Every finding on record at Mountain View of Cascadia

Based on observation, interview, and record review, the facility failed to ensure food was stored, monitored, and served under sanitary conditions; failed to monitor consistently and document refrigerator and freezer temperatures; failed to implement and maintain food holding temperature logs and ensure hot food was maintained at safe serving temperatures; and failed to maintain the kitchen in a clean and sanitary condition. These deficient practices increased the risk for foodborne illness and contamination of food for all residents served food from the facility kitchen. Findings include:1. During an interview on 6/27/26 at 3:11 p.m., staff member H was asked about the multiple missing entries on the refrigerator and freezer temperature logs. Staff member H stated, Employees just fill in the next line without looking at the date.During an interview on 6/28/26 at 1:52 p.m., staff member C said missing refrigerator and freezer temperature documentation was identified approximately a week earlier, was addressed with the dietary staff, and she needed to again remind staff to complete the logs in the a.m. and p.m. as shown on the log.Review of the facility's refrigerator and freezer temperature log showed there were no temperatures documented in the a.m. or the p.m. on 6/18/26, 6/24/26, 6/25/26, 6/26/26, and 6/27/26. There were no temperatures recorded in the a.m. on 6/19/26 and 6/23/26.Review of the facility's most recent Monthly Sanitation and Safety Audit completed on 2/20/26 at 7:00 a.m., identified refrigerator and freezer temperature monitoring concerns, noting routine temperature documentation was missing.Review of the facility's policy titled, Food Safety and Storage, released on 11/28/2017, showed, Policy: The facility stores and handles all food, non-food items and food preparation supplies in a manner that ensures safety, sanitation, and compliance with federal, state, and local regulations.Procedure.Temperature Control.4. Refrigerator and freezer temperatures shall be monitored and documented at least once daily, or more frequently as determined by the facility assessment, equipment reliability, or local/state health code requirements.2. During an interview and observation on 6/28/26 at 8:40 a.m., staff member G stated she had checked breakfast food temperatures before meal service but had not documented the temperatures. The food temperature log hanging on the wall behind the service area showed no logs for the date of 6/28/26; the last date on the temperature log was 4/5/26, demonstrating food temperatures had not been routinely recorded for an extended period. Staff member G obtained temperatures of the food on the serving line. The cream of wheat cereal measured 125 Fahrenheit, below the recommended holding temperature of 135 Fahrenheit.During an interview on 6/28/26 at 1:52 p.m., staff member C stated the facility does not have a temperature log showing what the serving temperatures were prior to service. Staff member C stated the facility was in the process of implementing the system.A review of the facility's Monthly Tray line Observation, dated 2/19/26, showed: .Spreadsheets are visible and in use? - Spreadsheets put in use today.- No temperatures were recorded on each item for each diet.Recommendations included: . Take and document temperatures of all foods served (hot, cold and texture altered).A request was made for food temperature logs for the last 30 days on 6/28/26 at 5:05 p.m. Staff member A stated the facility did not have the requested documentation. No temperature logs were provided before the end of the survey.3. During an observation on 6/27/26 at 3:15 p.m., the following were observed:- All ceiling air vents in the food preparation/service areas in the kitchen were observed with an accumulation of dark brown to black dust and debris covering the perforated vent grilles. The accumulation was significant with a dense circular pattern over the area of each vent, showing the vents had not been cleaned for an extended period.- A wall mounted ventilation fan located near the refrigerator and freezer was observed with heavy buildup of dust, grease, and debris on the metal grille, fan blades and fan frame. Numerous dark specks of accumulated grease and debris were observed on the adjacent wall and the ceiling tiles directly above. The buildup adhered to multiple surfaces near the fan showing the fan and area surrounding had not been routinely cleaned.- Ceiling mounted fluorescent light fixtures located throughout the food preparation and service areas in the kitchen were observed with visible accumulations of dust, grease, and debris along the exterior housing and edges of the fixtures. The buildup was evident along the upper surface and seams of the light fixtures directly above areas used for food preparation and service.- Numerous ceiling tiles throughout the kitchen showed discoloration, stained and soiled surfaces. The ceiling tiles surrounding the ventilation and lighting fixtures displayed widespread staining, with darkened seams and water-like discoloration extending across multiples tiles. The stained ceiling tiles were located directly above food preparation equipment and work surfaces.During an interview on 6/28/26 at 1:37 p.m., staff member F stated she had completed a sanitation audit in late February of 2026 at the facility's request and had not performed another audit since that time.During an interview on 6/28/26 at 1:52 p.m., staff member C recognized the ventilation fans and ventilation grilles required cleaning and stated she had discussed the need for cleaning with the chief executive officer on a prior occasion.Review of the facility's document titled, Monthly Kitchen Checklist for June 2026 showed, .3. Take down exhaust vents and thoroughly clean: Blank.5. Clean Fans.: Blank .Review of the facility's most recent monthly sanitation and safety audit completed on 2/20/26 at 7:00 a.m., showed:- Ceiling vent covers and the fan were dirty.- Sprinkler heads and vents were dusty.- Wall fan needed cleaned.Review of the facility's policy titled Kitchen Cleaning Schedule, released 9/18/25, showed: Policy: The facility is committed to maintaining a clean, safe and sanitary food service environment in accordance with federal, state, and local health regulations. All kitchen equipment, surfaces and utensils will be cleaned and sanitized using approved procedures to prevent contamination and ensure the health and safety of residents. Cleaning responsibilities will be clearly assigned, scheduled, and monitored to promote accountability and compliance with best practices in food safety.The facility demonstrated a lack of effective oversight within the dietary department. The lack of an employed Certified Dietary Manager contributed to the facility's failure to implement and monitor food safety practices, including temperature monitoring and sanitation.

Based on observation, interview and record review, the facility failed to ensure the food was consistently served at a palatable temperature and delivered within the facility's established meal service time for 8 (#s 2, 14, 15, 25, 42, 43, 55, 58) of 18 sampled residents. These deficient practices resulted in repeated resident complaints of cold food, delayed meal service, and decreased resident satisfaction with the dining experience. Findings include:During an interview on 6/27/26 at 3:39 p.m., resident #2 reported the food was sometimes served cold.During an interview on 6/27/26 at 4:24 p.m., resident #55 stated he received his meals in his room and they were served cold. Resident #55 further stated his breakfast this morning was barely on the warm side.During an interview on 6/27/26 at 4:31 p.m., resident #42 stated she wished the food served was more on time.During an interview on 6/27/26 at 4:59 p.m., resident #58 said the food on the weekends wasn't good and she was served half-cooked hashbrowns and cold eggs.During an observation on 6/28/26 at 8:50 a.m., approximately half of the residents had been served breakfast while numerous residents remained waiting for their meals. During the observation, several residents continued waiting as meal service progressed and appeared to become increasingly impatient while waiting. Resident #43 repeatedly stood up from the dining room chair and approached both residents and staff, asking when breakfast would be served. Review of the facility's mealtimes showed breakfast was served at 8:00 a.m.During an observation and interview on 6/28/26 at 8:56 a.m., resident #15 was in the dining room and had not yet been served breakfast. Resident #15 said he was hungry as a bear ready for hibernation.During an observation and interview on 6/28/26 at 8:57 a.m., resident #43 was worried because she had not been served breakfast and stated, I need something to eat; I am hungry!During an interview on 6/28/26 at 9:02 a.m., staff member J said breakfast service was usually completed by 8:30 a.m. but said a staff member had called out that day.During an interview on 6/28/26 at 9:06 a.m., NF1 was seated by resident #14 at the dining table and said meals were served late five days per week, and he was concerned because his family member had been seated at the dining table since 8:00 a.m., and she had not received her breakfast.During an observation and interview on 6/28/26 at 9:10 a.m., resident #25 had not been served breakfast and stated, It's like this every day, referring to the delay in the meal. Resident #25 expressed concern that residents with scheduled appointments could miss those appointments because of delayed meal service.Review of the facility's resident council minutes showed the following:- January 12, 2026, Dietary: Food temperature, . Sometimes served cool when should be warm, especially if eating in room. [sic]- February 10, 2026, Dietary: Food temperature, . Cold, late 45 minutes plus wait time. [sic]- March 3, 2026, Dietary: Food temperature, . Long waits at mealtimes, result in cold food. [sic]- April 7, 2026, Dietary: Food temperature, . sometimes still served cool when there is a long wait time. [sic]- May 5, 2026, Dietary: Mealtime: Breakfast 7:30 a.m. - 8:30 a.m.; Lunch 12:00 p.m. - 1:00 p.m.; Dinner 4:30 p.m. - 5:30 p.m. Serving Wait time - Ok most of the time but lately had some excessive waits (delays) at lunch. Sometimes for over an hour and half. it was acknowledged that there were days of genuine extended wait times when lunch was not ready for serving at 12pm as stated on the hours posted. [sic]- June 9, 2026, Dietary: Serving wait time - Better, wait times are 15-30 min average, with an occasional day where a 45 + min wait occurs.Food Temperature, . Cold.Review of the facility's mealtimes showed breakfast was served at 8:00 a.m., lunch was served at 12:00 p.m., and dinner was served at 5:00 p.m.

