Every finding on record at Logan Health - Conrad

Based on observation, interview, and record review, the facility failed to accurately complete the active diagnoses section of the MDS for 1 (#1) of 17 sampled residents. Findings include:During an observation and interview on 5/5/26 at 8:28 a.m., resident #1 was observed to have a dry, hacking cough, but no obvious shortness of breath. Resident #1 denied being admitted to the hospital or being treated for any respiratory illness.Review of resident #1's EHR, accessed on 5/6/26, showed a pneumonia diagnosis was present at the time he was admitted to the facility in May of 2025. The resident's EHR failed to show any hospital admission since May of 2025.Review of resident #1's Quarterly MDS assessment, with an ARD of 2/22/26, showed an active diagnosis of pneumonia.During an interview on 5/6/26 at 9:50 a.m., staff member C stated resident #1 had pneumonia at the time he was initially admitted to the facility in May of 2025. Staff member C stated she should have deleted the pneumonia diagnosis when the resident completed the treatment and had fully recovered from the illness.

Based on interview and record review, the facility failed to maintain documentation of the COVID-19 vaccination status (received or refused) for staff member F, out of those staff sampled for the received/refused COVID-19 vaccination tracking. Findings include: Review of staff member F's COVID-19 vaccination status, dated 5/6/26, showed the staff member had signed the declination on 5/6/26.During an interview on 5/6/26 at 10:42 a.m., staff member F stated he had been asked about getting the COVID-19 vaccination when he initially started at the facility (August of 2025). Staff member F stated he signed the declination form earlier on 5/6/26.During an interview on 5/7/26 at 8:59 a.m. staff members C and D stated staff member B was currently responsible for staff COVID-19 status documentation.Review of the facility's policy titled, COVID-19 Vaccination Program, 84.05.2021.OP.118, dated February of 2025, showed, Screening will be ongoing and allow for employees/residents who have initially declined, to receive the vaccine at a later date. The Infection Control Coordinator or designee will maintain surveillance data on COVID-19 vaccine coverage among employees/residents.

Based on observation and interview, the facility failed to discard expired food, and failed to properly date, label, and store food in the main kitchen freezer and cooler. These failures had the potential to affect all residents consuming food in the facility. Findings include:During an observation of the kitchen and interview with staff member G on 5/4/26 at 4:11 p.m., the dry storage area had two cups of instant oatmeal which expired on 3/11/26 and five boxes of instant cream of wheat which expired on 4/1/26. The cream of wheat boxes contained 10 packets each. There was also a 28-ounce box of creamy wheat which was open to air and not dated. The meat freezer was found to have a plastic bag containing some type of breaded meat product (possibly chicken tenders), a bag of breaded meat patties (possibly chicken), and a plastic bag containing beef patties. These three bags were open to air and not dated when received or opened. The vegetable cooler had an open bag of leaf lettuce which was not dated when received or opened. Staff member G stated she had been in her current position for one month. Staff member G stated she was aware all open items needed to be dated and that food needed to be discarded by their use by date or their expiration date. During an observation on 5/7/26 at 9:31 a.m., the three bags in the meat freezer and the bag of leaf lettuce were still present, open to air and not dated when opened.

Based on observation, interview, and record review, the facility failed to ensure an appropriate indication was given for the use of an antipsychotic medication for 1 (#7) of 17 sampled residents. Findings include:During an observation on 5/4/26 from 6:00 p.m. to 7:00 p.m., resident #7 was sitting at a table with two male residents. Resident #7 finished what was served for dinner and told staff she was still hungry. Staff provided a sandwich for the resident. The resident did not display any disruptive behavior during the dinner observation.Review of resident #7's physician order, dated 11/21/25, showed the resident was receiving olanzapine (anti-psychotic medication) 2.5 mg daily for a diagnosis of, F03.90 Unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety.During an interview on 5/6/26 at 1:45 p.m., staff member C stated she was responsible for ensuring pharmacy reviews and recommendations were completed. When asked about the use of an anti-psychotic medication (olanzapine) for a resident (#7) without behavioral disturbance, staff member C stated she had not noticed resident #7's most recent order for olanzapine (11/21/25) had a diagnosis that identified no behavioral issues. Staff member C stated, I know we can't use anti-psychotic medications if there are no behaviors. Staff member C did not know why this discrepancy was not identified.During an interview on 5/6/26 at 3:00 p.m., staff member E stated the discrepancy with the resident's diagnosis of dementia without behavioral disturbance was identified in March of 2026 during an IDT meeting. Staff member E stated the diagnosis was corrected on the resident's diagnosis list in the EHR. Staff member E did not know why the order for olanzapine, dated 11/21/25, did not have the correct indication for the use of an anti-psychotic medication for a resident with dementia. Staff member E stated the diagnosis list should match the medication order, and she could not explain why this discrepancy had been missed.During an interview on 5/7/26 at 9:43 a.m., staff member I stated that when resident #7 was initially admitted from an assisted living facility in May of 2025, the resident was demonstrating exit-seeking behaviors and anger towards the staff when she was not allowed to leave. Staff member I stated resident #7 was started on olanzapine while still at the assisted living facility. Staff member I stated the olanzapine was continued after admission due to her continuing behaviors. Staff member I stated the diagnosis of dementia without behaviors was from a previous admission in 2023. Staff member I stated he must have missed the discrepancy in the diagnosis, and it should have been dementia with behaviors. Staff member I stated the reason the olanzapine was being given was to control resident #7's exit seeking behaviors and anger.Review of the facility's policy titled, Pharmacy Medication Regimen Review, dated September 2025, showed, Pharmacist Medication Regimen Review (MRR) . c. The MRR may include, but is not limited to: . b. Evaluate medication for appropriate dose, indication, duration, .

Based on observation, interview, and record review, the facility failed to store food in accordance with professional standards by failing to dispose of expired food in dry storage and the walk-in cooler; track and record temperatures for a cooler located in a public area; and label and date food stored in the facility freezers; This deficient practice had the potential to affect all residents, staff, and visitors at the facility. Findings include: 1. During an observation on [DATE] at 12:32 p.m., a package of strawberries covered in thick white mold was observed in a small refrigerator on the secure unit, located inside the Sweet Shop. During an interview on [DATE] at 11:10 a.m., staff member J stated there was a resident who helped with the Sweet Shop, and it was possible she had placed the strawberries in the fridge that staff didn't catch. 47752 2. During an observation and interview on [DATE] at 11:26 a.m., the dry storage area contained six boxes of baking soda with an expiration date of [DATE]. The walk-in cooler had one open bag of Brussel sprouts, undated, and one five-pound bag of shallots with a use by date of [DATE], and a white, slimy appearance on the shallots and brownish liquid at the bottom of the storage bag. Staff member N stated everyone in the kitchen is responsible for checking items for expiration and disposing of any expired items. A small food cooler was in the corner of a small dining area, just outside of the kitchen. The cooler had no thermometer or temperature logs completed. In the cooler there were: - 5 yogurts - 5 individual cheese snack squares - 1 bowl of grapes - 1 bowl of pineapple - 3 bowls of cantaloupe, all undated - 20 Dasani water bottles were also in the bottom of the cooler. Staff member N stated the cooler was not supposed to be used and was not sure why staff kept using it. The freezer in the kitchen had a white plastic bag, sitting on top of a box labeled liver. The plastic bag contained 6 unidentifiable frozen meat product and had no label or date on the bag. Staff member N stated he thought the meat product was chicken fried steak but could not be 100 percent sure. During an observation and interview on [DATE] at 1:40 p.m., a refrigerator in the medication storage room contained three yogurt containers with an expiration date of [DATE]. Staff member D stated all staff were responsible for checking the refrigerators and freezers for expired or undated items. During an observation on [DATE] at 2:37 p.m., the freezer located in the main dining room contained one half eaten ice cream cake, no patient identifiers were noted on it, and was undated. There was a box of ice cream sandwiches, undated, and 3 disposable Pepsi cups with a frozen substance in them, which were undated. Review of a facility document titled, Food Storage, undated, showed: . 13. Refrigerated food storage: c. Every refrigerator must be equipped with an internal thermometer, 14. Frozen Foods: c. All foods should be covered, labeled and dated. All foods will be checked to assure that foods will be consumed by their use by dates or discarded. There was no documentation in the policy that addressed the expiration of food in the dry storage area.

