Every finding on record at Pioneer Care and Rehabilitation

Based on observation, interview, and record review, the facility failed to maintain potentially hazardous foods at safe temperatures during holding and distribution for residents receiving meals prepared by the facility's kitchen. The failure increased the risk of foodborne illness for all residents receiving food from the kitchen. Findings include:During observations of breakfast and lunch meal service, for trays being taken to resident rooms, on 6/2/26 and 6/3/26, it was noted that meal trays were not transported in insulated dietary carts to keep meals warm. The trays were either carried from the kitchen to the residents' rooms or were placed on an uninsulated open metal cart and then delivered to the rooms. Each cart contained three to four meal trays. On each tray, the plates were covered with reusable insulated plastic covers. No insulated bottom covers or warming bases were used. Several plate covers on resident meal trays were observed to be poorly seated on the plates, resulting in air gaps between the plate and cover.During an observation on 6/2/26 at 8:20 a.m., a breakfast tray delivered to the dining room was observed. A waffle from the tray was temperature tested at the surveyor's request, and the temperature reading was 78 degrees Fahrenheit.During meal tray preparation observations on 6/2/26 from 8:22 a.m. through 8:44 a.m., the tray line steam table was observed to have and hold waffles, sausage, bacon, toast, and Cream-of-Wheat cereal. At no time during the observation were lids present on the steam table pans covering the foods, while staff members E and F prepared resident meal trays. At 8:24 a.m., staff member F removed the toast from the steam table and placed it on a plate. The toast on the plate was not covered until 8:35 a.m., which was 11 minutes after being removed from the heated steam table. At 8:38 a.m., a sausage patty removed from the steam table was temperature tested at the surveyor's request, and the temperature was 108 degrees Fahrenheit. After temperature testing, the steam table trays were still not covered with lids, although the food was not being held at safe temperatures. During an interview on 6/2/26 at 8:41 a.m., staff member F stated she did not know what the food holding temperature should be for the steam table, and she did not routinely monitor holding temperatures within the steam table.During an interview on 6/2/26 at 8:45 a.m., staff member D stated all dietary staff had received ServSafe food service training approximately two years ago and were due for a refresher course this year. Staff member D stated the facility had an insulated cart for transferring food; however, the trays did not fit well with the insulated lids. Therefore, the staff chose to use the standard metal cart to deliver meals to the rooms. This process did not allow for the meals to be maintained at safe temperatures.During an interview on 6/3/26 at 10:48 a.m., staff member D stated the dietary staff had not been routinely temperature-checking foods held in the steam table or foods served on resident trays. Staff member D stated hot foods should be maintained at safe temperatures from cooking through meal delivery, and that foods on the steam table were intended to remain hot while resident trays were prepared and served.Review of a facility document titled Record of Food Temperatures, revised 1/15/26, showed: . 2. Hot foods will be held at 135 degrees Fahrenheit or greater. 5. Food containers will be kept covered to retain heat and prevent environmental contaminants from entering food.

Based on observation, interview, and record review, the facility failed to establish and communicate an effective process for submitting anonymous grievances for 2 (#s 13 and 27) of 34 sampled and supplemental residents. The failure impeded residents' ability to exercise their right to voice grievances by failing to communicate how and where anonymous grievances could be submitted. Findings include:During an observation on 6/3/26 at 4:02 p.m., the Social Services office was observed. The office had no identifying signage showing it was the Social Services office, and no grievance forms or grievance drop box were located outside the office for resident use.During an observation on 6/4/26 at 7:54 a.m., a wall-mounted file basket containing new grievance forms and an informational grievance poster was observed on the wall across from the nursing station. The instructions directed residents, guests, and employees to place a completed grievance form in the Social Services box, but did not identify the location of the Social Services box or explain how residents could submit grievances anonymously.During an interview on 6/4/26 at 7:58 a.m., resident #27 stated she did not know how to file a grievance anonymously and stated she would submit her grievances to someone in upper management.During an observation and interview on 6/4/26 at 8:00 a.m., staff member C stated residents could place anonymous grievances in a locked box near the nursing station and pointed to two gray, unmarked boxes mounted on the wall. Staff member C stated he was aware there was no identification outside the Social Services office, and the facility was ordering signage for the office.During an interview on 6/4/26 at 8:05 a.m., staff member B stated she reviewed the grievance policy with newly admitted residents, and then quarterly thereafter, so residents would know where to submit grievances. When asked how residents would know to place anonymous grievances in the two unmarked boxes near the nursing station, staff member B stated, Good point, we can put some signs up by the boxes.During an interview on 6/4/26 at 8:08 a.m., staff member M stated the two gray, unmarked boxes near the nurse's station were used for nothing.During an interview on 6/4/26 at 8:39 a.m., resident #13 stated he did not know how to file a grievance anonymously.Review of the facility policy titled Grievance Policy, dated 1/15/26, showed grievances could be submitted anonymously; however, the policy did not describe the process for submitting an anonymous grievance.

