(s) A review of the resident's Admission assessment, with an ARD of [DATE], showed the resident was coded as a three (severely impaired) for cognition. The resident had short and long term memory deficits and exhibited inattention, disorganized thinking, and an altered level of consciousness during the assessment period. For mobility the resident was coded as needing two plus person's physical assistance for bed mobility, transfers, and toileting. The resident was coded as frequently incontinent of bowel and bladder. Section J1700 was coded as a 0 showing the resident had no falls in the last six months, and the resident had no falls since his admission. The resident was documented as weighing 133 pounds. A review of the resident's Fall Evaluation forms showed the resident was coded as a 6 on [DATE] and Routine Precautions would be utilized. On [DATE], the Fall evaluation score increased to a 26 (a score of 13 or above showed fall interventions and review was required) which did not change throughout the remainder of his stay. A review of the resident's Pain Evaluation form showed the resident had identified back pain, but the form was incomplete for 7 of the 9 categories on the form. The form was not dated, or signed by the staff member who completed it. The form included information for the staff to review areas such as resident conditions, medications, pain type, pain quality, and interventions for pain. Falls A review of the resident's Multi-Disciplinary Progress Notes and Interdisciplinary Fall Review forms showed: - The resident had nine falls from [DATE] to [DATE]. The falls occurred on [DATE], [DATE], [DATE] (two falls), [DATE], [DATE], [DATE], [DATE], and [DATE]. - The resident received injuries during three of the falls, which included: complaints of chest and back pain on [DATE], complaints of pain (not specified) on [DATE], and a hematoma to the back of the head, and a skin tear to the left shoulder on [DATE]. - The nurse documented causes of the falls included sliding or falling out of the wheelchair and recliner, and he had attempted to ambulate on his own. On [DATE], [DATE] and [DATE], the medical record failed to show evidence for the potential direct causes of the falls. - The IDT Fall Review forms showed the IDT team reviewed details for eight of the nine falls, and made recommendations for fall prevention which were not all carried over to the resident's care plan or care directive for staff use. 5. Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Assessment(s) A review of the resident's Annual assessment, with an ARD of [DATE], showed the resident was coded as having moderately impaired decision making, and short term memory problems. The resident did not display any behaviors, and had a fall prior to the assessment. A review of the Quarterly MDS, with an ARD of [DATE], showed the resident needed two plus person's physical assistance for bed mobility, transfers, dressing and toileting. He needed only one person to assist with ambulation. The resident was coded as being frequently incontinent for bowel and bladder, and weighed 211 pounds. A review of the resident's Fall Evaluation form showed the resident was evaluated on [DATE] and was scored as a 20. Anything above a 13 required fall interventions be reviewed. Two more evaluations were completed on [DATE] and [DATE], and the resident's risk increased to a 26. A review of the resident's Device Evaluation(s) for [DATE] and [DATE] showed the resident utilized alarms in his wheelchair for several reasons to include falling asleep in the chair. Falls A review of the resident's nursing notes showed the resident's falls consisted of: -On [DATE] - The resident transferred himself in the bathroom and fell , and had no injury. The intervention was to not leave the resident unattended while in the bathroom. -On [DATE] - The resident fell from his wheelchair and hit his shoulder and forehead. He sustained a bump and abrasion to the head, and a bruise to his eyelid. The interdisciplinary team recommended the resident be screened by therapy for potential services, and the resident's urine was to be checked for a possible urinary tract infection. Documentation for the urine screening was not evident in the medical record. -On [DATE] - A physician's progress note included documentation that the resident had a witnessed fall while transferring to the bathroom, and it appeared his knee gave out. When the resident fell , he hit his left shoulder on the wall. The resident was assisted back into the wheelchair by the physician. Assessment information was included in the physician's progress note, and the blood pressure was documented as ,[DATE] as of two days ago. Attempts to contact the physician on [DATE] and [DATE] were unsuccessful. On [DATE] at 4:00 p.m., the physician returned the call. He stated he did assess the resident at the time of the fall, but did not check his skin for injury, or take his blood pressure/pulse. He stated he reported the event to the staff on duty at the nursing station. The nursing progress note lacked evidence of the fall. A review of the Vital Signs Record sheet showed vitals were taken on [DATE] and then again on [DATE]. The record lacked evidence of any nursing progress notes after [DATE], or monitoring for potential injuries or problems the resident may have had from the fall on [DATE]. Documentation relating to the fall was requested on [DATE] at 6:00 p.m. No further evidence was provided. A review of the Interdisciplinary Fall Review forms showed the IDT reviewed the falls on [DATE] and [DATE]. For [DATE], documentation included that the resident fell asleep in the common area and he was assisted after the fall to prevent recurrence. A review of the IDT progress notes showed the team reviewed the resident weekly for