Based on observation, interview, and record review, the facility failed to provide food at a safe and appetizing temperature for 6 (#s 1, 6, 9, 14, 19, and 139) of 17 sampled residents. This deficient practice increased the potential for foodborne illness and decreased the residents' satisfaction and enjoyment of their food. Findings include: During an interview on 4/21/25 at 11:19 a.m., resident #9 stated the food was sometimes cold when served in the dining area or in his room. During an observation and interview on 4/21/25 at 11:26 a.m., kitchen staff were placing food on plates, covering them, and placing them in a metal cart. The doors on the cart remained open while staff were plating food. Staff member N stated the metal carts were not insulated and did not hold heat like they should. Staff member N stated the metal food carts were delivered to the dining room right around noon. During an observation on 4/21/25 at 12:10 p.m., the first tray was served in the dining room. The metal food cart doors were opened, and the tray was removed. The doors were not closed. Passing meal trays in the dining room took another 25 minutes, and in that time the heat inside the uninsulated cart was not maintained due to the doors being open. During an interview on 4/21/25 at 12:29 p.m., staff member D stated meal trays were served in the main dining room first, then the room trays delivered. During an observation on 4/21/25 at 12:39 p.m., staff member P took the metal food cart and started to pass meal trays to the residents who preferred to eat in their rooms. During an interview on 4/21/25 at 2:41 p.m., resident #19 stated her biggest concern living at the facility was her food not being served hot. During an interview on 4/22/25 at 8:15 a.m., resident #14 stated, The food is always cold, I don't think I have had a warm meal since I have been here. During an interview on 4/22/25 at 8:18 a.m., resident #139 stated his food was not bad tasting but a lot of the time it was cold. During an interview on 4/22/25 at 8:42 a.m., resident #6 stated his breakfast was cold. Resident #6 stated, The food in this place is never really warm, it's always on the cold side ,and it takes forever to get the food. During an observation on 4/22/25 at 12:00 p.m., the metal food cart was brought to the dining room. During an observation on 4/22/25 at 12:10 p.m., staff members D and P started to pass meal trays to the residents in the main dining room. During an observation and interview on 4/22/25 at 12:25 p.m., staff member P stated, The food is often cold when it is time to pass the room trays because the room trays sit in this container, and the doors are often left open while trays are passed in the main dining room. Staff member P stated she does not know what the temperature is that food should be served at. During an observation on 4/22/25 at 12:27 p.m. Staff member P took resident #6's meal tray off the cart. The temperature of the fish sandwich was 123.6 degrees Fahrenheit, and the fries were at 119.0 degrees Fahrenheit. During an observation on 4/22/25 at 12:29 p.m. Staff member P took resident #139's meal tray off the cart. The temperature of the chicken sandwich (alternate entree) was 126.2 degrees Fahrenheit, and the fries were 120.8 degrees Fahrenheit. During an observation on 4/22/25 at 12:31 p.m. Staff member P took resident #14's meal tray off the cart. The temperature of the chicken sandwich (alternate entree) was 123.6 degrees Fahrenheit, and the fries were 119.0 degrees Fahrenheit. During an interview on 4/22/25 at 1:44 p.m., staff member G stated, Maintaining warm food temperatures is tricky for us. Staff member G stated when they used a steam table in the past it kept the food temperatures up, but they do not use it anymore due to lack of staffing. Staff member G stated sometimes food trays will sit for 20 to 30 minutes in the cart before they are served to residents. During an interview on 4/22/25 at 2:11 p.m., staff member D stated everyone tried to chip in to help get food trays out because of the food complaints. During an interview on 4/22/25 at 2:31 p.m., staff member D stated the staff tried to deliver trays as fast as they could to keep the food hot. Staff member D stated a steam tray would be helpful, but We don't know how to get it back, and now it is only used for special occasions. During an observation and interview on 4/23/25 at 11:55 a.m., lunch trays arrived in the dining area. Resident #19 received her lunch tray at 12:07 p.m., the pulled pork temperature was 121.5 Fahrenheit, and the temperature of the mashed potatoes was 126.6 Fahrenheit. Resident #19 stated her lunch was hotter than it normally was. During an observation on 4/23/25 at 12:02 p.m., the metal food cart arrived in the main dining room. During an observation on 4/23/25 at 12:10 p.m., multiple staff started to deliver food trays to residents seated in the main dining room. During an observation on 4/23/25 at 12:18 p.m., resident #1 was served pulled pork and unhappiest. The temperature on the pulled pork was 104.4 degrees Fahrenheit. Resident #1 was served in the main dining room. During an observation on 4/23/25 at 12:23 p.m., staff member IP started to deliver meal trays to residents who preferred to eat in their rooms. During an observation on 4/23/25 at 12:25 p.m., resident #6 was served pulled pork and creamed corn. The temperature on the pulled pork was 128.2 degrees Fahrenheit, and the creamed corn was 126.2 degrees Fahrenheit. During an observation on 4/23/25 at 12:27 p.m., resident #14 was served pulled pork and unhappiest. The temperature on the pulled pork was 127.9 degrees Fahrenheit, and the unhappiest were 121.4 degrees Fahrenheit. During an observation on 4/23/25 at 12:27 p.m., resident #9 received his lunch tray in his room. The pulled pork was 123.3 Fe, the creamed corn was 127.7 Fe, and the unhappiest were 117.5 Fe. During an observation on 4/23/25 at 12:28 p.m., resident #139 was served pulled pork and mashed potatoes. The pulled pork was 122.7 degrees Fahrenheit, and the mashed potatoes were 125.0 degrees Fahrenheit. During an interview on 4/23/25 at 1:26 p.m., staff member O stated, The food is tempted after it is cooked and when it is coming off the hot area. The food is then put on a plate, placed on a plate warmer, and covered. The food is then placed in the metal cart. The doors to the metal cart are left open until all the trays are placed inside. The doors stay open for about 15 minutes, sometimes longer, it just depends on what is being served that day. Once the doors are closed the metal cart is taken upstairs for staff to hand out (food trays) to the residents. Staff member O stated, The metal carts are not insulated so the food does lose some heat while we are plating. Another possibility (for food losing temperature) is once we deliver the metal cart, the staff upstairs do not always pass the food trays right away and they sit there. Review of a facility document titled, Production Temperature Log, dated 4/22/25, showed: Chicken breast- date-4/22/25, Time- 11:15 A, Temp-173. Breaded Cod- Time-no time documented, Temp-No temp documented Fries- Time-11:35 A, Temp-188. [sic] The sit time from the time the temperature was taken to when resident #S 6, 14, and 139 received their meals was between one hour and one hour and thirty minutes. Review of a facility document titled, Production Temperature Log, dated 4/23/25, showed: pulled pork- date 4/23/25, Time- 11:10 A, Temp-197.7 Corn- Time- 11:05 A, Temp- 204.4 Unhappiest- Time-11:13 A, Temp- 206.9 Mashed pot-Time-11:15 A, Temp-194.4. [sic] The sit time from the time the temperature was taken to when resident #S 6, 14, and 139 received their meals was between one hour and one hour and fifteen minutes. 52362 Review of a facility policy titled, Policy & Procedure Manual Food Temperatures, dated 2023, showed the following: . All hot food items must be cooked to appropriate internal temperatures, held and served at a temperature of at least 135 F . . Hot food items may not fall below 135 F after cooking . . Temperatures should be taken periodically to assure hot foods stay above 135 F . . Foods should be transported as quickly as possible to maintain temperatures for delivery and service. If food transportation times is extensive, food should be transported using a method that maintains temperatures (i.e., hot/cold carts, pellet systems, insulated plate bases and domes, etc.) . . Foods sent to the units for distribution (such as meals, snacks, nourishments, oral supplements) will be transported and delivered to unit storage areas to maintain temperatures . and at or above 135 F for hot foods . . Rapid Bacterial Growth and Foodborne Illness is in the Temperature Danger Zone when hot food temperatures are less than 135 F . [sic]

Based on observation, interview, and record review, the facility failed to have the required enhanced barrier precaution signage posted for residents who required enhanced barrier precautions for cares for 2 (#s 4 & 6) of 17 sampled residents; and failed to ensure staff adheared to proper infection control measures and policies for masking and hand hygiene for 1 (#9) of 17 sampled residents. This deficient practice had the potential to affect all residents who received care from staff not following infection control prevention measures. Findings include: 1. During an observation on 4/24/25 at 8:45 a.m., resident #4 was having wound care completed for a Stage III three pressure sore on her sacrum. Review of skin and wound assessments for the resident showed the wound had been present since early April 2025. There was no infection control signage, PPE supply cart, or extra PPE donned by staff, for enhanced barrier precautions. During an interview on 4/24/25 at 9:20 a.m., staff member F stated a pressure wound would require the use of enhanced barrier precautions. 47752 2. During an observation on 4/21/25 at 2:44 p.m., resident #6 was sitting in his wheelchair in his room. A foley catheter leg bag was attached to the left lower leg and drained by gravity. No enhanced barrier precaution sign was posted outside of resident #6's room. During an observation on 4/22/25 at 8:42 a.m., no enhanced barrier precautions sign was posted outside of resident #6's room. During an observation and interview on 4/22/25 at 12:30 p.m., no enhanced barrier precautions sign was posted outside of resident #6's room. Staff member P stated resident #6 was on enhanced barrier precautions because he had a Foley catheter. Staff member P stated there should have been signs posted. Staff member P stated she was not sure how anyone would know about the precautions if the sign was not up. Staff member P stated she had been educated on enhanced barrier precautions. During an interview on 4/23/25 at 10:54 a.m., staff member F stated when a resident was admitted into the facility or had a change and requires enhanced barrier precautions the nursing staff should notify him and initiate enhanced barrier precautions on that shift. Staff member F stated he was not sure why resident #6 did not have an enhanced barrier precautions sign posted outside of the room. Review of a facility document titled, Enhanced Barrier Precautions, with an effective date of 5/2021, showed: . During Enhanced Precautions: Everyone must perform hand hygiene entering and leaving the room, Providers and staff must also: Wear gloves and a gown for the following high contact resident care activities- Dressing, bathing/showering, changing linens, providing hygiene, changing briefs or assisting with toileting; Device care use (central line, urinary catheter, feeding tube, tracheostomy; wound care (any opening requiring a dressing [sic] CDC recommendations showed: . When implementing Contact or Enhanced Barrier Precautions, it is critical to ensure staff have awareness of the facility's expectations . Post clear signage on the door or wall outside of the residents room indicating the type of Precautions and required PPE. cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html 52362 3. During an interview on 4/21/25 at 11:19 a.m., resident #9 stated he was concerned about [Staff Member C Name] who had a cough and did not wear a mask. During an observation on 4/21/25 at 1:26 p.m., staff member C was not wearing a mask in the dining area while coughing; and the cough sounded deep and congested. During an interview on 4/22/25 at 2:31 p.m., staff member D stated staff member C does not wear a mask all the time when it should be used. During an interview on 4/23/25 at 9:48 a.m., staff member B stated staff member C, Has a horrible sounding cough, I tell him to please put on a mask, I gave him cough drops, I told him you need to wear a mask, I can't babysit him all the time, if I ask you to wear a mask, wear it. Staff member B stated a doctor told her to expect a lingering cough from the recent flu outbreak, and staff member C was given cough syrup. Staff member B stated she told staff member C, To sanitize regularly and don't be in people's faces. During an interview on 4/23/25 at 10:53 a.m., staff member F stated staff member C had a lingering cough from an influenza outbreak. Staff member F stated staff member C should be wearing a mask at work with a cough. Review of the facility's posted signage titled, Cover Your Cough, showed: .If you have any illness symptoms, PLEASE WEAR A MASK . [sic] Review of the facility's posted signage on the entrance door to the facility stated, WEAR A MASK IF YOU ARE SICK. [sic] 4. During an observation and interview on 4/22/25 at 10:23 a.m., staff member E did not perform hand hygiene after removing her contaminated gown and gloves, prior to walking into the clean side of the laundry facilities. Staff member E stated she performs hand hygiene every other load of dirty laundry. During an interview on 4/22/25 at 10:35 a.m., staff member A stated he had noticed staff member E did not perform hand hygiene after removing her contaminated gown and gloves, prior to walking into the clean side of the laundry facilities. Staff member A stated he was going to talk to staff member E regarding proper hand hygiene use when in the laundry area. Review of the facility's policy titled, Laundry and Linen Services, BHIC710, with a copyright date of 2025, showed: .1. Personal Protective Equipment (PPE) and/or handwashing is required when handling all types of linens. 2. All laundry are treated as infectious regardless of isolation precautions . Review of the facility's policy titled, Hand Hygiene, IPC104, with a copyright date of 2025, showed: 2 .situations/occasions where hand hygiene needs to be performed to reduce the risk to patients and health care workers . D. After handling contaminated laundry and waste .