Based on observations, interviews, and record review, the facility failed to ensure beds and belongings were kept a safe distance away from baseboard heaters, and the facility staff were informed of the risk the heaters posed due to fire/injury, for 7 (#s 8, 28, 39, 55, 60, 64, and 71) of 7 resident rooms sampled for heater hazards. Findings include:During an observation on 6/1/26 at 1:25 p.m., resident #64 was in his bed. His bed was against the wall and baseboard heater unit. A four-wheel walker was folded and sitting against the baseboard heater unit with clothing hanging off of it. During an observation on 6/1/26 at 1:28 p.m., resident #60's bed was against the baseboard heater unit. During an observation on 6/1/26 at 1:29 p.m., resident #71's bed was against the baseboard heater unit. During an observation on 6/1/26 at 1:30 p.m., resident #39's bed was against the baseboard heater unit. During an observation and interview on 6/2/26 at 4:25 p.m., staff member O stated the beds should be at least four inches away from the baseboard heater units. Staff member O stated half the building was water baseboard heaters, and the other half of the building was electric baseboard heaters. Staff member O stated it was more important the beds and personal items be away from the electric baseboard heaters because they get much hotter. Staff member O stated the Fire Department had warned the facility about the beds and personal items touching the heaters was a fire hazard. The following temperatures were found during a walk-thru with staff member O, using the facility's temperature gun. Staff member O stated the temperature gun readings were accurate: - Resident #8's room had the cover of the water baseboard heater falling off, with curtains and bed against the heater. The temperature of the heater unit was 82 degrees Fahrenheit. - Resident #55's room had the bed and dresser against the electric baseboard heater. The temperature of the heater unit was 98 degrees Fahrenheit. - Resident #28's room had the dresser and cords against the electric baseboard heater. The temperature of the heater unit was 100 degrees Fahrenheit. During an interview on 6/2/26 at 4:45 p.m., staff member P stated she did not know of any requirements for beds and belongings to be kept away from the heaters in the resident's rooms. Review of the facility's policy, HVAC system, no date, showed: 2a. All furniture and resident belongings ensured to be kept at least 4 inches from any fixed room heating units.