any concerns regarding the resident from [DATE] to [DATE], but the IDT entries lacked evidence relating to falls. A review of the Multi-Disciplinary Progress Notes showed the nurse documented on [DATE], and then not again until [DATE]. The clinical record lacked evidence that the resident was monitored following the fall for injuries or effects relating to the fall. During an interview on [DATE] at 7:50 a.m., with staff member A, administrator, B, DON, C, staff development coordinator, and D, MDS coordinator, staff member A stated the staff was not aware the resident had a fall on [DATE]. The facility was unsure why the clinical record was lacking nursing documentation from [DATE] to the date of survey, nor who signed a facsimile page, which was a copy of the physician's dictated progress note from [DATE]. The facsimile included the fall information witnessed by the physician. Confirmation of who documented the handwritten signature on the facsimile was requested during the meeting, but was not received prior to the end of the survey. Behavior and Resident Seclusion A review of the resident's Multi-Disciplinary nursing notes for [DATE] to [DATE], showed the resident displayed the following behaviors: self-transferred, raised his voice to other residents, yelled for his food, yelled at staff, demanded particular food items, punched a fell ow resident, was exit seeking, refused medications and refused treatment(s). On [DATE], the resident was in the dining room and another resident yelled out. Resident #9 told him to shut up and went over and punched the other resident in the face. The nursing note included documentation that the resident would remain in his room for the rest of the weekend. The nursing note did not explain what alternatives were attempted prior to the decision for him to eat in his room, or how the plan would be reviewed, or parameters of the plan. On [DATE], the nursing entry included documentation that the resident was to continue to eat in his room for the weekend, per the DON. On [DATE] at 11:05 p.m., a request was made for how the facility decided the resident needed to eat in his room, and where the plan was located. On [DATE] at 1:55 p.m., staff member DJ, CNA, stated she was aware the resident was required to be taken to his room if he had a behavioral outburst in the dining room. She said she would give him space to calm down, tell the nurse about the behavior, and let the managers know. She was not sure if this was on the resident's Care Plan or Care Directive. She stated she thought the resident liked the quiet environment of his room. On [DATE] at 2:00 p.m., staff member I, CNA, stated the resident would yell at other residents in the dining room. He said if this happens he was supposed to take the resident to his room for the meal. Once the resident calmed down, the resident could come out of his room. Staff member I was not sure if the care plan included this plan, but recalls being told by someone that this was to occur in order to manage the resident's behavior. On [DATE], documentation was provided, which was an updated copy of the resident's Care Directive. The document showed the facility updated the plan on [DATE]. The update read, If res (resident) appears upset do not take to dining room until time to eat - If get agitated, offer to set up tray in room. If insistent on eating in the dining room, must be one to one. 6. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Assessment(s) A review of the resident's Admission MDS, with an ARD of [DATE], showed the resident was coded as a 7 (severely impaired) for cognition. She displayed minimal depression, and was not coded as having any behaviors. The resident was a two plus person physical assistance for bed mobility, transfers, walking, dressing, toileting, personal hygiene and bathing. The resident was also occasionally incontinent of bowel and bladder. Prior to coming into the facility, the resident was coded as having one fall. A review of the resident's Fall Evaluation, completed on [DATE], showed the resident scored an 11 for fall risk. A score of ,[DATE] required routine precautions in place per the form. On [DATE], the resident was assessed for fall risk again, and scored a 17. A score of 13 or above required fall interventions be reviewed. A review of a Device Evaluation form dated [DATE] showed the resident was utilizing an alarm when in bed to alert staff to the patient rising and to potentially protect the resident from injury. On [DATE], a Device Evaluation was completed for the use of a wheelchair alarm. The form lacked what measures were attempted prio

Based on interview and record review, the facility failed to adequately assess residents for pain, falls, behavior, nutrition/weight, skin injuries and bruises for 6 (#s 1, 2, 4, 5, 9 and 10) out of 10 sampled and supplemental residents. Specific findings included: IMMEDIATE JEOPARDY The facility submitted an acceptable plan of abatement for the immediate jeopardy on 9/21/15 at 3:20 p.m. After the immediacy was removed, the scope and severity for this deficiency was determined to be at the level of an H. Refer to F323 - Accidents and Hazards, for details on the Immediate Jeopardy Abatement Plan. During an interview on 9/15/15 at 10:00 a.m., staff member A, administrator, stated he participated in the facility's daily clinical meeting. During the meeting resident falls were reviewed and discussed amongst the IDT team. He stated the team would then develop a plan for the resident's future safety. The IDT would look at the causes of the falls, how to prevent the falls, to ensure notifications were made, and to ensure the fall assessments were completed. He stated the nursing duties were reviewed during the meeting to ensure they were managed properly. He stated each resident fall was unique, and with each one the facility looked at what the current interventions were for the resident, and then tried to find an permanent fix. During an interview on 9/16/15 at 6:35 a.m., staff member B, DON, stated the facility received training from the Regional Director of Clinical Operations on fall prevention. This occurred in March or April of 2015. The training included fall risk, contributing factors for falls, fall interventions, care planning and required documentation. 1. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the nursing admission assessment, dated 4/17/15, reflected resident #2 was confused and had a history of [REDACTED]. The clinical record did not reflect an assessment of the medical necessity for use of the lap buddy. Review of the Fall Evaluation, dated 4/17/15, reflected resident #2 had a high potential for falls with a score of 14. Review of therapy recommendations, dated 4/30/15, reflected resident #2 had extreme level of pain and discomfort in her right leg and was very aware of the pain and any movements made towards her would cause pain. For resident #2, discomfort = striking out. Review of the initial care plan dated 4/17/15, reflected PT/OT to evaluate and treat, independent with bed mobility, one person assist with ambulation and independent when in wheel chair. On 4/20/15, a bed alarm and wheel chair tab alarm were implemented. Review of a nurse's note, dated 5/14/15 at 2:00 p.m., reflected resident #2 had an unwitnessed fall at 8:00 a.m. on 5/14/15. The resident was found on the floor with her pants partially down. The note reflected the resident was combative when staff attempted to clean her up. The resident's blood pressure at the time of the fall was 80/48. The nurse's note reflected the resident was sent to the ER for evaluation and returned with an order for [REDACTED]. at the time of transfer, who transported the resident to the ER, how the resident was transferred to the ER, what was reported to the ER staff, or an assessment of the resident's condition upon return from the ER. Review of the ER report, dated 5/14/15, faxed to the facility on [DATE], reflected an X-Ray of the LEFT hip. The resident returned to the facility on [DATE] with an order for [REDACTED].>Review of an interdisciplinary note, dated 5/15/15, reflected resident #2 had one documented fall on 5/14/15, which required transfer to the ER for evaluation. Review of the IDT Fall Review form, dated 5/15/15, reflected resident #2 had a fall on 5/14/15. IDT Conclusions reflected the resident had been ill with diarrhea, increased irritability and combativeness towards staff and resisting care. The resident was to have a lap buddy in place when up in wheel chair. Review of nurse's notes from 5/14/15 through 5/21/15 reflected the resident was combative towards staff and often refused assistance with cares. Nurse's notes reflected the resident was confused and complained of increased right hip pain with transfers. Review of a physician progress notes [REDACTED]. There was not a re-evaluation of the resident's current pain management regimen until 5/19/15. The following medication changes were made for resident #2: -4/17/15; [MEDICATION NAME] 50 mg, by mouth at bedtime, -4/25/15; [MEDICATION NAME] 25 mg, by mouth two times daily, -5/5/15; [MEDICATION NAME] 50 mg, by mouth three times daily, -5/6/15; [MEDICATION NAME] 25 mg, by mouth two times daily, -5/19/15; [MEDICATION NAME]/APAP ([MEDICATION NAME]) 5/325 mg 1 tablet, by mouth two times daily for 30 days, -5/20/15; Discontinue [MEDICATION NAME]/APAP 5/325 mg, by mouth four times daily. Review of a nurse's note, dated 5/21/15, reflected resident to be a bit more lethargic. CNA reported VS (sic) taken to be low. Bruise to the right leg, unchanged. (Physician's name) here yesterday, N.N.O (sic) r/t puffiness to leg. Noted O2 Sat (sic) to be low, placed on 2L N/C (sic). Tried to reach (physician's name). Opted to send resi (sic) to ER RE (sic) decreased SPO2 et (sic) POA request for X-Ray to be done to right leg. Review of the nurse's notes from 5/14/15 through 5/20/15 did not reflect an injury or bruising. Review of a nurse's note, dated 5/21/15 at 5:00 p.m., reflected resident #2 was admitted to the hospital for a fractured RIGHT hip. Resident #2 did not return to the facility. During an interview on 9/17/15 at 10:22 a.m., staff member E, RN, stated she completed a pain assessment on each resident every time she had contact with them, at least three times per shift. Staff member E stated the s/s of pain in a confused resident were grimacing, holding an area, change in behavior, change in mobility and anything out of the normal. Staff member E stated she would fax the physician her findings and request changes if the resident's pain regimen was not effective. During an interview on 9/17/15 at 10:45 a.m., staff member N, RN, stated he completes a pain assessment on each resident at least once per shift. Staff member N stated the s/s of pain in a confused resident were verbal complaints, holding an area, body language, grimacing, clenching jaw, furrowing brow, moaning and screaming. Staff member N stated he would notify the physician immediately if the resident's pain regimen was not effective. During an interview on 9/17/15 at 12:15 p.m., staff member B, DON, stated a CNA usually accompanies a resident to the ER, unless the resident is transported by EMS. Staff member B stated the nurse usually calls and gives a verbal report to the ER staff. Staff member B stated a copy of the current MAR, face sheet and POLST are sent with the resident when transferred to the ER. If the ER wants more information, they will call the nurse. Staff member B stated there was no documentation regarding who transferred resident #2 to theER on [DATE] or the time of transfer. Staff member B stated she did not know if the nursing staff made the ER aware of the resident's history regarding an unstable right hip with previous fracture. 2. Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the significant change MDS, with an ARD of 9/18/15, reflected resident #5 had severely impaired cognitive skills, long and short term memory deficits and required extensive assistance with ADLs. Section N0410 reflected resident #5 received antianxiety, antidepressant and anticoagulant medication. Review of the Fall Evaluation Form, dated 1/31/15 through 9/15/15, reflected the resident had a high potential for falls with scores of 18 and above. Review of the facility incident log, IDT Fall Review forms and nurse's notes reflected resident #5 had eight falls between 1/5/15 and 5/26/15. Three of the eight falls had documented injuries. Two of the eight falls reflected head trauma. All eight falls were unwitnessed. Four out of eight falls reflected the physician was notified via fax. Four out of eight falls did not reflect how the physician was notified. Review of the falls reflected the following injuries: -1/15/15; abrasion to left elbow, -2/25/15; no documented injury, -3/14/15; bruising to right knee, -3/21/15; hematoma to right side, back of head and abrasions to back, buttock, leg and right upper forearm, -4/14/15; no documented injury, -4/23/15; left shoulder ecchymosis, -4/26/15; no documented injury, -5/26/15; found with head wedged between the mattress and nightstand. Abnormal neurological findings. Review of the neurological sheet, dated 5/26/15 through 5/27/15 reflected abnormal neurological findings which included sluggish pupils, drowsiness, unable to follow commands and [MEDICAL CONDITION]. The abnormal neurological findings were not reported to the physician. Review of resident #5's medication changes reflected the following: -4/1/15; [MEDICATION NAME] 30 mg (an antidepressant) was discontinued. [MEDICATION NAME] 1 mg by mouth at bedtime was started. [MEDICATION NAME] 1 mg by mouth as needed was started. Order to watch for lethargy and increased fall risk and to notify MD if concerned, -4/8/15; [MEDICATION NAME] decreased to 0.5 mg at bedtime and [MEDICATION NAME] decreased to 0.5 mg as needed. Previous orders of the [MEDICATION NAME] were discontinued, -4/21/15; [MEDICATION NAME] discontinued, -4/23/15; [MEDICATION NAME] increased to 1 mg by mouth at bedtime, 4/26/15; [MEDICATION NAME] changed to add 0.5 mg four times daily as needed, -4/30/15; [MEDICATION NAME] discontinued. [MEDICATION NAME] 25 mg at bedtime started. If not effective after 3 days, then increase to 50 mg at bedtime. Start [MEDICATION NAME] 1 mg once daily at 12:00 p.m., 5/11/15; decreased [MEDICATION NAME] to 25 mg at bedtime for agitation, 5/8/15; decreased [MEDICATION NAME] to 0.5 mg daily at 12:00 p.m., 6/1/15; decreased [MEDICATION NAME] to 0.25 mg daily at 12:00 p.m., 8/13/15; [MEDICATION NAME] 0.5-1 mg every 8 hours as needed for agitation, 8/26/15; [MEDICATION NAME] 1 mg 3 times daily as needed for agitation. During an interview on 9/17/15 at 10:22 a.m., staff member E, RN, stated abnormal neurological findings were unequal grip, dilating pupils differ, muscle strength in limbs and indication of pain. Staff member E stated she would notify the physician right away of abnormal neurological findings. Staff member E stated the physician is notified via fax for non-emergent situations and via phone for other than non-emergent situations such as abnormal neurological findings. During an interview on 9/17/15 at 10:45 a.m., staff member N, RN, stated abnormal neurological finding were uneven hand grasps, drowsiness, not answering questions, how the pupils react to light, not able to move extremities and how they respond to touch and pain. Staff member N stated he would start neurological evaluation and notify the physician if neurological findings were abnormal. Staff member N stated that the physician is notified via phone if it is an emergent situation and via fax if it is non-emergent. 3. Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the facility incident log, nurse's notes and IDT Fall Review Forms reflected resident #10 had 2 falls, one fall on 4/12/15 with injury to the right shoulder and one fall on 9/2/15 with a bruise to the forehead. Review of a Care Conference Summary, dated 6/3/15, reflected a fall on 3/14/15. The facility did not provide documentation regarding the fall on 3/14/15. Review of the Fall Evaluation Form reflected resident #10 had a high potential for falls with scores of 15 or higher. Review of the IDT Fall Review Form reflected a fall on 4/12/15 at 5:30 a.m. while the resident was ambulating to the bathroom. Review of the nurse's notes for the fall on 4/12/15 did not reflect a post fall blood sugar check. The nurse's note reflected the resident complained of pain to the right elbow. The resident was sent to the ER for evaluation; however the note did not reflect what time the resident was transferred to the ER, how he was transferred or what time he returned to the facility. Review of a PT note, dated 4/14/15, reflected the resident was advised to rest arm for a few days so has not been walking, using w/c (sic) instead. The facility did not provide nurse's notes for review from 4/16/15 through 8/24/15. Review of the nurse's notes for the fall on 9/2/15 reflected the following: -Staff was notified by the visiting pharmacist of yelling from the bathroom. -The resident had fallen in the restroom at 12:10 p.m. and his head was up against the door. -The fire department was called and EMS to help get the bathroom door open. -At 11:30 a.m., the resident's blood glucose was 315. -The resident was removed from the bathroom and taken to the ER for evaluation. -The resident returned