Based on observation, interview, and record review, the facility failed to remove expired items from the medication room. Findings include: During an observation and interview on 4/21/25 at 1:40 p.m., the following items were found in the medication room: - 1 bottle of Humulin R insulin was open but had no resident identifiers or an open or expiration date on the bottle or box, - 1 box of Ayr Saline Nasal gel with an expiration date of 1/2025, - 1 box of 144 individual packets of A&D ointment with an expiration date of 12/2024, - 1 box diaper rash ointment with an expiration date of 3/2025, - 1 suture removal kit with an expiration date of 2/28/25, and - 4 duoderm adhesive dressings with an expiration date of 11/1/2024. Staff member D stated, Pharmacy comes down once a month and goes through the medication room for any expired medications. We are all responsible for double checking medications and supplies for expirations. During an interview on 4/23/25 at 1:30 p.m., staff member Q stated she was responsible for checking the medication room for expired medications. Staff member Q stated she checked the medication room monthly for expired medications, rotate medications, and stock medications that need stocked. Staff member Q stated she was unsure how she missed the expired medications. Review of a facility document titled, Medication Room, with an effective date of 6/2023, showed: . 3. Pharmacy staff should verify/check all medication expiration dates . 4. Medications that are expired will be removed .

Based on interview and record review, the facility failed to ensure the pharmacist identifed and addressed an as needed psychotropic medication for an excessive duration for 1 (#20) of 17 sampled residents. Findings include: Review of resident #20's physician orders, dated 11/21/24 to 4/23/25, showed an order for Lorazepam oral concentrate 2 MG/ML. Give 0.25 ml by mouth every 8 hours as needed for anxiety. No stop date was noted on the orders. Review of resident #20's monthly medication regimen review, completed by staff member L showed: - December 2024-Resident #20, No Significant Irregularities. - January 2025-Resident #20, No Significant Irregularities. - February 2025-Resident #20, No Significant Irregularities. - March 2025-Resident #20, No Significant Irregularities. During an interview on 4/24/25 at 9:01 a.m., staff member L stated she was responsible for the facility's medication regimen reviews. Staff member L stated when the medication regimen reviews were due she looked in the chart at progress notes, vital signs, current labs, physician's orders, assessments, and noted any change in condition. Staff member L stated, Psychotropic medications are frowned upon and should be minimized. Psychotropic medications have a 14-day limit and after that time the physician needs to re-evaluate the resident. Staff member L stated she was not sure how she missed resident #20's PRN lorazepam for multiple months. Review of a facility document titled, Extended Care Consultant Pharmacist, with an effective date of 5/2021, showed: 1. Pharmacist Medication Regimen Review (MRR) a. The pharmacist will review the resident's medical chart for irregularities monthly. .d. An irregularity includes, but is not limited to, the following: i. The use of a medication that is inconsistent with accepted standards of practice for providing pharmaceutical services, not supported by medical evidence . ii. An unnecessary drug, which is defined as any drug when used in: 1. Excessive dose, excessive duration, without adequate monitoring, . . iii. PRN Psychotropic Drugs: 1. PRN orders for psychotropic drugs are limited to 14 days a. Exception: If the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, the provider should document their rationale in the resident's medical record and indicate duration for the PRN order. [sic]

Based on interview and record review, the facility failed to ensure the Provider Order for Life Sustaining Treatment (POLST) was completed to include the signature, date, and time the provider signed the order for 1 (#31) and failed to ensure all areas of the form were completed by the resident or the resident representative for 1 (#139) of 17 sampled residents. Findings include: Review of resident #31's POLST form showed resident #31 wanted no CPR (cardiopulmonary resuscitation) with selective treatment. Resident #31 signed the form on [DATE], but the POLST form was not signed by a physician, or an advanced practice practitioner. Review of resident #139's POLST form showed resident #139 wanted comfort focused treatment with no CPR (cardiopulmonary resuscitation). In the patient signature section of the form there appeared to be what looked like an x and a check mark. There was no printed name or date signed by the resident or resident representative. During an interview on [DATE] at 10:32 a.m., staff member H stated the POLST forms should be filled out completely to include signature, printed name, and date by the resident or resident representative, and the physician needs to sign, print their name, and date the form. Staff member H stated all the POLST forms were in the medical record and also in a binder at the nurse's station. Staff member H could not verbalize why the two POLST forms were not entirely completed. Staff member H stated the physician usually signed the POLST within a couple of days, and if the physician is not available there were other providers who could sign the forms. Review of a facility document titled, Do Not Resuscitate, with an effective date of ,d+[DATE], showed: Procedure: . 2. Patients . will have their POLST form reviewed by the Provider each time the patient is admitted to the facility. A copy of the POLST will be placed in the patient's chart with an initial, date, and time .

Based on interview and record review, the facility failed to limit an as needed anti-anxiety medication order to 14 days or provide a physician's rationale for continued extension of the medication's use, for 1 (#20) of 17 sampled residents. Findings include: Review of resident #20's physician's orders, dated 11/21/24 to 4/23/25, showed an order for Lorazepam oral concentrate 2 MG/ML. Give 0.25 ml by mouth every 8 hours as needed for anxiety. No stop date noted on the orders. Review of physician's progress notes dated 12/18/24, 2/11/25, and 4/15/25, showed no documentation for the continued use of lorazepam past 14 days. During an interview on 4/24/25 at 9:01 a.m., staff member L stated, Psychotropic medications are frowned upon and should be minimized. Psychotropic medications have a 14-day limit and after that time the physician needs to re-evaluate the resident. Review of a facility document titled, Extended Care Consultant Pharmacist, with an effective date of 5/2021, showed: . iii. PRN Psychotropic Drugs: 1. PRN orders for psychotropic drugs are limited to 14 days, b. Exception: If the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, the provider should document their rationale in the resident's medical record and indicate duration for the PRN order.

Based on interview and record review, the facility failed to have a qualified Dietary Manager. This deficient practice had the potential to affect all residents in the facility. Findings include: During an interview on [DATE] at 11:26 a.m., staff member N introduced himself as the Director of Food Services. Staff member N stated he had been in that position since [DATE]. Staff member N stated that all of his certifications had expired, and had been for awhile, but he had been trying to get them up to date again. Staff member N stated he registered for the course in [DATE] but had not taken the test yet. During an interview on [DATE] at 4:00 p.m., staff member S stated they were working on getting staff member N certified. Review of a facility document titled, Food Service Director, Undated, showed: . Job requirements - Bachelor's degree or at least 5 years' experience managing a culinary department or operation. - ServSafe and State Certified in Safe Food Handling and Sanitation . - Certified Dietary Manager Preferred.

Based on observation, interview, and record review, the facility failed to provide hydration in cups that were not disposable. This deficient practice caused 2 residents (#s 1 and 31) of 17 sampled residents to feel distressed and frustrated. Findings include: During an observation on 4/21/25 at 12:29 p.m., staff member D was passing lunch trays in the main dining room. The lunch trays had hard plastic cups filled with juice or milk, and hard plastic handled cups for coffee, tea, or hot chocolate. After lunch trays were passed staff member D began to pass water in the dining room. The water was in clear, soft plastic, disposable cups. During an interview on 4/22/25 at 8:09 a.m., resident #31 stated using the disposable water cups upsets her and makes her feel like she is in jail. Resident #31 stated she was shaky at times and would spill the water from the soft plastic cup and caused her frustration. Resident #31 stated, I don't understand why my water cannot be in a normal cup, like my other drinks. During an observation and interview on 4/22/25 at 12:19 p.m., staff member D was passing water cups to residents. The water was in clear, soft plastic, disposable cups. Staff member D stated, I was told by [Staff member N] the kitchen does not have enough cups, so we were told to use disposable cups for the water. During an observation on 4/22/25 at 12:27 p.m., resident #1 was sitting at a small table, in his wheelchair. Resident #1 was trying to drink water from a clear, soft plastic cup and appeared to be having problems grabbing the cup. When resident #1 tried to grab the cup, he could not. Resident #1 made a loud sigh sound and moved on to a hard plastic cup, which contained milk. Resident #1 was not able to completely pick up his water cup to drink from it. During an observation and interview on 4/23/25 at 12:27 p.m., resident #1 was sitting at his table in the dining room. He had his lunch meal in front of him. Resident #1 appeared to be distressed. Resident #1 was upset because he could not pick up his water cup. Resident #1 pointed to the cup and stated can't. During an interview on 4/23/25 at 1:26 p.m., staff member O stated she had worked in dietary for many years. Staff member O stated, The nursing staff is choosing to use the disposable cups because it is easier for them. We have a ton of cups down in the kitchen that can be used, all they have to do is let us know, and we would take them upstairs for them. During an interview on 4/23/25 at 3:00 p.m., staff member R stated he worked in dietary. Staff member R stated there were plenty of medium-sized, hard plastic cups. Staff member R stated there was a shortage of small, hard plastic cups, but more had been ordered and they had been waiting for them to arrive. During an interview on 4/24/25 at 11:02 a.m., staff member N stated there was a shortage of small, hard plastic cups, but they had plenty of other sizes available. Staff member N stated staff member D was told they could not send up the small cups but offered them another size. Staff member N stated staff member D never told him to send up the other sized hard plastic cups. Review of a facility document titled, Standard of Care, BH227, with an effective date of 2/2025, showed: . G. Residents are provided with appropriate adaptive equipment . to maintain and or improve resident's ability to feed self.