Based on interview and record review, the facility failed to employ a Certified Dietary Manager or a full-time dietitian to direct the dietary department functions, and this resulted in inadequate oversight and systemic problems being identified in the facility's dietary department. This failure may affect any resident receiving services from the dietary department. Refer to F803 - Menus Meet Resident Needs, Prepared in Advance and Followed, F804 Nutritive Value and Appearance, Palatable and Preferred Temperatures, and F812 Food Procurement, Store, Prepare and Serve, Sanitary for other regulatory areas cited due to the lack of oversight and maintaining compliance. Findings include:During an interview on 6/28/26 at 1:25 p.m., staff member E, the consultant dietician, said she provided clinical services to the dietary department remotely and had not physically been to the facility's kitchen to oversee dietary operations.During an interview on 6/28/26 at 1:37 p.m., staff member F said she was invited to the facility for a quarterly sanitation audit in February 2026. Staff member F said she was working with staff member C in the training for the role of dietary manager.During an interview on 6/28/26 at 1:52 p.m., staff member C stated her prior experience consisted of front-of-house management and general kitchen management. Staff member C said she did not have experience managing a dietary department in a long-term care setting. Staff member C further noted she had completed the ServSafe training and was currently working on training through the facility's online training program.Requests were made for the dietary manager's certification on 6/28/26 at 10:31 a.m. and at 5:05 p.m. The facility reported that the certification was unavailable as the staff member was unable to access the system. No documentation was provided prior to the survey exit. The facility was provided an opportunity to submit further information post-survey related to the dietary manager's certification, if available. During an interview on 7/7/26 at 3:44 p.m., post-survey exit, staff member I said there was confusion between himself and staff member C related to the kitchen manager certification. Staff member I stated that staff member C had only completed the ServSafe certification and did not meet the criteria for the certified dietary manager. Staff member I further stated that staff member C did have some kitchen experience but had not managed dietary services in the long-term care setting.The failure to employ a qualified Certified Dietary Manager resulted in inadequate oversight of the dietary department and contributed to failures to ensure safe food temperatures, maintain required temperature monitoring records, implement sanitation and cleaning schedules, and maintain the dietary department in a clean and sanitary condition.

Based on observation, interview, and record review, the facility failed to ensure menus were planned and followed as approved; and failed to obtain registered dietitian approval prior to implementing facility-wide menu substitutions, including substitutions affecting therapeutic diets and altered food textures. The deficient practice resulted in residents receiving meals that differed from the approved menu and therapeutic menu extensions without prior review to ensure nutritional equivalency, affecting all residents who were served food from the kitchen. If the failure is not corrected, it may affect all residents at the facility in some manner as related to meal services and nutrition. Findings include:During an observation and interview on 6/27/26 at 2:52 p.m., staff member D stated dinner would consist of a chef's salad and said she needed to figure out something different for residents receiving minced and moist and pureed diets because they could not consume the chef's salad. Review of the posted week two menu showed the scheduled dinner for 6/27/26 was a chef's salad, dinner roll, choice of dressing, chocolate frosted peanut butter bar and milk. Observation further showed there was no posted menu or therapeutic menu extension identifying the required meal conversion for therapeutic diets and altered textures.During an observation on 6/27/26 at 5:32 p.m., the residents seated at the assisted table who required altered textures were served thickened tomato soup, pureed roast beef and butterscotch pudding, a meal that differed from the approved menu. There was no evidence the substitution had been reviewed or approved by the Registered Dietitian prior to service.During an interview and observation on 6/28/26 at 8:40 a.m., the breakfast menu for week three showed a choice of cereal, French toast with butter and syrup, sausage links, banana, and milk. The breakfast menu for week two showed a choice of cereal, waffles with fruit topping and whipped cream, sausage patty, orange wedges, milk, and a choice of vitamin C juice. Staff member G said waffles, the choice of cereal, and sausage patties were being served for breakfast that morning and further stated scrambled eggs were also being prepared because the kitchen was running low on waffles. Observation showed fruit topping, whipped cream, and orange wedges identified on the week two menu were not served for breakfast, and staff member G said the facility was out of the menu items. Staff member G served the week two breakfast menu despite 6/28/26 being the beginning of week three, resulting in residents receiving a meal inconsistent with the approved menu cycle.During an interview on 6/28/26 at 1:25 p.m., staff member E said any menu substitution required approval by the registered dietitian. Staff member E explained the facility utilized a menu system that identified therapeutic diet and texture modifications for staff to follow and stated she would expect to be notified before any facility-wide menu substitution occurred.During an interview on 6/28/26 at 1:37 p.m., staff member F said the facility's menu program contained menu extensions identifying therapeutic textures and therapeutic diets, including pureed, minced, and moist, cardiac, renal, and fortified diets. Staff member F explained that daily spreadsheets corresponded with the menu and recipe books were available for staff reference. She further stated that menu substitutions were submitted to the registered dietitian by email for approval to ensure a nutritionally equivalent replacement. Staff member F stated she had not received any requests for menu substitutions for the last month.During an interview on 6/28/26 at 1:52 p.m., staff member C said menus changed weekly and the new menu for the next week began each Sunday. Staff member C said the breakfast served that morning consisted of waffles and sausage and stated she would document the substitution and email the registered dietitian after the fact. Staff member C also identified the location of the menu books available for staff reference.During an interview on 6/28/26 at 1:57 p.m., staff member D said she went with what worked for the therapeutic texture modifications in place of the chef's salad. Staff member D stated she did not get approval for the substitution of the thickened tomato soup, pureed roast beef, and butterscotch pudding.Review of the facility's menu spreadsheet, showing the menu extension for the therapeutic diets, showed conversions of therapeutic textures and diets.Review of the facility's policy titled Menu Development, Substitutions and Implementation, revised on 8/1/23, showed: . Procedure1. Menu Planninga. Menus are planned in advance for regular and therapeutic diets.b. Menus must: .iii. Be reviewed for nutritional adequacy by a Registered Dietitian.c. The approved diet manual is used a as a reference and is: .iii. Accessible to medical, nursing and culinary staff.3. Menu Approval and Postinga. Menus are approved by the Registered Dietitian initially and upon significant changes.b. Menus and extension for therapeutic diets are:i. Posted in the kitchen or accessible electronically.ii. Posted in resident areas and nursing units in readable format.