from the ER at 4:30 p.m. -The resident had a bruised forehead. -The nurse's notes did not reflect an assessment upon return from the hospital. -The nurse's notes did not reflect monitoring for 72 hours post fall. -The nurse's noted did not reflect assessment for appropriateness to use the public bathroom independently. Review of the Neurological Evaluation Log, dated 9/2/15, showed it was incomplete. During an observation on 9/15/15 at 3:00 p.m., the resident bathroom located next to the nurse's station had a sign posted on the outside of the door which stated the bathroom cannot be accessed without a key. Once the resident is in the bathroom, staff cannot monitor without opening the door with a key. Review of the facilities Neurological Evaluation Policy reflected the following: 1. In the event that resident has an unwitnessed fall and/or it is suspected or known that the resident has bumped/hit his/her head, initiate neurological evaluations and continue for 24 hours. 2. Place resident on alert charting for 72 hours. 3. The nurse completes the Neurological Evaluation Log according to the following time frames: a. Every 15 minutes for the 1st hour. (If stable and within normal limits for the resident, continue.) b. Every 30 minutes for the 2nd hour after the fall. (If stable and within normal limits for the resident, continue.) c. Every 1 hour for next 3rd and 4th hour after the fall. (If stable and within normal limits for the resident, continue.) d. Every 4 hours for remaining 24 hours. 4. If any of the above evaluation are not within normal limits, immediately notify the physician. When reaching office personnel or an answering service, the nurse indicates that this is an emergency. 5. The nurse prepares resident for transfer to emergency room while awaiting return call from physician. 6. If the attending physician has not returned call within a reasonable time or the resident continues to decline, the nurse emergency transfers the resident to the hospital emergency department, notifies the physician and the Director of Nursing Services of the transfer and documents the evaluation findings leading to transfer. 7. If the resident is transported to the hospital during the evaluation, the nurse resumes Neurological Evaluation Log upon return. 4. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident discharged the facility on 3/19/15. Assessment(s) A review of the resident's Admission assessment, with an ARD of 1/30/15, showed the resident was coded as a three (severely impaired) for cognition. The resident had short and long term memory deficits. The resident exhibited inattention, disorganized thinking, and had an altered level of consciousness during the assessment period. For mobility, the resident was coded as needing two plus person's physical assistance for bed mobility, transfers and toileting. The resident was coded as frequently incontinent of bowel and bladder. Section J1700 was coded as a 0 showing the resident had no falls in the last six months, and the resident had no falls since his admission. A review of the resident's Fall Evaluation form showed the resident was coded as a 6 on 1/23/15 and Routine Precautions would be utilized. On 1/30/15, the Fall evaluation score increased to a 26 (a score of 13 or above showed fall interventions and review was required). The fall score did not change again throughout the remainder of the resident's stay. The medical record lacked evidence to show what measures were taken due to the increase in the fall score. A review of the resident's Device Evaluation Form (date not documented) for a bed alarm failed to show why the device was needed, what measures were attempted prior to the placement of the alarm, benefits of the intervention utilized, or signatures of the parties who evaluated the use/placement of the device. Falls A review of the resident's Multi-Disciplinary Progress Notes and Interdisciplinary Fall Review forms showed: - The resident had nine falls from 2/11/15 to 3/15/15. The falls occurred on 2/11/15, 2/13/15, 2/16/15 (two falls), 2/20/15, 2/23/15, 2/24/15, 3/6/15, and 3/15/15. -A review of the resident's MARs for January, February and March of 2015 showed he was given five medications which may have contributed to the falls. The medication side effects included, but also may have caused the resident to have: dizziness, drowsiness, fatigue, muscle cramping, anxiety or restlessness. These medications were: [MEDICATION NAME] HCL for generalized pain; [MEDICATION NAME] for behavior management, [MEDICATION NAME] for hypertension; [MEDICATION NAME] for Hypertension; and [MEDICATION NAME] for Parkinsonian features. A review of the resident's care plan showed a lack of monitoring for the medication's that had the potential to contribute to the resident's falls. The resident's Accident/Injury Care Plan included a category for Medication related side effects, which had not been selected as a problem for the resident. - The resident received injuries during three of the falls, which included: complaints of chest and back pain on 2/23/15, complaints of pain (not specified) on 3/6/15, and a hematoma to the back of the head, and a skin tear to the left shoulder on 3/15/15. - The nurse documented the causes of the falls included sliding or falling out of the wheelchair or recliner, and that he had attempted to ambulate on his own. On 2/13/15, 2/16/15, and 2/24/15, the medical record failed to show evidence of the potential causes or contributing factors to the falls. A review of the Event Reporting and Investigation policy showed, Event Investigation: 3. The Center should us the Event Investigation Report, or Fall Investigation report to document events for the center. 