Based on interview and record review, the facility failed to ensure a resident's diagnosed mental health condition was listed on their PASARR for 1 (#4) of 17 sampled residents. This deficient practice had the potential for appropriate mental health needs to be unaddressed. Findings include: Review of resident #4's physician orders, dated 12/17/24, showed the resident took Aripiprazole 2 mg daily for bipolar disorder. Review of resident #4's PASARR, dated 12/11/24, failed to show bipolar disorder as a listed diagnosis. During an interview on 4/23/25 at 10:00 a.m., staff member I stated the diagnosis of bipolar disorder was in resident #4's past medical history and H&P, but did not carry over to her current diagnoses, which were used when generating the PASARR. During an interview on 4/24/25 at 9:00 a.m., staff member L stated they did not know why a diagnosis which was in the H&P and attached to a medication would not be shown on the resident's list of medical diagnoses.

Based on observation, interview, and record review, the facility failed to implement a baseline care plan, outlining pertinent information needed to care for a new resident within 48 hours of admission for 1 (#139) of 17 sampled residents. This deficient practice had the ability to affect all new admissions receiving care in the facility. Findings include: During an observation and interview on 4/22/25 at 8:16 a.m., resident #139 was sitting on the edge of his bed watching TV. The volume on the TV was very loud. Resident #139 had his legs in a dependent position, with his feet on the floor. His legs appeared to be swollen and there was an indentation on his legs from his socks. Resident #139 stated he had heart problems, and his legs were swollen all the time. Resident #139 states it can be uncomfortable at times. Resident #139 stated he needed some assistance with getting dressed, personal hygiene, and some help with setting up his meals. Review of resident #139's diagnoses list showed he had congestive heart failure, diabetes mellitus Type 2, bipolar disorder, hypertension, obesity, and atrial fibrillation. Review of resident #139's electronic medical record showed he was admitted to the facility on [DATE]. Review of resident #139's baseline care plan was initiated on 4/14/25 and completed and locked on 4/21/25. During an interview on 4/23/25 at 2:55 p.m., staff member H stated she was responsible for completing baseline care plans. Staff member H stated resident #139's baseline care plan was not completed because she was not in the building at the time of his admission but initiated it when she returned. Staff member H stated there was no one else who initiated or completed the baseline care plan. Staff member H stated she knew the care plan was late, and staff looked at that information to care for new admissions. Review of a facility document titled, Care Planning, with a revision date of 6/2023, showed: . 3. The Care Plan is documented and part of the Medical record. A baseline Care Plan is developed within 48 hours of admission . The baseline Care Plan for each resident includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care . [sic]

Based on interview and record review, the facility failed to ensure a resident was showered according to their preference for 1 (#4) of 17 sampled residents. Findings include: During an interview on 4/22/25 at 11:11 a.m., NF2 stated the facility was sometimes short staffed and resident #4 would go a week and a half between showers. During an interview on 4/24/25 at 9:40 a.m., staff member B stated she was unsure if there was an error in documentation or if staff should have charted refused and selected n/a instead, but the records showed resident #4 was getting a shower about every nine days. Staff member B instituted a paper charting system to correct the deficiency. Review of resident #4's shower records, dated 1/1/25 - 4/23/25, showed the resident received 12 showers over the 96-day span. - 1/3/25 - 2/21/25 resident #4 was shown as having a shower every seven days. - 3/20/25 is the next documented shower, a 27 day gap. - 4/15/25 is the next documented shower, a 26 day gap. Review of resident #4's shower records, dated 1/1/25 - 4/23/25, showed only one documented refusal on 4/22/25. Review of resident #4's care plan, with a review date of 3/17/25, showed a focus area of ADLs. Interventions listed showed, I prefer a shower 2x/week.

Based on observations, interviews, and record reviews, the facility failed to provide adequate supervision on a secure dementia unit, resulting in 1 (#34) of 22 sampled residents ingesting odor eliminator; and failing to keep chemicals secure and inaccessible to residents with cognitive impairment; and failed to provide adequate supervision for fall prevention, for 2 (#s 6 and 15). Findings include: 1. During an interview on 4/25/24 at 11:17 a.m., staff member R stated she was uncomfortable working on the secure care unit by herself, and asked not to be assigned back there (secure care unit) unless there was another staff member with her. Staff member R stated there were too many incidents that happened on the secure care unit, and only having one staff member on duty during the day was unsafe. During an observation on 4/25/24 at 11:27 a.m., two residents were sitting in the dining room, and two residents were wandering around the dining room, of the secure care unit. No staff were present in the dining room. Staff member O came into the dining room at 11:37 a.m. The four residents were left unsupervised for 10 minutes. During an interview on 4/25/24 at 11:40 a.m., staff member N stated she was aware resident #34 had drank odor eliminator spray. Staff member N stated, The shower room was not locked, and [resident #34] walked in and was found drinking the odor eliminator. [Resident #34] will drink anything that is left around and unattended. She will try to drink anything and everything. Staff member N stated the only intervention she knew about was the sign that was posted in resident #34's room, reminding her to call staff for something to drink. Staff member N stated, Most of the doors (on the unit) do not have locks on them, and we really need to have them (locks) for resident safety. I have mentioned that to [Staff Member B] a couple of times. [Resident #34] needs one-on-one care, but we cannot do that, there is only one staff member back here (Secure Care Unit) during the day. I knew there were residents in the dining room, but I had to care for another resident. During an observation and interview on 4/25/24 at 11:45 a.m., the shower room door was closed, but unlocked. In the shower room the following chemicals were found: - two (2) purple top sani-wipe disinfectant cloths, located on a counter, - one (1) bottle of odor eliminator spray, located on a counter, - one (1) opened, undated bottle of vinegar, located in an unlocked cabinet, - two (2) plastic spray bottles labeled with a printed-out piece of paper labeled, Quat-Stat 5-deluted. There were no directions or indications for use on the bottle; and, - one (1) Plastic spray bottle with Sani-T-10 plus written in black marker. There were no directions or indications for use on the bottle. Staff member N stated she was not sure what kind of chemicals they were, but they were used to clean the shower after it was used. Staff member N stated she did not know where the chemicals came from or who maintained and refilled them. Staff member N stated she thought there was a binder in the soiled utility room, or in the clean linen closet, that had SDS information in it. Staff member N could not find the SDS information. During an interview on 4/25/24 at 11:51 a.m., staff member B stated the SDS binder is located at the nursing station. During an interview on 4/25/24 at 11:56 a.m., staff member B stated it was a team effort to update the SDS binder, which included staff member E, and staff member F. During an interview on 4/25/24 at 12:16 p.m., staff member M stated he was the staff member on the secure care unit when resident #34 ingested the odor eliminator. Staff member M stated he was doing resident care prior to lunch. Staff member M stated, I was walking down the hallway, saw [resident #34] sitting in the shower room, and she had the bottle of odor eliminator in her hand with the lid off, and the bottle was almost empty. I did not notify the nurse right away, but I should have. Staff member M stated he was not 100 percent positive that resident #34 had ingested the odor eliminator but felt she had ingested a least some of the contents of the odor eliminator bottle. During an interview on 4/25/24 at 12:23 p.m., staff member K stated staff member M did notify nursing staff of the incident with resident #34 on 4/20/24 at 3:00 p.m. Staff member W did the resident assessment and notified all the appropriate staff and resident #34's spouse. Staff member K stated poison control was contacted. Staff member K stated if the SDS sheets were not in the binder, she was not sure where they would be. Staff member K stated all the SDS sheets are to be in the binder. During an interview on 4/25/24 at 12:30 p.m., a call was placed to staff member W, who was the staff member on duty when resident #34 ingested the odor eliminator. No call back was received prior to the end of the survey. During an interview on 4/25/24 at 12:46 p.m., staff member F stated there were three staff members working together to get the SDS sheets together. Staff member F stated if there was not an SDS sheet in the binder, if one was not readily available, she would look it up online, print it out, and put it in the binder. Staff member F stated all cleaning chemicals were to have labels and directions for use. Staff member F stated, All of our spray bottles that have chemicals in them are properly labeled. During an interview on 4/25/24 at 12:51 p.m., staff member E stated the SDS binder is a collaborative effort (for the upkeep of it). Staff member E stated there was primarily three staff members responsible for maintaining the SDS binder. Staff member E stated, I have done a lot of education and training for the staff in this building regarding SDS information. As we get new chemicals, new SDS sheets are placed in the binder. Staff member E stated there should not be any chemicals in the secure unit unlocked. Staff member E stated, Those chemicals should not be back here at all, I am not even sure what that chemical is used for (plastic spray bottle with Sani-T-Plus written in black marker). During an observation and interview on 4/25/24 at 2:05 p.m., the following chemicals were observed in the secure care unit dining area and bathroom. - two (2) plastic spray bottles of Quad-Stat chemicals, located in the cupboard above the sink, with no lock, - eight (8) bottles of odor eliminator spray, in the bathroom off the main dining room, in the secure care unit, - 1 plastic bottle of eye glass cleaner, located in the bathroom off the main dining room, in the secure care area, - two (2) bottles of x-effect bowl cleaner located in an unlocked cupboard in the bathroom off the main dining room, in the secure care area; and, - one (1) half full gallon container of perineum cleaner, sitting on the paper towel dispenser, next to the toilet, in the secure care area. Staff member N stated, There are several residents who wander in and out of this bathroom all day, every day. Staff also use this bathroom to perform check and changes on the residents. The residents back here (secure care unit) can absolutely get into the drawers and cupboards in that bathroom. [Resident #34] is constantly in and out of this bathroom. The bathroom is located within the main dining area of the secure care unit. During an observation on 4/25/24 at 2:15 p.m., one bottle of perineum spray and one bottle of odor eliminator spray was on the shelf in resident #34's room. During an interview on 4/25/24 at 2:36 p.m., staff members A and B stated one of the interventions for resident #34 was not to have any kind of chemicals in her room, and a sign was placed (in the resident's room) reminding resident #34 to call staff for something to drink. A review of resident #34's Admission MDS, with an ARD of 2/27/24, showed resident #34 was severely cognitively impaired. - .Section C1000, Cognitive skills for Daily Decision Making. - .3. Severely impaired-never/rarely made decisions. Was checked by staff. A review of a facility binder titled, LTC SDS, showed: - no SDS sheets for the odor elimination spray, eye glass cleaner spray, Quad-Stat chemicals, x-effect bowl cleaner, or the Sani-T-Plus cleaner. A review of a facility policy titled, Hazardous Materials/Waste Management Program, EC290, with a revision date of 2/2024, showed: - . Policy 1. The program applies to all employees, patients, visitors, and departments of [Facility Name], . 4. The Program and related policies address Hazardous Material: chemicals . identification, handling, use, storage . and regulatory requirements, . 9. Responsibilities to ensure compliance with this policy are as follows: A. Environmental Services Manager . 3. Ensures compliance with the Program relative to all local, state, and federal regulations governing the use, storage, and disposing of hazardous materials and wastes . [sic] . 1. Maintains and updates electronic master file of all SDS. 50245 2. During an observation on 4/24/24 at 12:58 p.m., resident #15 was ambulating in her room, without her walker. The walker was turned away from her, and resident #15 was using the furniture to stabilize herself, as she walked from her nightstand, to the end of her bed. Record review of resident #15's care plan showed: - .I transfer with supervision and my 4WW . - . I am not to have a bedside table in my room so that I don't lean on it and fall . During an interview on 4/24/24 at 1:00 p.m., staff member K stated resident #15 was not a high fall risk resident. Staff member K stated resident #15 would be safe to walk without her walker outside of her room, without assistance. Staff member K stated resident #15 only fell when putting her shoes on herself, in the morning, as resident #15 would fall forward and lose her balance. Staff member K was not aware resident #15 was falling during the day. During an interview on 4/24/24 at 1:10 p.m., staff member M stated resident #15 was a high fall risk, and she had a bed alarm at night. Staff member M was not aware of resident #15 falling during the day. During an observation on 4/24/24 at 3:37 p.m., resident #15 ambulated by herself to the bathroom with her walker. During an observation on 4/24/24 at 3:41 p.m., resident #15 was ambulating in the hallway by herself, without her walker. Review of resident #15's nursing progress notes, dated 1/31/24 - 3/18/24, showed falls on the following dates: - 1/31/24 at 1:45 p.m., - 1/31/24 at 5:00 p.m., witnessed fall in the dining room where resident #15 fell lost balance, and fell backwards from her walker, - 2/3/24 at 12:45 p.m., - 3/6/24 at 11:00 a.m., unwitnessed fall resulting in injury, and - 3/18/24 at 12:54 a.m., resident walking in room without walker, next to her closet which was located across the room from resident #15's bed. 3. During an interview on 4/25/24 at 8:56 a.m., NF7 stated she was upset the facility did not have foot pedals on the wheelchair for resident #6. During an interview on 4/25/24 at 9:11 a.m., staff member U stated there were three falls last night. One of the witnessed falls was resident #6, who had been wheeled down the hallway by a staff member, and his feet caught the floor, causing him to fall head-first out of the wheelchair. Resident #6 had to be sent to the ER for a head laceration requiring four stitches. Staff member U stated, We have had so many falls. During an interview on 4/25/24 at 10:51 a.m., staff member I stated staff would always assist resident #6 back and forth to his room. Staff member I stated resident #6 did not usually use his feet to propel himself, in his wheelchair. Staff member I stated, I don't know, when asked why the foot pedals were not used on resident #6's wheelchair. During an observation on 4/25/24 at 11:42 a.m., staff member P brought resident #6 back to his room in his wheelchair. Foot pedals were not observed to be on resident #6's wheelchair. Resident #6 was not observed self-propelling down the hallway by himself. Once in resident #6's room, staff member P asked staff member Y, Why are these [foot pedals] not on his chair? Staff member Y stated, I don't know. Staff member Y attempted to put the leg rests on resident #6's wheelchair, but they were too short for resident #6. Staff member Y took the foot pedals off and placed them back in the closet During an interview on 4/25/24 at 11:49 a.m., staff member Y stated resident #6 is too weak to propel himself in the wheelchair down the hallway. During an interview on 4/25/24 at 11:54 a.m., staff member Y later stated, resident #6 does self-propel himself down the hallway in his wheelchair, which staff member Y found out about after she spoke with staff member K. During an interview on 4/25/24 at 12:42 p.m., when considering resident #6's tall height, staff member B stated she did not know why a larger wheelchair or longer foot pedals were not ordered sooner for resident #6. Record review of the Fall Investigation Form, dated 4/24/24, showed: . Action plan: Educate staff to use foot pedals when transporting/pushing resident in w/c. Remove foot pedals after transfer d/t resident able to self propel .