Based on interview and record review, the facility failed to ensure they employed qualified and competent staff to provide social work services. This deficient practice had the potential to affect all residents in need of social services. Findings include: During an interview on 6/4/25 at 10:05 a.m., staff member A stated NF3 was originally hired as a business office assistant. She was later promoted to social service director. He stated she had some on-the-job training when she first assumed the role. Stating she went to another corporate facility and received on-site training there with the social worker at that facility. A request submitted on 6/4/25 at 10:30 a.m., for additional training/education for NF3, for acting as a social work director, was submitted. No additional training or education for NF3, related to social work services, was provided by the end of the survey. During an interview on 6/4/25 at 2:40 p.m., NF3 stated she was not originally hired as the facility's social worker. She stated she was later promoted into the position. NF3 stated she did not have a background or education in social work or a related field. She stated the only training for the position she was provided was a day spent at another facility learning how to complete the care plan conferences. She stated she was not provided any further training by the facility or additional supervised on-the-job training for the position. Review of NF3's Personnel File, showed a hire date of 8/29/23, as the assistant business office manager. Promotion to social service manager on 10/13/24, and termination date of 5/5/25. Review of NF3's Work Experience did not show previous experience or education in human services or a related field. Review of NF3's facility Relias training transcripts from, 8/30/23 to 4/9/25, did not show additional education for social services. A review of the facility's Position Description for Social Services Manager, showed, Position Summary: The responsibility of the Social Services Manager is to act as an advocate for the residents. The Social Services Manager protects vulnerable residents and ensure that their best interest is observed and helps them to find remedies to their situation . A review of the facility's policy and procedure titled, Social Services, with a release date of 11/28/17, showed, Policy: Medically related social services are provided in order to attain or maintain the highest practicable physical, mental, and psychosocial well being of the resident. Definitions: Medically-related social services means services provided by the facility's staff to assist residents in attaining or maintaining their mental and psychosocial health .

Based on interview and record review, the facility failed to ensure safeguards to prevent unauthorized use of electronic signatures for residents Medicare Secondary Payer (MSP) Form for 3 (#s 9, 31, and 40) of 15 sampled residents. This deficient practice had the potential to affect all residents with the need to sign MSP forms. Findings include: During an interview on 6/4/25 at 10:05 a.m., staff member A stated it was brought to his attention that NF3 was electronically signing resident and/or resident's representative names on documents for MSP forms. He stated staff member G noticed a bunch of MSP forms being printed back-to-back for several residents. Staff member A stated when staff member G brought the concern to his attention it was noted that the documents, which had an electronic signature, were not actually signed by the residents or their representatives. During an interview on 6/4/25 at 2:46 p.m., staff member G stated NF3 was behind on getting the MSP forms signed by the residents or their representatives. She stated one morning she noticed there were several MSP forms which printed that showed the forms were signed within minutes of each other. She stated many of these forms would need authorization by the resident or their representative, and it would not be feasible to obtain those signatures in such a short period of time. Staff member G stated a resident's representative had called the office later in the day, and she had asked them about signing the MSP form. She stated the resident's representative confirmed they were not aware what the MSP form was and had not signed or given NF3 authorization to sign the form. Staff member G stated she recalled resident #s 9, 31, and 40, were affected by the unauthorized use of electronic signatures by NF3. During an interview on 6/4/25 at 2:40 p.m., NF3 stated she did electronically sign several residents' MSP forms in an attempt to get caught up. During an interview on 6/4/25 at 3:46 p.m., staff member G stated she received a list of residents who had an electronically signed MSP form in their EMR. She stated she contacted all the residents and or their representatives to validate if they actually signed or authorized the signing of the MSP. She stated many of the individuals contacted were not aware of what the MSP form was and had not authorized or signed the form. Review of resident #s 9, 31, and 40's MSP forms, and the facility's Investigation of E-Signed MSP forms validation document, showed the residents or their representatives did not authorize the signing of the MSP forms. A review of the facility's policy and procedure titled, Electronic Signatures, with a revision date of 10/15/22, showed, In an electronic medical record, the use of a unique [identification] and password and/or identification number is equivalent to an electronic signature. Only authorized persons employed or contracted by the facility for the purposes of resident care, treatment, service, or review of same, are allowed sign-on access to the electronic record. Components: 1. The Electronic Medical Records Access Authorization and Security Agreement is read and signed by those users designated as authorized, prior to being granted authorized access. Users are expected to adhere to the terms of the Agreement . A review of the facility's policy and procedure titled, Safeguards for Electronic Protected Health Information, with a release date of 11/28/17, showed: Policy: [Facility Name] computer-based protected health information (PHI) is safeguarded against theft, destruction and/or unauthorized disclosure through access controls . 11. The electronic format for medical or other resident documentation (for example, documenting progress notes, medication administration, electronic claims filing, etc.) complies with the Health Insurance Portability and Accountability Act (HIPAA) privacy and security rules .

Based on observation, interview, and record review, the facility failed to change oxygen tubing as ordered and keep oxygen tubing off the floor for 1 (#6) of 15 sampled residents. This deficient practice increased the risk for a respiratory infection. Findings include: During an observation on 6/2/25 at 1:25 p.m., oxygen tubing was at resident #6's bedside, and it was not dated. During an observation on 6/3/25 at 11:45 a.m., oxygen tubing was at resident #6's bedside; it was not dated, and the portion of the tubing that connects to the resident's face/nose was sitting on the floor. During an interview on 6/4/25 at 11:52 a.m., staff member K stated oxygen tubing should be changed every Tuesday or Wednesday by staff member I. During an interview on 6/4/25 at 11:57 a.m., staff member E stated oxygen tubing should be changed every Monday. During an interview on 6/4/25 at 12:02 p.m., staff member I stated she changed oxygen tubing every Monday afternoon for residents, unless she was not working, and in that case a nurse would change the tubing. During an interview on 6/4/25 at 2:39 p.m., staff member B stated oxygen tubing changes were supposed to be done once a week by staff member I. Review of the facility's policy titled, Respiratory Care, not dated, reflected the following: .The resident is provided the necessary medical and nursing care and treatment services consistent with professional standards of practice .Services include but are not limited to .Oxygen . .Procedure .5. Based on the type of respiratory care and services provided, may include, but are not limited to: .a. Oxygen services, including the safe handling .cleaning, storage .of oxygen; .k. Infection control measures during implementation of care, handling, cleaning, storage and disposal of equipment, supplies .