5. The nurse caring for the resident documents the occurrence and notification of the attending physician and resident's authorized representative in the Progress Notes in the Medical Record. A review of the Event Investigation Report included categories for the nurse to complete which included recording the location/injury, identification of the cause of the fall, and findings and action taken. The first page of the Report included a listing for staff duties to be completed for a fall. This included the care plan was to be reviewed or revised. - The IDT Fall Review forms showed the IDT team reviewed details for eight of the nine falls, and recommendations for fall prevention were not all carried over to the resident's care plan or care directive for staff use. Nutrition A review of the resident's Weight Record showed the resident gained 7.2 pounds between 1/26/15 and 2/13/15. The resident then lost 10.4 pounds from 2/13/15 to 3/5/15. A review of the Nutritional Evaluation Form and progress notes, Weight Record, and AIMs Evaluation showed: -The Nutritional Evaluation completed on 1/30/15, showed the resident had upper and lower dentures that did not fit well at the time of the evaluation. The medical record lacked evidence for how the dentures were addressed or if they caused the resident pain when eating. - The Nutritional progress notes, dated 2/28/15, showed the resident had poor intake, and the resident would be followed to ensure previous interventions were implemented. The documentation included, requesting weight. but did not state why the weight was requested or address the weight changes. The Nutritional assessment also lacked evidence for how the resident's behaviors may have affected his nutritional status. -A review of the resident's Abnormal Involuntary Movement Scale showed the resident had no problems with his teeth, and he did not wear dentures. The clinical record lacked evidence regarding the AIMs assessment, and whether the documentation was accurate regarding the dentures. -The Nutritional Status care plan lacked evidence for the resident's dentures or that the dentures did not fit well. The care plan also lacked evidence for interventions the staff could use when the resident was refusing meals. A review of the resident's Food Preference Record, dated 1/28/15, showed the resident's diet was mechanical soft. The category for Likes and Dislikes was incomplete. The facility failed to show if an assessment was done to determine the resident's likes and dislikes, or if the diet potentially affected his intake. A review of the resident's meal intake records showed: January - Thirteen meals were provided to the resident. - For nine of the meals, the resident consumed less than 50%. February - Eighty four meals were provided. - Nine of the meals had no documentation entered. - Seven of the meals showed the resident refused. - Seven of the meals showed the resident consumed 0%. - On 52 occasions the resident consumed less than 50% of his meal. March - Forty five meals were provided to the resident. - On six occasions, the resident was documented as consuming 0%. - On 36 of the meals, the staff documented less than 50% was consumed. The medical record failed to show what alternate interventions were assessed or attempted such as altering his meal texture, variety of food served, or times meals were offered in an attempt to increase the resident's intake. The facility failed to show if they assessed the resident's behavioral or cognitive deficits relating to meal intake. During an interview on 9/17/15 at 1:26 p.m., staff member M, dietitian stated she would document recommendations, and many things were used to assess a residents nutritional status. These included: reviewing the weight report, reviewing the resident's file, if the resident was new to the facility, did the resident have a new diagnosis, or if the resident had other contributing factors that may effect nutrition. During an interview on 9/15/15 at 11:20 a.m., staff member B, DON, stated she was specifically assigned to monitor the resident's status due to a facility program. If any concerns arose, staff member B would assist with resolving the issues. Staff member B recalled discussing the resident's falls, was aware of his behavior, and stated he refused care, meals and medications, but she did not believe she had documented on these areas. 5. Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Assessment(s) A review of the resident's Annual assessment, with an ARD of 1/2/15, showed the resident was coded as having moderately impaired decision making, and short term memory problems. The resident did not display any behaviors, and had a fall prior to the assessment. A review of the Quarterly MDS, with an ARD of 6/5/15, showed the resident needed two plus person's physical assistance for bed mobility, transfers, dressing and toileting. He needed only one person to assist with ambulation. The resident was coded as being frequently incontinent for bowel and bladder, and weighed 211 pounds. A review of the resident's Fall Evaluation form showed the resident was evaluated on 4/26/15 and was scored as a 20. Anything above a 13 required fall interventions to be reviewed. Two more evaluations were completed on 7/23/15 and 9/5/15, and the resident scored a 26. A review of the resident's Device Evaluation(s) for 7/5/15 and 7/24/15 showed the resident utilized alarms in his wheelchair for several reasons to including falling asleep in the chair. Fall A review of the resident's nursing notes showed the residents falls consisted of: -On 4/26/15 - The resident transferred himself in the bathroom and fell , and had no injury. The intervention was to not leave the resident unattended while in the bathroom. The nurse did not show the assessment of why the resident was transferring himself, or the environment at the time of the fall. -On 