Based on interview and record review, the facility failed to ensure a registered nurse was on staff at least eight consecutive hours a day, seven days a week. This practice had the potential to affect any resident needing RN services when one was not available. Findings include: Review of the CMS [NAME] Payroll-based Journal for this facility, with a run date of 4/16/24, showed the facility triggered for not having RN coverage for eight consecutive hours each day on 39 days between the dates of 10/8/23 and 12/31/23. Review of the facility's nursing schedules, dated 10/8/23 - 12/31/23, reflected the facility did not have RN coverage for eight consecutive hours on 10/29/23. During an interview on 4/23/24 at 3:35 p.m., staff member B reviewed the schedule with the surveyor, and stated the facility did not have a registered nurse on 10/29/23. Staff member B did not know why a registered nurse was not scheduled.

Based on observations, interviews, and record review, the facility failed to ensure food was stored off the floor in the cooler and freezer; that staff wore beard covers appropriately; cleaned thermometers before use; and ensured proper hand hygiene was used and followed when serving food. These practices had the potential to affect all residents who received food from the kitchen. Findings include: 1. During an observation on 4/22/24 at 1:25 p.m., there was a stack of 13 food filled boxes on the floor of the freezer. One crate of 2% Milk was on the floor of the cooler. During an interview on 4/23/24 at 10:05 a.m., NF5 stated, food in coolers and freezers should be six inches off the floor, as a standard practice. 2. During an observation on 4/25/24 at 8:10 a.m., staff member X was wearing a beard cover, only covering his chin and mouth, not covering his full beard. Staff member X repeatedly touched his beard, beard cover, and nose while serving breakfast food at the buffet line in the main dining room. Staff member X pulled at his beard cover adjusting it 14 times in six minutes, from 8:10 a.m. to 8:16 a.m. Staff member X did not perform hand hygiene after touching his face, beard, and beard cover. This surveyor notified the kitchen supervisor, who removed staff member X from the buffet service to re-educate the employee. 50245 3. During an observation on 4/24/24 at 8:07 a.m., the thermometer was not cleaned by NF8 before it was used to take the temperature of the foods on the buffet. NF8 had not cleaned the thermometer in between taking the temperature of different foods. During an interview on 4/25/24 at 10:57 a.m., NF5 stated staff was expected to clean thermometers before use when taking the temperatures of foods.

Based on observations, interviews, and record review, the facility failed to ensure the staff and residents had access to the grievance process forms, were able to complete grievance forms for concerns voiced by residents, investigate grievances, and maintain evidence demonstrating the results of all grievances for 3 (#s 16, 21, and 35) of 22 sampled residents. This practice had the potential to affect anyone wanting to file a grievance or who had filed a grievance. Findings include: 1. During an interview on 4/22/24 at 2:46 p.m., resident #16 stated she had many complaints regarding staffing, the quality of the food, a wound on her ankle, not getting ice water throughout the day, and not receiving food as ordered on her meal ticket. Resident #16 stated she had notified staff member A of her concerns, but did not hear anything back on how her concerns were addressed, and many of her concerns had not been addressed at all. Resident #16 stated her husband and her both wrote letters to the administrator regarding their concerns, and they called her sometimes as well. NF3 stated he had also written letters of concern to the administrator and stated he did not know of a grievance process or a form for grievances. During an interview on 4/22/24 at 6:40 p.m., staff member B stated the grievance forms are in (at) the nurses' station, and the nurses provides them to residents if they request one. Staff member B stated the facility did not complete a grievance form for many of the concerns received, because the facility addressed them in the moment, so she did not feel a grievance form was warranted. During an interview on 4/22/24 at 6:43 p.m., staff member I stated, Good question, I have no idea. when asked where to find a grievance form. During an interview on 4/22/24 at 6:44 p.m., staff member U stated, That seems to be the question of the day, I haven't seen those forms in a long time, when asked where to find a grievance form. 2. During an interview on 4/23/24 at 9:38 a.m., resident #35 stated she had complained about the room being cold for weeks, and no one had fixed it. It was cold by the bed because there was a draft. Resident #35 stated she had complained to staff on the unit about not receiving the double bed as discussed at their first care conference. Resident #35 resided with her husband in one room and was told by the management she could have a double bed or push the beds together, when they attended a care conference on 2/12/24. Resident #35 stated, The food is always cold and we (residents #33 and #35) are tired of the same things over and over. Resident #35 stated she and her husband did not know of a grievance form they could use and did not know there was a grievance process. Resident #35 stated she would notify the floor staff of concerns and hoped they would fix it. During an interview on 4/23/24 at 2:00 p.m., staff member V stated the grievances had been processed through the previous administrator up until a month ago. Staff member V stated she received the book with only two grievances in it, and was not aware of where the other grievances were previously filed. Staff member V stated she was now responsible for processing grievances; however, the staff had not notified her of any grievances, and she had not received any grievance forms. Staff member V stated all grievances should have a form completed, including documentation of the complaint, the investigation notes, the resolution, and the follow-up to be sure the problem was addressed. Staff member V stated the facility was in the process of placing grievance boxes with grievance forms today, after surveyors questioned where they were located. Review of the facility's Grievance Log, 2023 - 2024, reflected two grievances in 2024. The concerns voiced by resident #16, NF3, and resident #35 were not in the grievance log. During an interview on 4/23/24 at 4:02 p.m., staff member A provided a spreadsheet of concerns reported to her by resident #16, not included in the grievance log. The spreadsheet reflected a column for the grievance, and a comments column that gave feedback on the grievance, some with resolutions and others with no comments. The spreadsheet failed to show any investigation process or follow-up regarding the effectiveness of any resolutions provided. Staff member A stated this was the only grievance spreadsheet not included with the grievance log, originally. 50245 3. During an interview on 4/22/24 at 3:50 p.m., NF7 stated she did not know about the grievance process. She would notify administration about any problems or concerns that she had about resident #6. During an interview on 4/23/24 at 10:32 a.m., resident #21 stated, No, never heard of it (grievances or the grievance process). During an interview on 4/22/24 at 6:44 p.m., staff member U stated the residents can put any comment, concern, or grievance in a box located outside of the administrator's door. When asked how a resident in a wheelchair would access this box, as it was located at shoulder level while standing. Staff member U stated residents would not be able to reach the box. Staff member U stated a resident could fall trying to reach the box. During an interview on 4/22/24 at 6:45 p.m., staff member A stated the facility did not have any more grievances than what was located in the grievance book. During an interview on 4/22/24 at 6:46 p.m., staff members I and U both stated they did not know where to find grievance forms at the nursing station.