Based on observations, interviews, and record review, the facility failed to implement care planned fall interventions contributing to falls for 2 (#s 6 and 12) of 15 sampled residents. This deficient practice increased the risk for falls. Findings include: 1. Resident #6 Review of resident #6's Care Plan Report, date initiated 12/1/23, reflected the following: .Goal: She will be free of fall related injuries . Environmental: Provide non-skid strips on floor next to bed on both sides of bed . [sic] During an observation on 6/2/25 at 1:25 p.m., non-skid strips were not visible on the floor of resident #6's room. During an observation on 6/4/25 at 8:44 a.m., non-skid strips were not visible on the floor of resident #6's room. During an interview on 6/4/25 at 11:52 a.m., staff member K stated resident #6 did not routinely call for help and stated, I think there are strips on the floor by her bed, but no fall mat. During an observation on 6/5/25 at 8:36 a.m., non-skid strips were noted on the floor of resident #6's room. The bed was positioned near the window thus revealing non-skid strips which were not previously observed on 6/2/25 and 6/4/25. With the bed centrally positioned during previous observations in resident #6's room, the non-skid strips were hidden under the bed. Review of resident #6's electronic medical record reflected the following fall investigation root causes and changes made in care planned fall prevention interventions: 4/1/25 Unwitnessed fall in resident's room with no injury; Improper footwear noted; use of a tab alarm when in bed and wheelchair were added to the care plan on 4/6/25. No additional fall prevention interventions were added to the care plan. 5/4/25 Witnessed fall in resident's room with no injury; staff educated on locking wheelchair; no additional fall prevention interventions added to the care plan. 5/8/25 Unwitnessed fall in resident's room with major injury including multiple fractured ribs, bruising of the right hip, laceration to face, skin tear to right wrist, and bleeding into sclera of right eye; no documentation regarding whether tab alarm was activated at time of fall. No additional fall prevention interventions were added to the care plan. 2. Resident #12 Review of resident #12's Care Plan Report, date initiated 10/19/23, reflected the following: .Goal: I will be free of fall related injuries . Fall mat placed to prevent injury if rolling out of bed .Place in my room to remind me to call for help . Increased visual checks to ensure non-skids footwear is on . [sic] During an observation on 6/2/25 at 2:17 p.m., resident #12 was in bed, awake, the call bell and bed controls were out of her reach, sitting in the top drawer of the bedside table. There was no floor mat noted in the room. During an observation on 6/3/25 at 2:29 p.m., resident #12 was in bed, awake, with no floor mat noted in the room. There were no non-skid socks on resident #12's feet, and there was no signage posted reminding resident #12 to call for help. During an interview on 6/3/25 at 2:50 p.m., staff member L stated she was not aware of a floor mat or posted signage reminding resident #12 to call for help as part of the care planned fall prevention interventions. Staff member L stated the only fall prevention interventions she was aware of for resident #12 was Keeping her bed low, and a raised mattress, that's it. During an interview on 6/3/25 at 2:54 p.m., staff member M stated she did not know resident #12's fall prevention interventions. During an interview on 6/3/25 at 2:58 p.m., staff member N stated the only fall prevention interventions he could think of for resident #12 was a perimeter mattress. During an interview on 6/3/25 at 2:59 p.m., staff member O stated she was not aware of a fall mat or posted signage reminding resident #12 to call for help as part of the care planned fall prevention interventions. During an interview on 6/3/25 at 3:02 p.m., staff member P stated she was not aware of a fall mat or of signage reminding resident #12 to call for help as part of her fall prevention interventions. During an observation on 6/4/25 at 8:52 a.m., resident #12 was not in the room; a floor mat was noted next to the bed. During an interview on 6/4/25 at 2:39 p.m., staff member B stated her expectations for making sure new fall prevention interventions were implemented was, I would expect the CNAs to know them and do them. Staff member B stated she puts new fall prevention interventions on the communication board and Kardex which was the CNAs plan of care, and RNs sign off that they were implemented. Review of resident #12's electronic medical record reflected fall investigation reports on 2/7/25 and 5/3/25. The only new fall prevention intervention initiated on 2/10/25 was making sure resident #12 wore her CPAP at night, and on 5/8/23 a fall mat. Review of a facility document titled, Accidents and Supervision to Prevent Accidents, with a revision date of 10/15/22, reflected the following: .The facility provides an environment that is free from accident hazards over which the facility has control and provides supervision and assistive devices to each resident to prevent avoidable accidents .Implement interventions to reduce hazard(s) and risks(s) .Implementing specific interventions as part of the plan of care .Ensuring that interventions are implemented correctly and consistently .

Based on interview and record review, the facility failed to inform and include the residents' guardian in the decision-making process for initiating physical and occupational therapy services, for 3 (#s 15, 19, and 44) of 15 sampled residents. This deficient practice caused the representative frustration and limited their ability to participate in resident care. Findings include: 1. During an interview on 6/4/25 at 3:36 p.m., NF2 stated she was concerned she was not informed by the facility that resident #19 was receiving therapy services. She stated she only became aware the resident was receiving therapy services when she was contacted about needing to sign a form to discontinue physical therapy. NF2 stated she was the legal guardian for resident #19, and the resident was not capable of making informed decisions for her own care. She stated she would have liked to be part of the decision-making process for resident #19, regarding her therapy services, so she could have attended the evaluation to discuss therapy goals for the resident. Review of resident #19's Physical Therapy Evaluation and Plan of Treatments, showed continuing certification periods from 12/17/24 - 5/19/25. Review of resident #19's progress notes, therapy notes, and consents to treat, from 12/17/24 to 6/4/25, failed to show NF2 was informed and included in the decision-making process for initiating physical therapy services for the resident. During an interview on 6/5/25 at 9:26 a.m., staff member H stated it was necessary to obtain consent prior to starting therapy services. She stated if a resident was not cognitively competent to consent to therapy services their legal representative should be notified prior to initiating services. She stated this consent could be obtained by the therapist or the nursing staff. Staff member H stated, there was potential for improvement that they should have notified NF2 about for resident #19's initiation of therapy services, but failed to do so. During an interview on 6/5/25 at 9:47 a.m., staff member B stated it was the expectation for the resident or their legal representative to be notified when there was a change in treatment. She stated the resident, or their representative should be contacted when a need for therapy services was identified to get consent for services. She stated her expectation would be for therapy to notify the resident or their representative when therapy services were involved. 2. During an interview on 6/4/25 at 3:30 p.m., NF2 stated they were unaware resident #15 had started therapy in March 2025. NF2 stated it was frustrating to be blind-sided and not included in the goal setting process for the resident with a new therapy initiation. During an interview on 6/5/25 at 10:22 a.m., staff member H stated resident #15 was currently in therapy, and her guardian had not been notified back when she started. Review of resident #15's Occupational Therapy Evaluation and Plan of Treatment notes showed a continuous certification period of 3/6/25 - 5/4/25. 3. During an interview on 6/4/25 at 3:30 p.m., NF2 stated she was unaware resident #44 had been in therapy for strength and conditioning since August of 2024, and stated, I only knew about the lymphedema therapy. NF2 stated she was frustrated at not being included for resident #44's physical therapy treatment and goals, after asking the facility repeatedly to include her, and she was concerned because resident #44 had been walking independently for a while. During an interview on 6/5/25 at 10:22 a.m., staff member H stated resident #44 was currently in physical therapy, and her guardian was made aware as of yesterday during the case conference, and stated, I don't know if she was made aware when she started (in August 2024), but I see we can improve how we communicate that better now. Review of resident #44's Physical Therapy Evaluation and Plan of Treatments, showed continuing certification periods from 8/6/24 - 6/16/25. A review of the facility's policy and procedure titled, Consent, with a revision date of 2/20/25, showed: Policy: . Valid consent is therefore central to health care. Residents have the right to be given clear and transparent information, including risks and benefits associated with treatment options. They have the right to accept or refuse; it is a continuous process; therefore, a person has the right to change their mind. Procedure: 1. Informed consent occurs when clear communication is provided outlining the risks, benefits, and alternatives to a procedure, medication, or care intervention. Informed consent may be identified on a tool, in a progress note, or anywhere in the resident record . 7. Notifications/updates in resident care/condition are made to providers, residents, resident advocates, etc. and are noted within the resident record .