7/22/15 - The resident fell from his wheelchair and hit his shoulder and forehead. He sustained a bump and abrasion to the head, and a bruise to his eyelid. The interdisciplinary team recommended the resident be screened by therapy for potential services, and the resident's urine was to be checked for a possible urinary tract infection. The medical record lacked evidence for the urine follow up. -On 8/20/15 - A physician's progress note included documentation that the resident had a witnessed fall while transferring to the bathroom. It appeared his knee gave out. When the resident fell , he hit his left shoulder on the wall. The resident was assisted back into the wheelchair by the physician. Assessment information was included in the physician's progress note, and the blood pressure was documented as 126/58 as of two days ago. The clinical record lacked information relating to the fall other than the physician progress notes [REDACTED]. Attempts to contact the physician were unsuccessful on 9/17/15 and 9/18/15. A review of the Vital Signs Record sheet showed vitals were taken on 8/16/15 and 8/30/15. Documentation relating to the fall on 8/20/15 was requested on 9/17/15 at 6:00 p.m. No further evidence was provided. A review of the Interdisciplinary Fall Review forms showed the IDT reviewed the falls on 4/26/15 and 7/22/15. For 7/22/15, documentation included that the resident fell asleep in the common area and he was assisted after the fall to prevent recurrence. A review of the IDT progress notes showed the team discussed the resident from 5/15/15 to 7/20/15. The entries lacked evidence relating to falls, or if the team assessed any areas relating to falls. A review of the Multi-Disciplinary Progress Notes showed the nurse documented on 4/23/15, and then not again until 5/1/15. The clinical record lacked evidence that the resident was monitored, or assessed adequately for injuries. The record also lacked evidence for any nursing progress notes after 8/4/15, or any monitoring for potential injuries from the fall on 8/20/15. During an interview on 9/17/15 at 7:50 a.m., with administrative staff, staff member A, administrator, stated the staff was not aware of the resident falling on 8/20/15. Staff member A stated the nurses were questioned also on the fall. Staff member A also stated it was unclear why the clinical record lacked nursing documentation from 8/4/15 to the date of survey, nor who signed a facsimile page, which was a copy of the physician's dictated progress note from 8/20/15. The facsimile included the fall information witnessed by the physician. Confirmation of who documented the handwritten signature on the facsimile was requested during the meeting, but was not received prior to the end of the survey. Behavior and Resident Seclusion A review of the resident's Multi-Disciplinary nursing notes for 5/5/15 to 8/4/15, showed the resident displayed the following behaviors: self-transferring, raising his voice to other residents, yelling for his food, yelling at staff, demanding particular food items, punched fell ow resident, exit seeking, refusing medications and treatment. The notes did not show if the resident assessed why the resident was displaying the behaviors at the time they were occurring, or how to prevent them in the future. On 5/29/15 the notes showed the resident was in the dining room and another resident was yelling out. Resident #9 told him to shut up and went over and punched the other resident in the face. The nursing note included documentation that the resident would remain in his room for the rest of the weekend. The nursing note did not explain why he would be staying in his room, or if he was assessed for his mood/behavior or psychosocial status to ensure staying in his room was in his best interest. The clinical record did not show what alternatives were attempted prior to the decision to have the resident stay in his room. On 5/30/15, the nursing entry included documentation that the resident was to continue to eat in his room for the weekend, per the DON. On 9/17/15 at 11:05 p.m., a request was made for how the facility identified the resident needed to eat in his room, and where the plan was located to ensure he was not being secluded. No further information was received. On 9/18/15 at 1:55 a.m., staff member J, CNA, stated she was aware the resident was required to be taken to his room if he had a behavioral outburst in the dining room. She said she would give him some time and space from others to calm down, then would tell the nurse about the behavior, and let the managers know. She was not sure if this was on the resident's Care Plan or Care Directive. On 9/18/15 at 2:00 p.m., staff member I, CNA, stated the resident would yell at other residents in the dining room. He said if this occurred he was required to take the resident to his room for the meal. Once the resident calmed down the resident could come out of his room. Staff member I was not sure if the care plan included this information, but he recalled being told this was how the resident's behaviors needed to be managed. On 9/21/15 documentation was provided, which was an updated copy of the resident's Care Directive. The document showed the facility updated the care plan on 9/20/15. The update read, If res (resident) appears upset do not take to dining room until time to eat - If get (sic) agitated, offer to set up tray in room. If insistent on eating in the dining room, must be one to one. 6. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Assessment(s) A review of the resident's Admission MDS, with an ARD of 2/10/15, showed the resident was coded as a 7 (severely impaired) for cognition. She displayed minimal depression, and was not coded as having any behaviors. The resident was a two plus person physical assistance for bed mobility, transfers, walking, dressing, toileting, personal hygiene and bathing. The resident was also occasionally incontinen