Based on interview and record review, the facility failed to provide safe transfers and transport, complete assessments for appropriate safe transfers with a lift, and the safe use of an electric recliner; failed to educate staff for safe conditions, and failed to implement adequate safety interventions, resulting in 5 falls, a decline in health which ultimately led to the resident passing away, for 1 (#1) of 5 sampled residents. Findings include: 1. Review of resident #1's Safety, Quality & Risk Form, dated 7/3/18, showed the resident slid out of the wheelchair while in the transport bus, bumped her mouth, and obtained skin tears to her left and right arms. During an interview on 3/12/18 at 1:40 p.m., staff member B stated she secured resident #1 into the transport bus, but forgot to secure her seat belt. She stated she stopped suddenly at a yellow light, and the resident came out of her chair. She stated the facility provided training on safe transports after the accident, and she usually makes sure the seat belt is secure. Review of the facility'sPMC Driving Competency Evalution for staff member B, dated7/12/18, did not inlcude training on the use of seat belt security. Review of the facility policy for transporting residents, showed a transport required a facility attendant. The transport for resident #1 included a family member but no facility attendant. Review of resident #1's Care plan, dated 7/5/18, showed the root cause for the fall as an unsafe condition. 2. Review of resident #1's Safety, Quality & Risk Form, dated 8/12/18, showed the resident had her ankles crossed during a Sara Lift transfer, which the CNA did not notice, and the CNA had to lower the resident to the floor. She tried the transfer a second time and could not get the resident up. The resident's leg was stretched out side ways. The CNA said she thought the leg might be broken. The intervention to prevent further falls was Instructed to use lift for safety. Patient cannot stand. Remind staff to ensure legs are not crossed before standing. No further education for staff was provided by the facility. Review of resident #1' Care Plan, dated 8/16/18, showed the root cause of the fall was an unsafe condition. The intervention was to remind staff to make sure my legs are crossed. Resident #1 was not reassessed for a chanage in transfer status. 3. Review of resident #1's Safety, Quality & Risk Form, dated 9/4/18, showed the resident was being toileted in her bathroom, and her hand was caught between the grab bar, and the handle on the Sara lift. The resident's injury required an x ray and sutures to a lacerated finger. During an interview on 3/12/19 at 2:00 p.m., staff member D said she should have been more aware of the grab bar, because it sticks out. She stated the laceration occurred from the resident's ring. She stated she was not provided any further training on safe transfers. 4. Review of resident #1's Safety, Quality & Risk Form, dated 11/26/18, showed the resident was in the Sara Lift and her legs buckled. She began to slide to the floor. She was lowered to the floor. The action taken was may need to use a hoyer on her for safety. When CNA's put her in bed she never uses her legs to help and is very weak in the legs - truthfully, she is like lifting a bowl of Jello . Review of resident #1's Care Plan, dated 11/29/18, showed the root cause for the fall was unsafe use of equipment. The plan was to re-educate staff on equipment use. Documentation for the re-education of staff was not provided by the facility. Review of the facility Mechanical Lift Policy, for the criteria for the use of the Sara Lift, included The resident must be able to bear some weight on at least one leg, and some upper body strength in one arm. All employees must promote safety at all times and provide feedback to management staff when residents abilities change. 5. Review of resident #1's Safety, Quality & Risk Form, dated 12/12/18, showed the resident was being transferred with the Sara Lift, after 2 previous falls with the Sara Lift, and became weak and was lowered to the floor. The CNA was re-educated on the appropriate way to use a Sara lift. During an interview on 3/12/19 at 1:45 p.m., staff member C stated the CNA had not used the leg straps during the transfer. Staff member C stated she does periodic rounds for safe transfers. Review of resident #1's Care Plan, dated 12/18/18, showed the root cause for the fall was unsafe action by the staff. During an interview on 3/12/19 at 11:30 a.m., staff member A stated after three falls for resident #1 with the Sara Lift, she was changed to a Hoyer lift transfer. No assessment was completed for the continued use of the Sara Lift from 08/12/18 through 01/15/19. Staff member A stated falls and supervision were a work in progress for the facility. 6. Review of resident #1's Safety, Quality & Risk Form, dated 1/20/19 at 10:30 p.m., showed the resident was found on the floor - her electric recliner was raised as high as it could go, and she slid out onto the floor, and her legs were twisted in the blanket. Her hands are too crippled to push the buttons to stop the recliner from rising. Review of resident #1's Progress Note, dated 1/20/19 showed This recliner is unsafe for pt. She could not compute to stop the chair from continuing to rise. The resident stated no injuries, but later stated her right hip hurt but she thought it was from the way her legs were twisted up under her. Review of resident #1's Care Plan, dated 1/22/19, showed the resident was bed fast since the fall, with bruising from the knee to the ankle, and an X-ray was taken which showed a fracture. I have opted not to have surgery, and the orthopedic felt my fracture will heal. Review of resident #1's Progress Note, dated 1/21/19, showed resident has bruising on her right lower extremity from knee to ankle, with swelling present. She has complaints of pain with range of motion of the extremity. Resident complains of pain with repositioning. Review of resident #1's Progress Note, dated 1/22/19, showed the resident had complaints of discomfort with repositioning, and was given pain medication. Resident unable to follow instructions to swallow medication. Review of resident #1's Progress Note, dated 1/23/19, showed the resident was lethargic, able to answer some questions, catheter in place and draining yellow urine. Review of resident #1's physician progress notes [REDACTED]. Review of resident #1's Care Plan, dated 1/24/19, showed the root cause for the fall out of the recliner was an unsafe condition. Hands too crippled to push and stop recliner. Review of resident #1's Progress Note, dated 1/27/19 showed Unable to hold her head up. All offered fluids and pudding oozed out of her mouth. Poorly responsive to verbal and tactile stimuli. Review of resident #1's Progress Note, dated 1/28/19, showed the doctor removed the soft splint from the right lower extremity, and the resident was noted to have two open areas on the lateral malleolis and shin. Review of resident #1's Progress Note, dated 1/28/19, showed Called to room - no pulse - no respirations. The resident had passed away.

Based on interview, observation, and record review, the facility staff failed to use a gait belt to prevent a resident from falling, during a transfer. The resident had previously been identified as a fall risk, fell forward, hit his head and sustained a cut to his left temple, and a skin tear to his left hand, for one resident (#12). The facility also failed to identify hazards and risk factors after a resident (#13) had a fall with a fracture. The facility failed to identify the root cause of the fall, and implement and follow-up on new, individualized interventions. These failures affected 2 out of 15 sampled residents. Findings include: 1. Resident #12 was readmitted to the facility on [DATE], following surgery for [REDACTED]. He had fallen and incurred a left brachial injury with left hemiparesis prior to admission. A review of resident #12's Care Plan, started on 11/20/16 and updated on 2/10/17, showed the resident was at risk for falling and sustaining injury. Under the category of Approaches it specifically read: TRANSFER: I transfer with the Sara lift prn out of bed in the a.m. or SBA 1-2 (standby assist of one or two), gait belt and walker. A review of resident #12's Nursing Progress Notes showed a late IDT entry on 2/2/17 at 9:20 a.m. It read as follows: Resident had fall 1/28/17 @ 7:15 a.m. CNA was pivot transferring from bed to W/C and fell forward and hit forehead sustaining cut to L temple and skin tear to L hand. Had non-skid shoes on @ time of fall . Care plan reviewed and will have staff use Sara lift in AM when getting out of bed. Care plan updated. Review of resident #12's Care Plan showed an entry, dated 2/2/17 under transfer approaches. It read: CNAs will use Sara lift to get me out of bed in mornings as I'm stiff in the mornings. May use walker, gait belt and A1-2 (assist of one or two) as day progresses. For my safety, I will do these things. Review of the Incident Fall Report form, regarding investigation of resident #12's fall on 1/28/17, showed that the CNA had not used a gait belt when she attempted to pivot transfer the resident. During an interview on 4/27/17 at 11:05 a.m., staff member B was shown the incident fall report from resident #12's fall of 1/28/17. The staff member said the CNA had not used a gait belt when she attempted to pivot the resident and that if she had done so, the CNA using the gait belt may have been able to prevent the resident from falling forward and hitting his head. She stated the CNA should have known she needed to use a gait belt as it had been communicated to use one in the CNA care cardex for resident #12. A review of the CNA Care Cardex, for resident #12, showed under the column for resident transport: SBA, gb, 1-2 person, Sara lift p.m. During an interview on 4/27/17, at 11:37 a.m., staff member D stated she had written the original incident report regarding resident #12's fall. She stated she had concluded that the CNA should have used a gait belt during the resident's pivot transfer, and the use of a gait belt could have prevented the resident's fall. She stated she had counseled the CNA to use a gait belt for the resident's future attempts to transfer or to use the Sara resident lift as had been indicated in the resident's care plan. 2. Resident #13 was admitted to the facility on [DATE], with history of dementia with behavioral disturbance, a fall with a hip fracture, coronary artery disease, chronic kidney disease. Review of the facility's Incident Logs dated, January 2017, and March 2017, showed resident #13 had a skin tear on 1/11/17 with no documentation about the actual fall. On 3/14/17, the document showed a major injury fall. The incident log showed the following details for each fall: 1/11/17 -Location: 6 in room, other. -The form did not clarify where the fall occurred. -The cause: 9 unknown. -Investigation/possible cause: fell back and hit head on wall, landed on buttocks. -The form did not identify hazards or the root cause of the fall. -Comments: frequent checks after spouse leaves. -The facility did not define the frequency or identify what to the staff should check. 3/14/17 -Location: 2 in room by bed. -The cause: 6 illness/diagnosis. -The form did not show what illness or [DIAGNOSES REDACTED]. -Investigation/possible cause: found resident on floor by bed, pressure alarm on. Resident tried to look out window without assistance. -The form did not identify hazards or the root cause of the fall. -Comments: frequent checks. -The facility did not define the frequency or identify what to the staff should check. The form showed that a new intervention was not put in place from the resident's initial fall on 1/11/17. It also does not show a complete investigation with a root cause analysis, and it did not identify possibly hazards for falls or future prevention of falls. Review of resident #13's nursing Progress Notes, dated 3/14/17, showed the resident had an unwitnessed fall in her room. She was found lying on the floor, supporting herself up with her arms, and legs out in front of her. She verbalized feeling pain in her hip to the mid femur region. She was yelling out in pain. Her son was notified, and she was transferred to the ER within 10 minutes of her fall. Review of resident #13's nursing Progress Notes, from the IDT meeting dated 3/16/17, showed the following: Resident had an unwitnessed fall 3/14/17 at 10:40 p.m Pressure alarm sounding and CNA found sitting on floor. Complained of right hip pain and was sent to ER for evaluation and had a fractured hip. Sent to hospital for surgery. Will be skilled physical therapy/occupational therapy upon readmission. During an interview on 1/26/17 at 8:00 a.m., staff member B stated the facility did not have a separate form for fall reports. They used an internal form that was not a part of the resident's medical record. The root cause and investigation was discussed at IDR (a monthly meeting) and all notes from the investigation go in the nurses' progress notes. The staff member stated the internal form was not a fully complete, as it was an internal form, and not a part of the resident's medical record. Review of resident #13's care plan showed an intervention of frequent checks. The interventions on the fall care plan were not dated with when the intervention was put in place. There was no indication of the interventions being evaluated. During an interview on 4/27/17 at 8:30 a.m., staff member B stated the intervention for resident #13 was not tracked or documented when the frequent checks took place. The staff member stated that frequent checks on residents were a part of the CNAs' regular job duties and were to be completed hourly. Review of the facility's Extended Care Safety, Quality, and Risk Form dated 3/15/17, also showed the resident had an un-witnessed fall with an injury and fracture. The form showed the resident stated I need help, I wanted to look out the window. It did not identify any potential hazards or the root cause of the fall. During an interview and observation on 4/27/17 at 10:00 a.m., resident #13 and her family member both stated her room was crowded. They stated there was an old walker and wheelchair stored in her room that she did not use anymore. An old wheel chair was observed being stored next to the resident's bed and in front of the window. Next to the wheel chair was a walker, which the resident and family member stated she did not use anymore. Under the resident's sink were two wheelchair foot attachments, laying loose on the floor, which the resident and family member also stated was not used on her wheelchair. The facility did not show the potential hazards or root cause of resident #13's fall, which lead to a hip fracture. The intervention of frequent checks was not measured or re-evaluated for effectiveness.