Based on observations, interviews, and record review, the facility failed to ensure a resident was served a meal when tablemate's were served, and the resident had to wait 20 minutes while the other residents at the table finished their meals, for 1 (#43); and failed to ensure catheter bags were covered with a dignity bag in public areas for 1 (#15) of 15 sampled residents. Findings include: 1. During an observation on 6/3/25 at 8:21 a.m., resident #43 was seated at the dining table across from another resident. This resident had his plate and was eating breakfast. Resident #43 did not have her food. Residents at nearby tables were served their plates in no particular order. During an observation on 6/3/25 at 8:37 a.m., resident #43's tablemate had finished his breakfast. Resident #43 was still waiting for her plate. She wondered out loud if she could leave. During an observation on 6/3/25 at 8:44 a.m., resident #43 was served her breakfast. Resident #43 waited 23 minutes for her plate while those at her table and surrounding tables ate their meals. During an interview on 6/4/25 at 4:23 p.m., staff member J stated the seating chart in the dining room stayed consistent. Staff member J stated they tried to serve all residents at the table at the same time, however they also got a lot of the minced and moist or pureed plates out together instead of switching back and forth on consistencies. Review of resident #43's care plan, with an initiation date of 5/24/24, showed, [Resident #43] is at risk for being nutritionally [un]stable [related to] dementia, poor dentition, need for mechanically altered diet and slow weight loss. [sic] 2. During an observation on 6/3/25 at 12:25 p.m., resident #15 was seated at the table in the dining room waiting for lunch. Her catheter bag was on the side of her chair, uncovered. During an observation on 6/3/25 at 2:51 p.m., resident #15 was watching a movie in the day room with several other residents. Her catheter bag was on the side of her chair, uncovered. During an observation and interview on 6/4/25 at 8:07 a.m., resident #15 was seated at the table for breakfast. Her catheter bag was on the side of her chair, uncovered. Staff member C stated she should have a cover over the bag, and the facility had several cloth ones which had been made for that reason. Review of resident #15's care plan, with an initiation date of 11/28/23, showed, . has a supra pubic catheter. Position catheter bag and tubing below the level of the bladder. Cover with privacy bag . The staff failed to ensure the resident's dignity was maintained related to covering the catheter.

Based on interview and record review, the facility failed to ensure a staff member that was hired as a medication aide was certified or licensed. This deficient practice had the potential to affect all residents in the facility receiving medications, to include 1 (#2) resident. Findings include: During an interview on [DATE] at 2:46 p.m., staff member C stated during the time when staff member E was hired the previous DON had checked licensing and certifications for new hires. Staff member E had a certified medical assistant certificate but not a medication aide license. During an interview on [DATE] at 2:57 p.m., staff member B stated she audited nursing staff licensing in February 2024 and discovered staff member E did not have a medication technician license or certificate. During an interview on [DATE] at 9:54 a.m., staff member A stated the previous DON confused medication aide with medical assistant certification when staff member E was hired. A review of an Offer of employment, document dated [DATE], addressed to staff member E, and signed by staff member A, showed: Dear [Staff member E]: on behalf of [Company name], I am pleased to offer you a position as a Certified Medical Assistant with a start date of [DATE]. A review of staff member E's timecards showed, she worked as a medication aide for approximately 102 shifts from [DATE] to February 8, 2024. A review of resident #2's MAR in the facility's EHR showed for the month of [DATE], staff member E administered medications approximately 69 times to resident #2. A review of the facility policy titled, New Licensed Employee Policy, with a release date of [DATE], showed: POLICY [Facility Name] ensures that all employees who apply for a licensed position are qualified to work the required field of practice and have a valid and active license in the State of Montana. A review of a facility document titled, New Hire Checklist, with a revised date of ,d+[DATE], for staff member E, with a start date of [DATE], showed, a check box for Check Licenses/CPR (RN, LPN, PT, OT, SLP, CNA) not checked. A review of a facility policy titled, Medication Aide - Certified in Skilled Nursing Facility, with a revision date of [DATE], showed: . POLICY Certified Medication Aide (CMA), Medication Assistant - Certified (MA-C), Certified Medication Technician (CMT), Medication Aide I & II (MA I & II) may be used in accordance with the Nursing Board Standards of Practice of the state in which the aide practices. Definitions: Certified medication aides are nursing assistants who have been certified by the Board of Nursing in the state in which they practice. Their main function is to administer routine oral medications and perform other clinical duties in which they have been trained and demonstrate competency. PROCEDURE 1. Certified medication aides are to meet the following requirements unless otherwise specified by state regulation: . a. Successfully completed an approved state medication aide program or national council of state boards of nursing curriculum. b. Passed the state medication aide certification exam approved by the national council of state boards of nursing or other nationally recognized testing organization that provides testing for certified medication aides. c. Become certified by the state board of nursing as a CMA, MA-C, CMT, or equivalent. Based on the investigation, the facility acted timely by identifying the deficient practice, and had corrected the deficiency on [DATE]. The facility reported the incident as required by the Centers for Medicare and Medicaid.

Based on interview and record review, the facility failed to provide an end date for an as needed anti-anxiety medication order, for 2 (#s 1 and 4) of 14 sampled residents. Findings include: A review of resident #1's physician orders, dated 12/5/23, 3/5/24, and 3/7/24, showed, Lorazepam 1 mg. Give 1 tablet orally once a day as needed for anxiety. The orders did not include a duration. Lorazepam is the generic name for Ativan, an anti-anxiety medication. Review of resident #1's physician progress note, dated 12/5/24, showed, Patient had single episode . feeling very claustrophobic and anxious . Will write prescription for LORAZEPAM to have on hand just as needed . There was no duration noted. During an interview on 6/5/24 at 8:47 a.m., staff member F stated they did the 14-day limit for antipsychotic medications, but she was not aware of a duration requirement on PRN psychotropic medication orders. 41952 During an interview on 6/5/24 at 10:50 a.m., staff member F was not aware of needing to have a specified duration or stop date for continued PRN psychotropics. Staff member F stated she would crush the lorazepam and rub it into the gums of resident #4 after a seizure event due to her vomiting, so that it would be absorbed, since August 2023. Staff member F stated she had never used the lorazepam for anxiety for resident #4. During an interview on 6/5/24 at 2:55 p.m., staff member I stated he was given the directive to review medications for a corresponding diagnosis. Staff member I stated resident #4 was prescribed PRN lorazepam for anxiety, but he changed the diagnosis to post seizure activity because resident #4 did not have anxiety as a diagnosis. During an interview on 6/5/24 at 4:03 p.m., NF2 and NF3 stated only risk versus benefits were reviewed for psychotropic medications that were not antipsychotics. NF2 stated they had never been aware of needing a stop date, just a duration such as 30, 60, or 90 days, but agreed indefinite was not appropriate to have for medication orders. Record review of resident #4's order recap report for PRN lorazepam, showed 0.5 MG by mouth every 12 hours as needed for anxiety with a start date of 2/14/23 and discontinued on 2/5/24. The lorazepam order was changed on 2/5/24 to 0.5 MG by mouth every 12 hours as needed for post seizure activity related to unspecified convulsions. There was no set duration or end date for the PRN lorazepam and it was still an active order as of 6/6/24. Review of the facility policy, Unnecessary Medications and Psychotropic Drugs/Antipsychotic Medication, dated 11/28/2017 showed: . 5. PRN orders for psychotropic and anti-psychotic medications are only used when the medication is necessary to treat a diagnosed specific condition and PRN use is limited to 14 days. 6. The PRN order may be extended beyond 14 days if the attending physician or prescribing practitioner believes it is appropriate to extend the order. The attending physician or prescribing practitioner documents the rationale for the extended time period in the medical record and indicates the specific duration .