Based on observations, interviews, and record review, the facility failed to ensure proper hand hygiene when moving between wounds during cares for 1 (#8); failed to ensure hand hygiene was performed during meal service for 2 (#14 and 54); failed to ensure linens were handled to prevent contamination between clean linens and dirty linens for 1 (#8); failed to use clean dishes during meal service for 1 (#2); and failed to clean equipment after use with resident for 1(#8) of 34 sampled and supplemental residents. These deficient practices placed residents at risk for the spread of infections. Findings include:During an observation on 6/2/26 at 8:10 a.m., staff member G was serving breakfast drinks to residents in the memory unit. Staff member G removed a coffee cup from the cupboard and started scratching a crusted substance off the side and top edge of the coffee cup. Staff member G then poured coffee into the cup and served resident #2 the coffee. During an observation on 6/2/26 at 8:18 a.m., staff member H was repeatedly touching and adjusting her hair while setting up resident trays, serving the trays, and then starting the setup of the next tray without hand hygiene being performed. Staff member H then cut up resident #54's waffles and took the bacon off her plate, handing it to her. Staff member H then placed her hands in her pockets and stood next to the table. Staff member H noticed a resident did not have a tray and went to the cart and grabbed her tray. Staff member H then set up the tray for resident #14 after her hands were in her pockets and hand hygiene was not performed. During an observation on 6/2/26 at 12:33 p.m., staff member J went to resident #8's room to complete a brief change. Resident #8 was lying in bed on a draw sheet and a bed pad. No sheets covering the mattress were on the bed. Resident #8 had a large bowel movement in the bed. Staff member J pulled a pillow out from under the resident's legs, which had fecal matter on it, and placed it at the top of the mattress. The mattress had fecal matter present. Staff member J removed the soiled pad and draw sheet, placing a new pad under resident #8. Staff member J then cleansed resident #8 further to remove all fecal matter. Resident #8 stated he wanted a shower. Staff member J stated he could shower. Staff member L entered the room with linens for the bed and stood over the bedding covered in fecal matter, which was at the end of the bed. Staff member L allowed the clean linens to come into contact with the dirty linens and placed them on the wheelchair at the end of the bed. A new pillow was placed on the trash can. The peri-wipes staff member J had on the bed while cleaning the fecal matter from resident #8 was placed on the pile of clean linens at the foot of the bed. Staff member J noticed the fecal matter on the pillow and wiped it off with a cleansing wipe, leaving some fecal matter still on the pillow. The pillow was then placed on the pile of clean linens with the wipe's container. Staff member J then placed the Hoyer sling under resident #8. Resident #8 was lifted using the mechanical lift and moved to the shower chair. The Hoyer lift was then lowered, and resident #8's sling was removed from the Hoyer and placed in the hallway. Resident #8 was taken to the shower. Staff member H began remaking resident #8's bed. Staff member H took the pillow with fecal matter on it, placed a pillowcase on the pillow, covering the fecal matter, and put it on the bed. Staff member H picked up an open box of Kleenex from the floor, placed it on the bedside table, and left the room. The Hoyer lift remained in the hallway, uncleaned. Staff members J, L, and H failed to keep clean linens from coming in contact with dirty items and items with fecal matter on them, and failed to maintain a clean environment related to infection control hazards. During an observation on 6/2/26 at 2:08 p.m., staff member L was assessing resident #8's wounds after his shower. Staff member L moved from resident #8's left buttock wound to his left ankle, to his left knee wound, touching and cleansing each wound. Staff member L did not remove the soiled gloves and perform hand hygiene between the care of the wounds, potentially cross contaminating the wounds. During an interview on 6/3/26 at 11:22 a.m., staff member B stated the CNAs should have communicated with each other in an attempt to prevent the cross-contamination of linens during resident #8's toileting and ADL care, and the bed's linen change. Staff member B stated the linens were changed after this surveyor reported the observation of the soiled linens being placed on the bed of resident #8. Staff member B stated that staff should practice hand hygiene after touching hair when serving food. Review of the facility's policy, Infection Prevention and Control Program, no date, showed: . 12. Linens: b. Clean linen shall be separated from soiled linen at all times. Review of the facility policy, Clean Dressing Change, dated 1/15/26, showed: . 3. Each wound will be treated individually.

Based on observations, interviews, and record review, the facility failed to ensure showers and grooming were provided for 1 (#71) of 34 sampled and supplemental residents. This deficient practice resulted in resident #71 not being offered a shower or grooming seven times during the month of May 2026, placing resident #71 at risk of infections and compromised the resident's right to maintain personal hygiene and dignity. Findings include:During an observation and interview on 6/1/26 at 2:44 p.m., resident #71 was in his bed, resting. Resident #71 was disheveled with greasy, messy hair, an unkept beard with food in it, and a strong body odor. Resident #71 stated he did not get his two showers a week, as scheduled. Resident #71 stated he refused once when the staff came while he was sleeping, and the staff did not offer an alternate shower time. Resident #71 stated he had not been offered shaving, so his brother would shave him when he came to visit. Resident #71 stated he had requested the staff trim his nails, but no one had. Resident #71's nails were longer than 1/4 inch and yellow and brown in color, with dirt under his nails. During an interview on 6/3/26 at 11:37 a.m., staff member B stated someone changed the schedule in the computer or the shower sheet and should not have. Staff member B stated the change caused resident #71 to miss his showers over the past month. Staff member B stated records indicated resident #71 refused one shower, and one shower was given from May 6th to May 31st, 2026. Review of the facility's policy, Resident Showers, dated 1/15/26, showed: - . 1. Residents will be provided showers/bed bath as per request or as facility schedule (2 times a week) or protocols and based upon resident safety or requests.