Based on interview and record review, the facility failed to identify or obtain a [DIAGNOSES REDACTED]. The facility failed to show the medication was necessary, due to the lack of documentation evident in the medical record. The facility also failed to monitor the effectiveness of the medication and prevent the resident's functional decline of 1 (#1) out of 15 sampled residents. This had the potential to affect all residents who used a [MEDICAL CONDITION] medication. The findings included: Resident #1 was admitted to the facility on [DATE], with history of an aneurysm, [MEDICAL CONDITION] with an ejection fracture of 28%, [DIAGNOSES REDACTED], [MEDICAL CONDITION], and dementia without behavior disturbance. The resident's Admission MDS assessment, with an ARD of 1/28/16, showed a BIMs of 1 out of 15, severely impaired. During an interview on 4/25/17 at 4:38 p.m., NF1 stated the resident's POA was not notified about his medication changes. She felt the resident received unnecessary medications. NF1 also stated she was very concerned about the amount of decline the resident experienced since being admitted to the facility. Review of resident #1's medical record showed the following: 1/21/16 -Resident #1's admission to the facility. -Phase sheet showed Dementia in other diseases classified elsewhere without behavioral disturbance. -Admission physician note showed: The patient does have foot pain with ambulation due to his foot deformities. Alzheimer's dementia makes him quite [MEDICATION NAME] and he appears to be oblivious to conversation. -Alzheimer's dementia, severe, with behavioral issues, including nocturnal wandering. January -Behavior plan/monitoring started. -Resident did not have any behaviors documented during this month. February -Resident had behaviors noted on the following dates: 2/1, 2/7, 2/15, 2/17, 2/19, 2/20, 2/25, 2/26, 2/29. -The resident's pain was addressed two times during the month of February, 2/17/16 and 2/29/16. -Resident received PRN [MEDICATION NAME] on 2/8/16 and 2/10/17, which did not match the dates that his pain was assessed. 2/13/16 -Resident received [MEDICATION NAME] 5 mg IM ordered. -Behavior not documented in February behavior log, which means no nonpharmaceutical interventions were documented. -Nursing notes showed resident was very aggressive to staff and another resident. The resident refused cares but it does not show what nonpharmacutical interventions were used to address the behavior. -The physician order [REDACTED]. -Many older adult patients receive antipsychotic medications for inappropriate nonpsychotic behavior. Before initiating antipsychotic medication, the clinician should investigate any possible reversible cause; any stress or stress from any disease can cause acute confusion or worsening of baseline nonpsychotic behavior. Most commonly acute changes in behavior are due to increases in drug dose or addition of new drug to regimen; fluid electrolyte loss; infections; and changes to environment.¹ 2/17/16 -[MEDICATION NAME] 5 mg BID as needed, ordered. -Nursing notes for 2/17/16 showed resident was provided [MEDICATION NAME] for wandering in residents rooms and trying to use their bathroom, confused to be able to find his own. -The physician ordered [MEDICATION NAME] related to anxiety/agitation. -Resident was administered [MEDICATION NAME] the following dates: 2/17, 2/18, 2/19, 2/24, 2/25, 2/27, 2/29, 3/1, 3/1, 3/2, 3/2, 3/3, 3/5, 3/6. This is 14 doses over 22 days. -Warnings/Precautions state: Paradoxical reactions, including hyperactive or aggressive behavior have been reported with benzodiazepines, particularly in psychiatric patients. Does not have [MEDICATION NAME], antidepressant, or antipsychotic properties.¹ 2/23/16 -[MEDICATION NAME] 5 mg IM now ordered. -Behavior not documented on the behavior monitoring plan, which means no nonpharmaceutical interventions were documented. -Nursing notes showed resident was aggressive towards staff. The resident refused cares but it does not show what nonpharmaceutical interventions were used to address the behavior. 2/24/16 -[MEDICATION NAME] 25 mg in a.m., 50 mg in p.m., ordered. -Physician ordered [MEDICATION NAME] related to dementia with behavior disturbances. 2/25/16 -Resident had 30 day doctor's visit. Progress Note showed Reviewed labs from admission. At this time given his increasing agitation and some concern from staff we will start him on [MEDICATION NAME] 25 mg in the morning and 50 mg at in the afternoon to try to help with some of the agitation and aggression that he is having. We will monitor and adjust as needed. We will see him back at his next 30 day visit. -No new labs were ordered during this visit. March -Resident has behaviors every day in March, 3/1/16-3/6/16. -His pain was assessed 2 times, 3/1/16 and 3/6/17. -The resident did not receive any PRN pain medication in the month of March. 3/1/16 -[MEDICATION NAME] discontinued. [MEDICATION NAME] 5 mg in a.m., 10 mg in p.m., ordered with a [DIAGNOSES REDACTED]. -Nursing notes showed resident had continued behaviors on the [MEDICATION NAME] and nursing asked the provider to consider changing the residents medication to [MEDICATION NAME]. -Geriatric dosage: Consider lower starting dose of 2.5-5 mg/day for elderly or debilitated patients; may increase as clinically indicated and tolerated with close monitoring of orthostatic blood pressure.¹ -Warning/Precautions: Patients with dementia-related behavioral disorders treated with atypical antipsychotic's are at an increased risk of death compared to placebo. An increased incidence of [MEDICAL CONDITION] adverse events (including fatalities) has been reported in elderly patients with dementia-related [MEDICAL CONDITION]. [MEDICATION NAME] is not approved for this indication.¹ 3/7/16 -discharged to behavioral facility unit. Review of resident #1's nursing' Progress Notes showed progression of resident #1's behaviors over 6 weeks. He started out as pleasantly confused, then began urinating in inappropriate areas, and his behaviors advanced to aggression and crawling on the floors. Week 1 (1/21/16 - 1/30/16) -1/21/16: Admission day. Resident is ambulating but very confused. -1/22/16: Adjusting well to new environment. Sitting quietly in the dining room. -1/24/16: Resident had difficulty finding bathroom this morning, did urinate on pajamas, found ambulating in hall. Cooperate with cares. Confused and requests to go home. Ambulated in hall after lunch, easily redirected to dining room. -Three more notes about resident being confused but cooperative with cares. Week 2 (1/31/16 - 2/6/16) -2/1/16: Resident in room [ROOM NUMBER] urinating on a recliner. Resident was redirected back to his room and his bathroom, will suggest resident to be toileted rounds. -No nursing notes recorded from 1/25/16 to 2/1/16. Week 3 (2/7/16 - 2/13/16) -2/7/16: During supper tonight patient got up from the table, went in by the TV, pulled out his penis and began to pee on the floor. -2/9/16: IDT NOTE: Adjusting well. no psychoactive meds. Wanders looking for bathroom. No behavior problems. -2/13/16: Wandering about in haste, in other residents rooms, voiced threatening remarks to other residents and staff. Noted to have stool in his underwear, but refused all efforts to help with hygiene. -2/13/16: Very aggressive to staff and another resident. Order obtained for [MEDICATION NAME] after discussing behavior with resident's wife, Pauline. Asleep in a chair in common area, refuses to go to his room, will monitor. -There was no follow-up on root cause of the resident's change in behavior. Week 4 (2/14/16 - 2/20/16) -2/15/16: Staff found patient in female patient's room, had opened gate and got close to her recliner. Patient did leave when patient started to scream. Monitored closely for whereabouts. -Two more behaviors noted this week. Week 5 (2/21/16-2/27/16) -Three behaviors noted this week of continued aggression. -2/25/16: Resident appeared lethargic with a blank affect on face and was unable to keep head off table while sitting in chair. Week 6 (2/28/16 - 3/5/16) -3/1/16: When staff got him up he got aggressive and swung at CNA but did not connect with his punch. -3/2/16: Resident ambulating in room, got on his knees, then was unable to get up. Became combative, swinging at staff. Resident was seen by Dr. Taylor for ingrown, right, toenail and lower/extremely [MEDICAL CONDITION]. -3/2/16: Discussed resident going to St. Pete's Hospital in Helena with family. Will get lab work done. -3/4/16: Pt on floor picking at dark spots and trying to collect dust/dirt, assist up, agitated trying to strike staff, assisted to bed, unable to assess pupils or get temperature, or blood pressure. -3/4/16: Resident found on floor asleep, extremely combative. Provider and family notified. -Four additional behaviors noted this week, including the new behavior of resident being found on floor and crawling around attempting to pick things up. -No attempts have been made at this point to determine the root cause of the resident's change in behaviors. 3/7/16: discharged to behavioral facility unit. During an interview on 4/25/17 at 1:40 p.m. staff member F stated she remembered resident #1 switching to extreme behaviors really quick after admission. During an interview on 4/26/17 at 8:40 a.m., staff member B stated the nursing staff needed education on [MEDICAL CONDITION] medications. She stated for example, a nurse should never administrator [MEDICATION NAME] to a resident with history of [MEDICAL CONDITION]. During an interview on 4/27/17 at 10:00 a.m., staff member E stated [MEDICATION NAME] should be provided with a [DIAGNOSES REDACTED]. Review of resident #1's physician orders [REDACTED]. 2/13/16: -No [DIAGNOSES REDACTED].>2/23/16 -No [DIAGNOSES REDACTED].>A review of the facility's policy, [MEDICAL CONDITION] Medication Monitoring, showed the following: 1. Non-Pharmacological interventions will be tried and documented prior to the recommendation of [MEDICAL CONDITION] medication to the provider. Appropriate medications will be ordered based on the assessed needs of the resident. Resident and family will be educated to the reason for the medication change as appropriate, and alternatives tried prior to the medication. 2. The interdisciplinary team assesses residents on a [MEDICAL CONDITION] medication using the psychoactive/Hypnotic Monitoring Summary. Assessment must include documentation of alternative interventions tried without success. 5. A Behavior Monitoring Sheet will be initiated for residents with an addition, discontinuation, or dosage change of a [MEDICAL CONDITION] medication. These Behavior Monitoring Sheets are reviewed monthly. The interdisciplinary team will determine whether further monitoring is required. ¹Semla, T. P., PharmD, BCPS, FCCP, Beizer, J. L., PharmD, CGP, FASCP, & Higbee, M. D., PharmD. (2007). Geriatric Dosage Handbook (12th ed.). Hudson, OH: Lexi-Comp.