Based on observation, record review and interview, the facility failed to ensure that residents entering the facility without pressure sores did not develop a pressure sore for 1 (#3) of 4 sampled residents. Specifically, the facility failed to ensure adequate hydration and nutrition; failed to accurately evaluate, update the physician of a pressure ulcer condition change, and document and implement skin condition changes on a facility acquired pressure ulcer. Findings include: Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the facility's Nursing Admission Evaluation dated 1/15/15, showed in Section II; Integumentary, the resident did not have any skin ulcers. During an observation on 4/14/15 at 9:12 a.m., staff member C, LPN, provided wound care on open left ischium pressure ulcer. The resident was wincing and reaching back in attempts to push the staff member's hand away. The staff member continued with the dressing change. The open area was the size of a small lemon and had swelling extending towards the iliac crest, coccyx and groin. The wound bed was covered with a brownish-black eschar. There was yellow slough at the margins of the wound and the wound edges were thick. The staff member stated the wound appeared to look worse than it did a few weeks prior. During an interview on 4/14/15 at 10:44 a.m., staff members C and I, LPNs, stated upon admission, the resident absolutely did not have any open skin wounds. During an observation on 4/14/15 at 10:10 a.m., staff member B, DON, removed the dressing cover to assess the pressure ulcer. The resident winced and reached back with his right hand in attempts to push staff member B away from the wound. The resident was pulling his hips away from the staff member's hand. Staff member B stated the resident appeared to be in pain, look at him, he's rolling around and in pain. During an interview on 4/14/15 at 10:10 a.m., staff member B, DON, stated the pressure ulcer to the resident's left ischium was acquired on 2/26/15. A review of the facility's Nursing Notes showed: - 1/25/15 at 3:10 p.m., Sore noted on left buttock. - 1/26/15 at midnight, Dressing to left buttocks intact, clean no drainage noted. - 1/27/15 at 1:35 a.m., Bandages to buttocks intact. - 1/28/15 at 12:35 a.m., Buttocks bandage in place. - 1/31/15 at 12:30 a.m., Dressing changed to left buttock area. - 2/5/15 at 1:00 a.m., Dressing changed to left upper thigh left lower buttock. - 2/19/15 at 4:30 p.m., Lg (sic) pressure wound noted on left ischium. - 3/17/15 at 11:30 p.m., Lt (sic) ischium wound beefy red with some light green areas. - 3/21/15 at 12:30 a.m., ulcer on ischium larger with streaks of green material. - 4/2/15 at 12:45 a.m., Dsg (sic) to ischium. Eschar noted. Temp (sic) 99.5. Tylenol given as scheduled. - 4/3/15 at 6:35 p.m., Dsg (sic) was (changed) to ischium this shift. Eschar present. - 4/12/15 at 11:30 p.m., Dsg (sic) changed to ischium. Unable to remove previous medi-honey. Appears to need debridement. - 4/13/15 at 10:30 a.m., dressing to ischium changed and cleansed, medi-honey was removed with ease wound has necrotic tissue on the wound new medi-honey dressing applied and covered with [MEDICATION NAME] dressing. - 4/14/15 at 1:00 a.m., Dressing to ischium changed as directed. Repositioning off of left ischium to assist with healing. No S/S of infection will continute to monitor. A review of a Physician's Telephone Orders on 4/6/15 showed, Ischium wound: cleanse, loosely pack wound with med-honey (sic) gauze (ensure dressing does not over lap wound edges, cover with [MEDICATION NAME] thin derma film, change BID. No further notifications of status changes to the physician were located. A review of the facility's Best Practice Guidelines showed: 1. Evaluate wound bed, wound edges, periwound (sic), and document status, including patient response to treatment every visit. 2. Measure wound(s) weekly & PRN using wound gauge measurement tool and document length, width, and depth. 3. Document and Coordinate with MD any worsening/changes in wound status such of S/S or infection, advance in stage, increased necrosis, non-adherence to treatment, etc. A review of the facility's Wound Care instructions showed: Step 3: Treatment plan- Decide on a treatment to start with. This will be reviewed by the facility wound care nurse. She is the person responsible for deciding that a treatment plan is appropriate. Step 4: Nursing notes- Describe the wound and treatment in the nurses (sic) notes. Update the family and MD if the wound worsens. Begin Alert Charting. During an observation on 4/13/15 at 11:17 a.m., resident #3 was lying flat in bed wearing only an incontinent undergarment brief. He was pointing and asking for water. The resident had dry oral mucosa with a dry furrowed tongue. A review of the resident's Care Plan Nutritional Status, dated 1/27/15 and 2/17/15, showed a potential in nutrition and hydration with risks of dehydration and skin breakdown. The goal was to maintain moist mucous membranes. A review of the facility's Meal Monitor Flow Sheet for March and April 2015 showed the resident ate on average between 0-50% of his meals. No supplements or alternate meals were offered. On average, the resident received less than 500 cc of fluids a day. A review of the facility's Nutrition Evaluation Form with Progress Notes showed an initial assessment on 1/15/15 indicating dietary would monitor for possible weight loss. On 1/30/15 progress notes showed the resident was at risk for weight loss due to dementia and inadequate oral intake. On 2/13/15 progress notes showed the resident would be monitored closely. No further notes were available.