Based on interview and record review, the facility failed to ensure a PASARR Level I was completed for 1 (#3) of 34 sampled and supplemental residents. This deficient practice resulted in resident #3 not receiving potentially needed mental health services. Findings include: Review of resident #3's PASARR Level I showed that resident #3 was approved for a 29-day convalescent stay. The approval letter rationale included that the approval was supposed to expire 29 days after admission. After the 29 days, a new Level 1 would need to be completed and submitted for resident #3 if the resident remained in the building. During an interview on 6/3/26 at 4:36 p.m., staff member B stated the facility failed to complete the follow-up PASARR and was going to complete one. Staff member B stated the lines (understanding of the process) were unclear on whose duty it was to follow up on the Level screenings. Review of the facility's policy, Resident Assessment-Coordination with PASARR Program, no date, showed: . 5. If a resident who was not screened due to an exception above and resident remains in the facility longer than 30 days: a. The facility must screen the individual using the State's Level I screening process and refer any resident who has or may have MD, ID or a related condition to the appropriate designated authority for Level II PASARR evaluation and determination. [sic]

Based on interviews and record review, the facility failed to ensure all physician orders were signed and dated for 1 (#29) of 34 sampled and supplemental residents. This deficient practice placed residents at risk of medication errors. Findings include:Review of resident #29's Psychiatry Follow-up Visit, dated 4/27/26, showed resident #29's risperidone medication was discontinued after a gradual dose reduction was completed, and the resident did not display aggression in the last three weeks. Review of resident #29's EHR medication list, dated 6/3/26, showed resident #29 was actively receiving risperidone 0.125 mg beginning 3/7/26. During an interview on 6/3/26 at 4:42 p.m., staff member B stated the Psychiatric Nurse Practitioner emailed her verbal orders and she could not find an order to discontinue the risperidone for resident #29. Staff member B stated she has been trying to get the Psychiatric Nurse Practitioner to comply with proper ordering of the medication process for a while now. Staff member B stated that the Psychiatric Nurse Practitioner emailed notes to the nurses, and the nurse transcribed them into orders. Staff member B stated the Psychiatric Nurse Practitioner was not following ordering protocols, and when she brought this up to her, the Psychiatric Nurse Practitioner removed staff member B from the emails and continued to email the other nurses. Staff member B stated she was not aware that the Psychiatric Nurse Practitioner was still emailing the nurses and was now going to get the Medical Director involved to work toward having the Psychiatric Nurse Practitioner follow compliance requirements. The Psychiatric Nurse Practitioner was not available for an interview due to vacation. Review of the facility's policy, Consulting Physician/Practitioner Orders, not dated, showed instructions reflecting that physician orders could be received in writing, via fax, or via telephone. The policy did not include receiving orders by email for controlled substances.

Based on interview and record review, the facility failed to provide necessary services and supervision to prevent a resident with dementia from continuing to enter other residents' rooms after an altercation with injury. The failure increased the risk for emotional distress and physical injury for 1 (#3) of 8 sampled residents and placed other residents at elevated risk for physical or verbal altercations. Findings include:Review of a facility-reported event, submitted to the State Survey Agency on 11/14/25, showed resident #3 entered resident #4's room and a physical altercation occurred when resident #4 attempted to redirect resident #3 out of the room. Resident #4 sustained minor injuries.During an interview on 12/30/25 at 1:22 p.m., staff member C stated resident #3 had been known to wander into other residents' rooms since he arrived at the facility. Staff member C stated resident #3 would not remember where his room was and would think another resident was in his room. Staff member C stated resident #3's room was now part of the new secured memory care wing which was opened on 12/22/25.During an interview on 12/30/25 at 2:18 p.m., staff member B stated resident #3 was placed on 1-to-1 observation from 11/15/25 to 12/1/25 and on fifteen-minute checks from 12/1/25 to12/22/25 when his wing was converted to a secured unit.During an interview on 12/31/25 at 9:38 a.m., staff member D stated resident #3 does continue to wander into other rooms since being in the secured unit, . but had not had any other conflicts that I know of. Staff member D stated the staff usually can redirect him out of other residents' rooms.Review of resident #3's nursing progress note, dated 12/3/25, showed, Resident was attempting to enter other resident's rooms but, was redirected by staff. He was aggressive. [sic]Review of resident #3's nursing progress note, dated 12/12/25, showed, Resident wandering at 6 am, up and down halls, went in to another residents room and sat in his w/c, he got up and resident returned and shut his door to keep him out and he was banging on the door. As he walked away he said 'I should kick his Ass'. Very aggressive this am . [sic]Review of an SBAR note, dated 12/21/25, showed, Resident (#3) wondering in and out of other residents' rooms. [sic]Review of resident #3's nursing progress note, dated12/28/25, showed, (Resident #3) was wandering in and out of other Residents rooms. He was taking their personal items etc. He picked a glass vase and I tried to get it from him and staff assisted me in getting the glass vase from him. Staff redirected him to his room to eat his dinner when he picked up his plate and took it to (room number) and dumped his food down the toilet. He began to dump other items like deodorant and toothbrushes down the toilet. Staff had to intervene and assisted him to his room. [sic] Review of a facility policy titled Dementia Care, dated 2025, showed, It is the policy of this facility to provide the appropriate treatment and services to every resident who displays signs of, or is diagnosed with dementia, to meet his or her highest practicable physical, mental, psychological well-being.Resident #3 continued to wander into other residents' rooms while on fifteen-minute checks and while residing on the secured memory care unit. The facility failed to consistently ensure the resident had adequate supervision as to prevent the resident from entering other resident rooms, placing resident #3 and other residents at risk for verbal or physical altercations.