Based on observation, interview and record review, the facility failed to meet professional standards of quality for one (#7) of 14 sampled residents. Specifically, the facility failed to ensure staff followed physician's orders [REDACTED]. Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During an observation on 8/13/15 at 8:20 a.m., resident #7 was sitting at the dining room table eating breakfast. The resident was served unblended scrambled eggs and blended sausage gravy and biscuits. Staff member D, CNA, was assisting the resident with his breakfast. During an observation on 8/13/15 at 8:25 a.m., the resident was vomiting into an emesis bag at the dining room table. Staff member E and staff member F, CNAs, took the resident to his room. Staff member G, RN and staff member A, DON, came into the resident's room. Staff member A began suctioning the resident's mouth and throat. During an interview on 8/13/15 at 8:28 a.m., staff member A, DON, stated the resident had choked in the past and that was the reason the resident was on a pureed, thickened liquid diet. During an observation on 8/13/15 at 8:28 a.m., staff member G, RN, checked the resident's lung sounds and oxygen saturation and encouraged the resident to continue to cough. Staff member G stated the resident's left lower lung sounded a bit junky. During an observation on 8/13/15 at 8:40 a.m., the CNAs were checking the resident's vital signs and the resident continued to cough up thick sputum. Staff member A, DON, returned to the resident's room and the resident requested more suctioning in his throat. Staff member A stated staff had to be careful with the resident because of his choking risk. Staff knew what the resident could and could not eat and the resident would often request items that he could not have. Staff member G, RN, continued to suction the resident's mouth and throat. The resident stated there was still sputum and food stuck in his throat. The resident was coughing up large amounts of sputum and his nose was running. A large amount of sputum was suctioned from the resident's mouth and throat by staff member G. During an observation on 8/13/15 at 8:50 a.m., the resident had another large emesis and the content included pieces of scrambled egg. Staff member A cleaned the emesis from the resident's hand and shirt. Staff member A stated the resident has had swallow studies done. Staff member G stated she would call and notify the family and physician. Staff member A took the resident out to the nurse's station. During an interview on 8/13/15 at 9:10 a.m., staff member H, dietary cook, stated the resident received steamed scrambled eggs. The cook stated he did not puree any eggs that morning because scrambled eggs were not on the menu. He stated that was the reason why the resident may have choked. During an interview on 8/13/15 at 9:12 a.m., staff member I, dietary server, stated she looked at the resident's diet card and told staff member D, CNA, that she did not have pureed eggs on the dietary cart. Staff member D, CNA, told staff member I that she would mash up the eggs because the resident really liked scrambled eggs. During an interview on 8/13/15 at 9:22 a.m., staff member D, CNA, stated the resident loved eggs and he wanted eggs for breakfast every morning and it was reflected on his diet card. She stated she smashed up the eggs for the resident. When informed that the eggs were not pureed, staff member D stated the resident asked for the scrambled eggs, so she gave them to him. During an interview on 8/13/15 at 9:30 a.m., staff member J, dietary supervisor, stated there was nothing scheduled on the menu for eggs that day, but the kitchen staff would prepare scrambled eggs daily for the residents that wanted them. She stated the eggs would come already scrambled in a carton and then put in a steamer. She stated the consistency of the steamed eggs were more solid than pudding. Review of the physician's orders [REDACTED].

Based on observation, interview, and record review, the facility failed to ensure that one (#7) of 14 sampled residents remained free of accident hazards. The resident was on a physician's prescribed blended diet and the resident received scrambled eggs and the resident choked. Findings include: Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During an observation on 8/13/15 at 8:20 a.m., resident #7 was sitting at the dining room table eating breakfast. The resident was served unblended scrambled eggs and blended sausage gravy and biscuits. Staff member D, CNA, was assisting the resident with his breakfast. During an observation on 8/13/15 at 8:25 a.m., the resident vomited into an emesis bag at the dining room table. Staff member E and staff member F, CNAs, took the resident to his room. Staff member G, RN and staff member A, DON, came into the resident's room. Staff member A began suctioning the resident's mouth and throat. During an interview on 8/13/15 at 8:28 a.m., staff member A, DON, stated the resident had choked in the past and that was the reason the resident was on a pureed, thickened liquid diet. During an observation on 8/13/15 at 8:28 a.m., staff member G, RN, checked the resident's lung sounds and oxygen saturation and encouraged the resident to continue to cough. Staff member G stated the resident's left lower lung sounded a bit junky. During an observation on 8/13/15 at 8:40 a.m., the CNAs were checking the resident's vital signs and the resident continued to cough up thick sputum. Staff member A, DON, returned to the resident's room and the resident requested more suctioning in his throat. Staff member A stated the staff had to be careful with the resident because of his choking risk. Staff knew what the resident could and could not eat and the resident would often request items that he could not have. Staff member G, RN, continued to suction the resident's mouth and throat. The resident stated there was still sputum and food stuck in his throat. The resident was coughing up large amounts of sputum and his nose was running. A large amount of sputum was suctioned from the resident's mouth and throat by staff member G. During an observation on 8/13/15 at 8:50 a.m., the resident had another large emesis and the content included pieces of scrambled egg. Staff member A cleaned the emesis from the resident's hand and shirt. Staff member A stated the resident has had swallow studies done. Staff member G, stated she would call and notify the family and physician. Staff member A took the resident out to the nurse's station. During an interview on 8/13/15 at 9:10 a.m., staff member H, dietary cook, stated the resident received steamed scrambled eggs. He stated he did not puree any eggs that morning because scrambled eggs were not on the menu. The cook stated that was the reason why the resident may have choked. During an interview on 8/13/15 at 9:12 a.m., staff member I, dietary server, stated she looked at the resident's diet card and told staff member D, CNA, that she did not have pureed eggs on the dietary cart. Staff member D, CNA, told staff member I, that she would mash up the eggs because the resident really liked scrambled eggs. During an interview on 8/13/15 at 9:22 a.m., staff member D, CNA, stated the resident loved eggs and he wanted eggs for breakfast every morning and it was stated on his diet card. She stated she smashed up the eggs for the resident. When informed that the eggs were not pureed, staff member D stated the resident asked for the scrambled eggs, so she gave them to him. During an interview on 8/13/15 at 9:30 a.m., staff member J, dietary supervisor, stated eggs were not on the menu for that day, but the kitchen staff would prepare scrambled eggs daily for the resident that wanted them. She stated the eggs would come already scrambled in a carton and were put into a steamer. She stated the consistency of the steamed eggs were more solid than pudding. Review of the physician's orders [REDACTED]. Review of the swallow evaluation, dated 6/4/13, reflected resident #7 was at risk for complications from dysphagia, increased respiratory compromise, which alone increased aspiration risk, and risk for recurrent pneumonia secondary to the severity of dysphagia and potential penetration/aspiration. The swallow evaluation reflected the resident was at increased risk for aspiration and choking on food, liquid, and medications. The swallow evaluation recommended a pureed/blended diet with thin liquids and aspiration and reflux precautions. Review of the current resident diet list reflected the resident's diet was blended, nectar thick liquids and no green vegetables. Review of the resident's dietary card, dated 2/5/15, reflected a regular, blended diet, nectar thick liquids and a blended poached egg every morning. Review of the menu, dated 8/13/15, reflected juice of choice, malt-o-meal, sausage gravy on biscuits, melon, syrup, coffee or tea and milk. Review of the resident's care plan, dated 8/11/15, reflected the staff should offer blended fried or poached eggs at breakfast when the resident requested it and he would consume blended scrambled eggs. The care plan reflected the resident was very sensitive to small lumps in his blended foods. The staff were to strain all blended foods to ensure no lumps if processed blended foods were not used. At times, the resident would complain of receiving blended foods and thickened liquids and staff would re-educate the resident on his need for altered consistencies per swallow evaluation recommendations.