Based on interview and record review, the facility failed to ensure the residents' medical record included documentation the resident, or resident representative, was provided education regarding the benefits/side effects of Covid-19 vaccinations for 5 (#s 1, 4, 5, 21, and 182) of 5 sampled residents. Findings include: During an interview on 5/22/23 at 1:52 p.m., staff member B stated the facility did not have signed vaccine declinations with education about risks/benefits for resident #s 1, 4, 5, 21, and 182. Review of resident #s 1, 4, 5, 21, and 182's electronic medical records, accessed 5/20/23 - 5/22/23, showed a lack a documentation regarding education being provided to residents, or their representatives, on Covid-19 vaccinations. Review of resident #1's immunizations showed she refused the Covid-19 vaccine. Review of resident #4's immunizations showed she refused the Covid-19 vaccine. Review of resident #5's immunizations showed she refused the Covid-19 vaccine. Review of resident #21's immunizations showed she refused the Covid-19 vaccine. Review of resident #182's immunizations showed he refused the Covid-19 vaccine.

Based on interview and record review, the facility failed to ensure the residents' medical record included documentation the resident, or resident representative, was provided education regarding the benefits/side effects of pneumococcal and influenza vaccinations for 4 (#s 1, 4, 21, and 182) of 5 sampled residents. Findings include: During an interview on 5/22/23 at 1:52 p.m., staff member B stated they did not have signed vaccine declinations with education about risks/benefits for resident #s 1, 4, 21, and 182. Review of resident #s 1, 4, 21, and 182's electronic medical records accessed 5/20/23 - 5/22/23, showed a lack a documentation regarding education being provided to residents, or their representatives, on influenza and pneumococcal vaccinations. Review of resident #1's immunizations showed she refused the influenza vaccine. Review of resident #4's immunizations showed she refused the influenza vaccine. Review of resident #21's immunizations showed she refused the influenza and pneumococcal vaccines. Review of resident #182's immunizations showed he refused the influenza and pneumococcal vaccines.

Based on interview and record review, the facility failed to ensure a staff member adjusted the bed height, to prevent a fall during a transfer, for 1 (#1) of 2 sampled residents. Findings include: During an interview on 5/20/23 at 3:31 p.m., resident #1 stated she had fallen in the past at the facility, once at the toilet, and a few times near her bed. Resident #1 stated the fall on 2/5/23 involved her air mattress sliding out from under her while she was transferring, using a sit to stand with one staff member, resulting in her falling to the floor. Resident #1 stated she was to have at least two staff helping with her sit to stand transfers. During an interview on 5/21/23 at 1:19 p.m., staff member I stated resident #1 had fallen in the facility and had always been a resident who required a two-person physical assist with the resident's transfers. During an interview on 5/21/23 at 1:56 p.m., staff member B stated post fall investigations were documented in PCC, and staff involved in the falls would be educated. During an interview on 5/22/23 at 2:38 p.m., staff member B stated staff member E was supposed to orient with staff member J the first few days of working at the facility. Staff member B stated staff member J told her staff member E was a seasoned CNA, and staff member E insisted she was ready to work with residents. Staff member J stated staff member E was insistent on doing resident transfers herself, even if a resident needed a two-person transfer. Staff member B stated when she learned staff member E was performing resident transfers herself, she educated staff member E, but did not document the education. Staff member B stated when resident #1 had her fall with the sit to stand on 2/5/23, staff member E transferred the resident by herself, when resident #1 was supposed to have two-person assistance with transfers. Review of resident #1's EMR Incident Note, dated 2/5/23, at 6:30 a.m., showed, CNA (staff member E) came to this nurse and stated that resident (#1) slid off of the bed and was sitting on the floor. Residents bed was in a high position. bed is an air mattress with a flat sheet on it. while resident was sitting on the side of the bed with the sit-to-stand in front of her, resident and the flat sheet slid off of the bed. the bed was high, residents feet were not on the foot plate of the lift. resident stated that she was not injured, did not hit her head, which was witnessed by CNA (staff member E). [sic]. Review of resident #1's MDS, with an ARD of 12/26/22, showed the resident needed a two-person physical assist with transferring from the bed to a standing position. Section G0400 showed the resident had impairment of both sides of her lower extremities (legs).

Based on interview and record review, the facility failed to ensure care plans were updated after falls for 2 (#1 and #26) of 2 sampled residents. Findings include: 1. During an interview on 5/20/23 at 3:31 p.m., resident #1 stated she had falls in the past at the facility, once at her toilet, and a few times near her bed. Resident #1 stated the fall on 2/5/23 involved her air mattress sliding out from under her while she was transferring, using a sit to stand with one staff member, resulting in her falling to the floor. Resident #1 stated she was to have at least two staff helping with her sit to stand transfers. During an interview on 5/21/23 at 1:39 p.m., staff member C stated resident #1 had a history of falls at the facility. Staff member C stated he, staff member B, or staff member F, updated the resident's care plan after fall investigations were completed by the management team. During an interview on 5/21/23 at 1:56 p.m., staff member B stated after a fall, the care plans were updated with interventions based on the determined cause of the fall, and she created a fall follow-up note in the EMR with what the interventions were on the care plan. Review of resident #1's EMR Incident note, dated 2/5/23, at 6:30 a.m., showed, CNA (staff member E) came to this nurse and stated that resident (#1) slid off of the bed and was sitting on the floor. Residents bed was in a high position. bed is an air mattress with a flat sheet on it. while resident was sitting on the side of the bed with the sit-to-stand in front of her, resident and the flat sheet slid off of the bed. the bed was high, residents feet were not on the foot plate of the lift. resident stated that she was not injured, did not hit her head, which was witnessed by CNA (staff member E). [sic]. Review of resident #1's care plan did not show fall intervention changes or updates after the resident's fall on 2/5/23. The latest fall intervention date was 1/10/23. 46400 2. During an interview on 5/20/23 at 3:00 p.m., resident #26 stated she had fallen twice at the facility. She was adjusting to not being in her own home anymore. Review of resident #26's MDS Admission Assessment, with a target date of 8/28/22, showed she was admitted to the facility on [DATE]. Review of resident #26's care plan, dated 8/23/22, showed she was identified as being at risk for falls. All fall interventions listed had the same initiation date of 8/23/22, one day after the resident's admission to the facility. Review of resident #26's nursing progress notes, dated 11/18/22, showed the resident was found on the floor after sliding out of bed while taking herself to the bathroom. There were no updated interventions in the care plan to address the cause of the fall as determined by the completed fall investigation, or to address contributing factors to prevent future falls. Review of resident #26's nursing progress notes, dated 1/17/23, showed the resident was walking without her walker when she fell . There were no updated interventions in the care plan to address the cause of the fall as determined by the completed fall investigation, or to address contributing factors to prevent future falls. A review of the facility's policy, Care Plans, revised 10/15/22, showed, 7. The residents care plan is reviewed . and revised based on changing goals, preferences and needs of the resident and in response to current interventions. A review of the facility's policy, Fall Response & Management, revised 5/17/21, showed: 1. Document in resident medical record: .c. Revise the care plan with interventions.