Based on interview and record review, the facility failed to identify and implement beneficial interventions to prevent further falls for a resident with dementia, limited safety awareness, and who was at risk for falls. The resident used psychotropic medications and the care plan contained only minimal fall interventions and the resident had an unwitnessed fall and had head lacerations. The resident had subsequent falls and sustained a fractured hip for 1 (#10) of 17 sampled residents. Findings include. Review of resident #10's nursing note, dated 4/28/25 at 7:06 p.m., showed: - found resident sitting on his floor at 1700 (5:00 p.m.). Assessed for injury. ROM provided. No pain or discomfort noted. - The nursing note included another fall, within the same note, - .RN went to assist another resident. While walking down the hallway, RN noted blood on the floor and on the door jam of resident's (#10's) room. Resident was laying on this left side in bed. It appears resident is strong enough to get up off the floor on his own. Upon further assessment, resident was noted to have 2 small head lacerations to the back of his head. Resident assessed for further injuries . [sic] Review of resident #10's fall event report, dated 4/28/25, showed the facility investigated the cause of the fall, but did not take into consideration the recent increase in the resident's Ativan dose. Review of resident #10's 5/2025 medication administration record showed a physician's order on 4/17/25, which was to give Ativan 1 mg, given every 24 hours as needed, for anxiety. On 4/28/25, Ativan was ordered every 8 hours. The first routine dose of Ativan was given at approximately 3:00 p.m., on 4/28/25, approximately 2 hours before resident #10 sustained his first fall. Review of resident #10's eINTERACT SBAR summary note, dated 5/6/25 at 1:06 a.m., showed the resident fell due to general weakness. The note did not show the cause, or situation surrounding the fall. Review of resident #10's nursing notes, dated 5/6/25 at 2:32 p.m., showed the resident had increased falls since starting the lorazepam 1 mg every 8 hour dose. Review of resident #10's nursing notes, dated 5/7/25 at 4:39 p.m., showed, RN walked past resident's room and he was lying on his left side in bed. When RN and CNA met at 100/200 nurses station, yelling out was heard coming from the resident's room. All available staff were called to come to the resident's room for assistance. Vital signs obtained. Neuro checks started. ROM was provided to all extremities. Resident c/o increased pain to LLE with range of motion. Upon transferring him from the floor to his bed resident expressed increased pain to L hip . Review of resident #10's nursing notes, dated 5/7/25 at 7:00 p.m., showed resident #10 sustained a fractured hip. During an interview on 5/8/25 at 12:07 p.m., staff member B said the Ativan contributed to resident #10's falls, and the medication was not appropriate for him. Staff member B said resident #10 said he was scared, but he wanted company or comfort and didn't need that much Ativan. The Ativan dose decreased on 5/6/25, but was too late to help prevent the last fall that caused resident #10 to sustain a hip fracture. Staff member B said if it wasn't for the psychotropic medication, resident #10 would not have fallen and fractured his hip.

Based on interview and record review, the facility failed to ensure the medical director effectively coordinated medical care for 1 (#20) of 17 sampled residents. The medical director was not responsive to the nursing staff when direction was needed regarding resident care issues. The medical director was also an attending physician for numerous residents in the facility. There was no process to ensure there were no concerns with the individuals' performance as a physician. The facility failed to have a process for how to address concerns with the medical directors' care of residents. This deficient practice had the potential to affect all residents residing in the facility. Findings include: During an interview on 5/6/25 at 9:39 a.m., resident #20 said he had a bad headache, and he was sick to his stomach all day, yesterday. Resident #20 said he still had a headache and was tired. Review of resident #20's vital signs from 5/6/25, showed the resident's pulse was 45 beats per minute at 11:57 a.m. Review of resident #20's vital signs from 5/1/25 through 5/7/25 showed resident #20's pulse was as low as 44 beats per minute. Resident #20's pulse documentation showed 5/7/25 the resident was exhibiting symptoms of bradycardia, with a pulse below 50 beats per minute. During an interview on 5/7/25 at 2:21 p.m., staff member B said the medical director came to the facility on ce per month, but she was primary physician for many of the residents. Staff member B said you could call the medical director's clinic in Texas, but you did not talk to the same person very often. Staff member B said the calls made to the medical director concerning a residents' medical condition were not always addressed timely and the facility may not get a return call for several days. Staff member B said she called the medical director on 5/6/25, and again today, regarding resident #20's slow pulse. Staff member B said she was only able to leave a message, and the physician had not called back to address the slow pulse. Staff member B said with the medical director not being from here, the residents do not get the care they need. Staff member B said the medical director's practice had a nurse practitioner on staff, but if the time was close to 5:00 p.m., she sends a response back in all capital letters to call the call center and leave a message. Review of resident #20's nurses notes from 5/7/25, showed resident #20 went to the local emergency room and was provided care. Resident #20 returned on an antibiotic for a urinary tract infection, an order to stop the Metoprolol, and an order to see a cardiologist. During an interview on 5/8/25 at 9:45 a.m., staff member A said the facility was aware of the concerns with the medical director.

Based on interview and record review, the facility failed to have a designated infection preventionist for the facility. This deficient practice had the potential to affect all residents in the facility. Findings include: Review of the requested entrance conference materials failed to show an infection preventionist certificate or person responsible for the infection control program in the facility. During an interview on 5/8/25 at 12:04 p.m., staff member A stated there was not a current staff member possessing an infection preventionist certification. Staff member A stated the previous infection preventionist was no longer at the facility, and the new hire was just finishing up infection preventionist training.

Based on interview and record review, the facility failed to have an antibiotic stewardship program, which had the potential to affect all residents who received antibiotics in the facility. The facility failed to ensure the pharmacy delivered medications and completed monthly drug regimen reviews for all residents from May 2024 through April 2025. The facility failed to ensure a current QAPI (Quality Assurance and Performance Improvement) plan was developed. The QAPI plan had not been reviewed and revised for more than two years. Goal dates on the Quality Assurance & Performance Improvement (QAPI) Plan for the facility were documented as 12/1/2022. Findings include: During an interview on 5/7/25 at 1:40 p.m., staff member A said the facility used [Pharmacy Name] for their resident medications, and their drug regimen reviews. Staff member A said the facility was not getting the medications as ordered and needed. Staff member A said the staff would hurry to the local store at the end of the day to try to get medications not available by the pharmacy. Staff member A said the drug regimen reviews were coming through a portal the facility could not access. The facility continued to use that pharmacy until another pharmacy could be contracted with. The facility was not able to get drug regimen reviews from the pharmacy and no gradual dose reductions were completed for any psychotropic medications from 4/2024 through 4/2025. During an interview on 5/8/25 at 9:00 a.m., staff member A said the past infection preventionist was not completing the required job duties. Staff member A said the facility does not have anyone certified as the infection preventionist at the time of the survey. Staff member A said a new nurse had been hired, but the nurse was not certified in infection prevention. The nurse hired as the infection preventionist had worked some shifts and was currently taking the infection preventionist training to become certified. Staff member A said QAPI activities were based on survey citations, grievances, and firsthand observations made by the QAPI team. Staff member A stated the facility was working on hiring and training, and had a plan to recruit and retain facility hired staff, in an attempt to get away from interim agency staff. The QAPI plan had 12/1/2022 as a goal date for the facility to reduce turnover from 50 percent to 20 percent by 12/1/2022. Staff member A said staff member B had worked 11 days in a row without a day off.