Based on interview and record review, the facility failed to notify the physician of resident concerns, including a significant weight loss for 1 (# 4); and missed doses of medications for 1 (#6) of 2 sampled residents. Findings include: 1. Review of resident #4's documented weights showed: - 1/15/23 the resident weighed 124.2 lbs. - 2/12/23 the resident weighed 116 lbs. This represented a 6.6% weight loss in one month. There was no documentation stating the physician was aware of the significant weight loss. During an interview on 5/22/23 at 3:15 p.m., staff member F stated they would notify the doctor of resident changes by fax, versus a phone call, as long as there was no injury. During an interview on 5/22/23 at 3:30 p.m., staff member D stated physician notification done by fax would be saved and scanned into the chart. Documentation of physician notification of resident #4's weight loss was requested on 5/22/23. It was not provided by the end of the survey. 2. Review of resident #6's nursing progress notes, dated 2/15/23, showed the resident did not receive two of her scheduled doses of Ativan. The resident reported her anxiety was affected by the missed medication. During an interview on 5/22/23 at 11:55 a.m., staff member B stated the physician was not notified of the missed medications, and the nurse should have notified him.

Based on observation, interview, and record review the facility failed to prevent drug diversion of [MEDICATION(S)] pain patches for 2 (#s 8 and 27) of 2 sampled residents. Findings include: Review of resident #8's Nurse Progress Note, dated 6/20/22, showed, It was brought to our attention that the residents [MEDICATION(S)] patch was not changed on 6/15 as scheduled. Resident did not exabit increased [MEDICATION(S)] use, or increased pain indicators. Family and MD were notified. [sic] During an interview on 6/22/22 at 10:45 a.m., staff member B stated the missed [MEDICATION(S)] patch changes for residents #27 and #8 were an active investigation reported to the State Survey Agency. Staff member B stated the staff member involved would be terminated due to the evidence from the investigaton. Staff member B stated the nurse on 6/18/22 went to change the [MEDICATION(S)] patches as ordered. When the nurse saw the patches on the residents, she felt there was something wrong with them and started to investigate and recheck the medication patch documentation, the medication carts, and [MEDICATION(S)] patch counts since the last two patch changes on 6/12/22 and 6/15/22. Staff member B stated, the nurse determined the patches on the residents had been tampered with and tried to call staff member B. Staff member B was out of cell service, so the nurse called staff member A who called another nurse manager to come in immediately and start investigating. Staff member B stated staff member A put staff member J on suspension pending investigation. Staff member B stated resident #27 and #8 were both assessed and prior pain medication use was reviewed for changes in pain levels due to the patches not being changed. She stated no increase in pain levels or pain medication use was noted. During an observation and interview on 6/22/22 at 11:10 a.m., staff member B showed the two tampered patches. Staff member B showed the nurse had placed both patches on 6/12/22 and initialed and dated them with a pen. One residents patch had 6/15/22 and initials for staff member J written over the original pen in black Sharpie. The other resident's patch's original pen date and initials were wiped off with a substance, and then had black Sharpie written over as 6/15/22 and staff member J's initials for that day. The indent of the original date of 6/12/22 and the nurse initials were still visible on the patch. Staff member B stated no other residents had pain patches. When investigating the incident, it was found the patches were not changed as ordered on 6/15/22. She stated the documentation was falsified so the nurse responsible was asked to come in for disicpline paperwork, but would not return communication attempts by the facility. The paperwork was filed for termination to human resources. During an interview on 6/22/22 at 3:43 p.m., staff members A and B stated they had completed the other reporting for the nurse license requirements and to local authorities. They had reviewed documentation, and the common area cameras. The cameras showed the patches being signed out and the nurse walking into the residents' room. There was no way to see what was done with the patches. Staff member A stated while gathering information for the investigation, he and staff member B noticed the narcotics log sheets for a time in April to May 2022 were ripped out of the book and not accounted for, and the new sheets were started by staff member J. They were continuing to review information and check other medications for other residents. Staff member B stated she already put together a training on an enhanced process for the [MEDICATION(S)] patches including two nurses verifying patch placement, nurse initials, and the date of the patches on the residents at each shift change matched the documentation and order. During an interview on 6/23/22 at 9:02 a.m., staff member A stated the [MEDICATION(S)] patch investigation was going to be reviewed in QAPI and ongoing, and they had their meeting the next week, but they had already put interventions into place while conferring with their corporate office for implementing practices to prevent future missing medications. In addition to the change in procedure for checking the [MEDICATION(S)] patch placement, the nursing management team was also checking the narcotics logs weekly for any discrepancies or suspicious documentation. Staff member B had added physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . QAPI managment were also reviewing the process of when patches were placed to adjust the times to when nurse management was present to verify. They were continuing to educate nurses at the next staff meeting to ensure facility staff knew the expectation and consequences of not following the regulations or facility policies for medication management and abuse related to drug diversion. During an interview on 6/23/22 at 10:12 a.m., staff member H stated the new process for two nurses, to verify the placement, date, and initials of each pain patch at shift change, was a great idea and gave her a peace of mind coming onto her shift now. Review of resident #8's June 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The verifcation of the patch placement task was completed for night shift of 6/22/22 and the morning of 6/23/22. Review of resident #27's Nurse Progress notes showed: -6/20/22, It was brought to our attention that the residents [MEDICATION(S)] patch was not changed on 6/15 as scheduled. Resident did not exabit any increased pain indicators. Family and MD were notified. [sic] -6/22/22, [MEDICATION(S)] patch was on the rt side of chest with the date 6/21 and [staff initials] was the initials and [MEDICATION(S)] patch checked at shift change with [nurse name]. patch is on the right side of the chest, dated 6-21-22, initials [staff initials]. [sic] Review of facility investigation of missing [MEDICATION(S)] patches for resident #27 and #8 showed: -the missed [MEDICATION(S)] patch change was discovered on the night of 6/18/22 when it was due for a change and was reported to the State Survey Agency on 6/19/22, -the nurse involved was reported to the state nursing boards and the local authorities on 6/22/22, -the facility had already implemented new procedures and training to staff, -the staff member involved was terminated on 6/23/22, and -the final report was submitted to the State Survey Agency.

Based on interview and record review, the facility failed to obtain a resident representative's consent for a cognitively impaired resident's POLST for 1 (#129) of 2 sampled residents. Findings include: During an interview on [DATE] at 11:07 a.m., staff member I stated the admitting provider signed the resident's POLST upon admission. If the resident was cognitively impaired, the nurses were notified to arrange to have the POA sign the document before the provider signed it. During an interview on [DATE] at 12:27 p.m., staff member G stated the provider would not complete the POLST unless it was signed, or he got a verbal consent from the POA. During the admission process the POA was usually present, and if not, most of the residents were from this area, so the POA's were usually visiting often. During an interview on [DATE] at 12:31 p.m., resident #128, stated, NF1 has visited us every day since we got here on [DATE], except yesterday. Review of residents #129's POLST showed the resident was a DNR, and the signature box for the patient or decision-maker was not signed. Review of a facility policy titled, Advance Directive including Cardiopulmonary Resuscitation (CPR) and Automated External Defibrillator (AED)-Rehab/Skilled, with a revision date of [DATE], showed: Procedure Admission/Readmission Advance Directive 1. At the time of admission or re-admission, social services or designated staff member asks the resident/healthcare decision-maker whether the resident has prepared an advance directive such as a living will, durable power-of-attorney for healthcare decisions, guardianship, portable and enduring order form etc. 2. The designated staff member will meet with the resident/healthcare decision-maker to answer questions and determine if the resident/healthcare decision-maker wish to develop or amend advance directives.

Based on interview and record review, the facility failed to revise a care plan to include interventions for a resident who had a admission history of chronic UTIs, for 1 (#3) of 2 sampled residents. Findings include: During an interview on 6/21/22 at 11:14 a.m., staff member I stated resident #3 came to the facility in January of 2022, and was already taking an antibiotic for [CONDITION(S)] prophylaxis, due to chronic UTIs. During an interview on 6/21/22 at 12:19 p.m., staff member G stated resident #3 was on 100 mg of [MEDICATION(S)] that she received prior to admission. Staff member G stated the resident was to follow up with urology, but had yet to see them because she was resistant to visits. Staff member G stated the preventative measures for UTIs were not always on the care plans, and resident #3 did not have any [CONDITION(S)] preventative interventions on her care plan. Staff member G stated UTIs were not triggered on resident #3's MDS either, and staff member F would be responsible for that portion of the MDS. During an interview on 6/21/22 at 2:13 p.m., staff member F stated he updated the care plans and worked with the rest of the facility staff to do so. Staff member F stated he knew resident #3 was admitted on prophylactic antibiotics. Staff member F stated there was nothing on resident #3's care plan to address her history of UTIs. Staff member F stated there should have been interventions on her care plan to address [CONDITION(S)] prevention, and he would fix it. During an interview on 6/21/22 at 2:57 p.m., staff member B stated if a resident demonstrated a history of UTIs, she would want to see something on the care plan about following signs, symptoms, and the protocol for identification of UTIs. If a resident came to the facility on a [CONDITION(S)] prophylactic, it should have been on the care plan. Staff member B stated she would expect to see interventions such as monitoring and encouraging fluid intake. Review of resident #3's admission documentation, dated 12/18/21, reflected the resident had, Chronic [CONDITION(S)] and she is on prophylactic treatment with [MEDICATION(S)] 100 mg p.o. daily along with cranberry capsule. [sic] Review of resident #3's medical record reflected a lack of a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of resident #3's Care Plan, dated 6/21/22, did not show any interventions for [CONDITION(S)] prevention, or a history of UTIs, prior to 6/21/22. A review of the facility's policy, Care Plan- R/S, LTC, Therapy & Rehab, dated 5/3/22, reflected, The comprehensive plan of care .will be modified to reflect the care currently required/provided for the resident.

Based on observation, interview, and record review, the facility failed to ensure pain management was provided to 1 (#29) of 19 sampled residents, and this resident voiced pain, at the level of 10 out of 10 on a pain scale, had pain during the provision of care, and staff were aware of the resident's pain. Findings include: During an observation on 11/22/21 at 3:36 p.m., resident #29 was observed in her room, moaning, her shirt was pulled up with her breast exposed, she was rubbing her abdomen saying, Ow, please help me. Her door was open to the hallway. Staff member F was in the hall and was informed of the observation. She went in to help resident #29. During an interview on 11/22/21 at 4:16 p.m., resident #29 was alert and oriented to person, place, and time. Resident #29 complained of abdominal pain and nausea. She stated she had been in pain since she came from the hospital. She stated the nurses had not given her anything for pain. She stated she told someone that she was in pain but they had not done anything about it. During an interview on 11/22/21 at 5:08 p.m., resident #29 stated she was still in pain. She rated her pain a 10 out of 10 on the pain scale, and stated, It (her abdomen) hurts really bad. During an interview and record review on 11/22/21 at 5:11 p.m., Staff member G stated, I think she [resident #29] got something for pain. We have been in there off and on, she is a new admit, and I heard she can be dramatic. Staff member G looked at resident #29's medication list and found that the resident had not received anything for pain and did not have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] During an observation on 11/23/21 at 8:45 a.m., resident #29 was lying in bed moaning and could be heard saying, Oh god, ow, help me, from the hallway. The resident was breathing hard. Staff member C walked in and the resident told him her back hurt. Staff member C repositioned the resident. The resident stated that did not help her pain. Staff member C told the resident he was going to get another nurse to help. During an interview on 11/23/21 at 9:02 a.m., staff member G stated, We got her some Tylenol, we are working on getting something stronger. Staff member F stated, We have an email out to the doctor, and if he doesn't respond soon, I will call. During an interview on 11/23/21 at 9:54 a.m., Staff member F stated she spoke to the doctor's office, and learned the doctor was not coming in that day, and the office did not receive the fax requesting pain medication either. Staff member F stated she resent the fax after she got off the phone with the doctors office. During a record review on 11/23/21 at 10:16 a.m., resident #29's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #29's MDS was not complete but was still within the 14 day window allowed for new admissions. Resident #29's 48-hour initial care plan did not show any interventions related to pain. During an interview and record review on 11/23/21 at 10:30 a.m., Staff member C stated, The only time we do pain assessments are on admission and MDS, if we give a pain medication, or if they fall. If the resident suddenly is complaining of increased pain, I would chart that assessment in the progress note. Staff member C could not find an assessment for pain in resident #29's EMR other than the initial nursing assessment on admission on 11/17/21. During an interview on 11/23/21 at 10:35 a.m., Staff member F stated, I want to think that her pain is related to her [CONDITION(S)]. I did my assessment around 3 p.m. She is difficult to assess, and we did not get a good report from [medical facility]. During an interview on 11/23/21 at 10:45 a.m., staff member J was bringing resident #29 back from getting a shower. Staff member J stated, She (resident #29) definitely seemed to be in pain during her shower. She kept saying we were hurting her even when we were not touching her. During an observation and interview on 11/23/21 at 3:19 p.m., resident #29 was in bed, moaning she stated, Too tight, help me. Resident #29 rated her pain a 10 out of 10 on the pain scale in her legs. She stated if her pants were not too tight, her legs would be fine. A CNA arrived to assist the resident and found the resident did not have pants on. During a record review on 11/23/21 at 4:38 p.m., resident #29's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation on 11/24/21 at 8:37 a.m., resident #29 was lying in bed, moaning, and saying, Please help me. During an observation and interview on 11/24/21 at 8:42 a.m., resident #29 stated she needed her pain pills. She stated she was in pain and her stomach was also hurting. Staff members H and I came in to get her up for breakfast. Resident #29 stated she would not get up without getting something for pain. Staff member H checked with the nurse, and reported to resident #29 that the nurse had already given her something for pain and that the nurse would help her when they got her to the dining area. Resident #29 allowed the staff to get her up and continued to state, It hurts it hurts, while staff members H and I got her up and ready for breakfast. During an observation on 11/24/21 at 8:54 a.m., resident #29 was in a lift to transfer to her wheelchair, and she stated her stomach and her arm were hurting. During an interview and record review on 11/24/21 at 9:13 a.m., staff member C was looking in the EMR to see when resident #29 had Tylenol last. He found the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff member G stated, The documentation says no, she did not get any pain medicine. Staff member C stated it was possible that the medication was given, but not charted, and the nurse that would have given it had already gone home. Staff member C attempted to call the night shift nurse. That nurse did not answer the phone. During a phone interview on 11/24/21 at 10:27 a.m., NF2 stated, resident #29's anxiety was pretty high and that was brand new for her. He stated he saw her yesterday and she was in pain. He added, I think she is stressed and I'm afraid she won't last much longer. During an interview on 11/24/21 at 10:41 a.m., staff member C stated, he still had not been in contact with the night nurse to find out if she had given the Tylenol. He still did not know if the resident was given any medication for pain. During an interview on 11/24/21 at 11:06 a.m., staff member C stated, If the resident is in pain, the orders should get put in (the EMR) right away. During an interview and record review on 11/24/21 at 11:28 a.m., the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff member G stated, I gave it, but apparently I didn't chart it. I gave it around 8:30 this morning. During an observation and record review on 11/24/21 at 11:33 a.m., resident #29's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . At 11:33 a.m., resident #29 was observed resting comfortably and snoring.