Based on interview and record review, the facility failed to use antibiotics in accordance with accepted standards, identify a residents potential colonization of a specific organism causing the resident to be on almost continuous antibiotics for several months, gave two different antibiotics at the same time for the same UTI, and the resident contracted Clostridium difficile for 1 (#35) of 17 sampled residents. Findings include: During an interview on 5/8/25 at 11:44 a.m., staff member B stated resident #35 was on Macrobid antibiotic for sinusitis, currently. Staff member B stated the facility did not administer antibiotics without receiving the culture and sensitivity back for any resident. Staff member B stated the former infection preventionist did not do infection tracking as they should, and the facility did not have an infection preventionist at the time of the survey. Staff member B was unaware of resident #35 being on two different antibiotics at the same time for the same UTI. Review of resident #35's MARs, from 2/1/25 to 5/8/25, showed the following antibiotics were used: February 2025 - Bactrim DS Oral Tablet 800-160 MG, Give 1 tablet by mouth two times a day related to UTI for 7 days, until finished, with a start date of 2/23/25. It was given once on 2/23/25, then given twice a day 2/24/25 through 3/2/25, and once on 3/3/25. March 2025 - Vancomycin HCL Oral Capsule 125 MG, Give by mouth four times a day for C-Diff infections until 3/23/25, with a start date of 3/13/25. Documented as given twice on 3/13/25 and four times a day on 3/14/25 - 3/23/25. April 2025 - Bactrim DS Oral Tablet 800-160 MG, Give 1 tablet by mouth two times a day for UTI for 7 days, with start Date 4/4/25, and discontinue date 4/9/25, which was given once on 4/4/25 and 4/9, and twice 4/5 - 4/8/25. - At the same time, Ciproflaxin HCL Oral Tablet, 500 MG, by mouth two times a day, for UTI, were taken until 4/11/25. The start date of 4/4/25, and there was a discontinue date of 4/9/25. This medication was given once on 4/4 and 4/9/25, and twice on 4/5/25 - 4/8/25. There was no documentation for the rationale for discontinuing the ciproflaxin before the course was completed and switching to macrobid. - Macrobid Oral Capsule 100 MG, by mouth two times a day, for UTI, for 7 days until finished, with a start date of 4/9/25, and this was given once on 4/9/25 and twice 4/10/25 - 4/16/25. - Macrobid Oral Capsule, 100 MG, by mouth two times a day for UTI, for 7 days until finished, with a start date of 4/25/25, and this was given once on 4/25/25 and twice 4/26/25 - 5/2/25. May 2025 - Cefdinir Oral Capsule, 300 MG, Give 1 capsule by mouth two times a day for Sinusitis, for 14 days, and the order showed it may wait until the medication arrives from pharmacy to begin administration with a start date of 5/5/25. Review of resident #35's lab results, from 2/23/25 to 5/8/25, showed she was tested for a UTI multiple times, and they all came back as positive for Escherichia coli (e. coli)/Extended Spectrum Beta Lactamase (ESBL). Resident #35 was also was positive for Clostridium difficile on 3/15/25, and after returning from the ER visit on 5/3/25, with an order for antibiotics for sinusitis to start on 5/5/25.

Based on interview and record review, the facility failed to address the timely completion or implementation of treatment wishes, specifically related to the Provider Orders for Life-Sustaining Treatment (POLST) forms, and ensure the forms were complete so the document would not be voided, for 3 (#s 9, 16, and 20) and failed to ensure a resident's code status was consistently correct for 1 (#22) of 17 sampled residents. Findings include: 1. Review of resident #9's care plan showed the resident was admitted on [DATE]. Review of resident #9's POLST (Physician Orders for Life-Sustaining Treatment) showed the form did not have a printed name, signature, or date in the mandatory section identifying the person making the decision for life sustaining treatment. The POLST form was signed by a physician on [DATE], without verification of who was making life sustaining choices for resident #9. Resident #9's POLST showed the resident was a full code. The lack of the resident's or responsible party's signature may void the form. 2. Review of resident #16's POLST showed the physician did not print their name on the form and did not fill in the mandatory date when the form was signed. Resident #16 signed and dated the form on [DATE]. 3. Review of resident #20's care plan showed the resident was admitted on [DATE]. Review of resident #20's POLST showed the resident wished to have no CPR and for comfort focused treatment. Resident #20 signed the POLST on [DATE] to make those wishes known. The section of the form reflecting the date and person completing the form was blank. The mandatory physician signature and date section on the POLST was blank, therefore, in Montana the form would be invalid. During an interview on [DATE] at 3:31 p.m., with staff members A and I, staff member I stated when the resident was admitted the POLST was completed by the Social Services Supervisor. The Social Services Supervisor would request assistance from a nurse or the Director of Nursing when needed. Staff member I said the POLST was held at the facility and would be signed next time the physician was at the facility. Staff member A said the time lapse for signature could be up to a month time frame. Staff member I said the POLST was considered effective even without a physician signature. Staff member I said there was an audit process as staff member C checked all POLSTs to ensure the forms are complete. Staff member A said the process had recently changed and the admission staff person would be taking over this process. Staff member A said the admission person was a nurse and will be able to assist residents and their families. 46400 4. Review of resident #22's POLST, dated [DATE], showed the patient had elected and signed a DNR status. Review of resident #22's physician orders, dated [DATE], showed the resident was a, full code supported by durable power of attorney for healthcare. Review of an informal document titled, Nursing Report/Tasks, printed daily, and present on all nursing workstations and referenced by staff, showed each resident's room, name, code status, and special tasks or notes. Resident #22 was documented as a DNR on the document. During an interview on [DATE] at 3:56 p.m., staff member B stated resident #22 had just returned from the hospital, and on his admission paperwork the resident representative had selected for him to be a full code. Resident #22's physician stated the resident was not competent to make his own decisions and changed the ordered code status. A request for resident #22's healthcare power of attorney was made on [DATE]. Provided was a document titled, Durable Power of Attorney, dated [DATE]. Review of the document showed the representative was named a financial POA. The document failed to show any instances where healthcare decisions could be made or reversed by the representative who had signed the form. The National Polst document, which provides information related to the POLST forms and required signatures, shows Montana does require a patient and physician signature for a POLST to be valid in the State of Montana. Refer to: https://polst.org/wp-content/uploads/[DATE].02.28-Signature-Requirements-by-State.pdf, for the current state by state listing of signature requirements. The Montana Department of Health and Human Services participates in a POLST program, and on the DPHHS website, provides information related to the POLST forms and process. The website included information such as, the POLST must be, Completed by a health care professional based on patient preferences and medical indications, and: - Provider signature must be a Montana licensed physician, advanced practice registered nurse or physician assistant. - Patient (or legal decision-maker, if patient unable to make medical decisions), must sign to be valid. - Verbal orders are acceptable with follow-up signature by provider in accordance with organization. This information may be located at: https://dphhs.mt.gov/publichealth/emsts/polst.

Based on interview and record review, the facility failed to ensure a licensed pharmacist sufficiently addressed and documented the monthly medication regimen reviews for 1 (#10) of 17 sampled residents, and the resident received medications for anxiety and depression which fell into the classification of a psychotropics per CMS; and failed to complete the monthly medication regimen reviews with recommendations to ensure residents were provided the appropriate medications and doses to treat their diagnoses, for 4 (#s 3, 22, 24, and 35) of 17 sampled residents. Findings include: 1. Review of resident #10's medication administration record for May 2025 showed the following: - Olanzapine, an atypical antipsychotic, 2.5 mg by mouth, every day, which was ordered on 7/11/24. - Ativan, an benzodiazapine, 1 mg by mouth, every 24 hours as needed, which was ordered on 4/17/25 and discontinued on 4/28/25. - Ativan 1 mg by mouth, every eight hours, was ordered 4/28/25. - Buspirone, an anxiolytic, 5 mg three times a day, for anxiety, which was ordered on 8/16/24, - Escitalopram, an antidepressant, 20mg daily, for anxiety and depression, was ordered 12/21/24. A request was made on 5/6/25 for the facility's gradual dose reduction requests for resident #10 for one year, but the GDR's were not received by the end of the survey. Review of the facility's Monthly Medication Reviews, for resident #10, dated May 7, 2025, showed a form that included: - Note to attending physician/prescriber. The pharmacy identified the resident as taking: Lexapro (Escitalopram), Buspar (Buspirone) and olanzapine. The pharmacy did not identify the Ativan on the document. The pharmacy requested a gradual dose reduction, or a risk versus benefit analysis or rationale, for recommendations. The physician checked a box showing the GDR was clinically contraindicated, and the continued use was in accordance with the current standard of practice. A GDR attempt was likely to impair the individual's function. There was no documentation to identify what function would be impaired for the resident. There were no risks versus benefits for the medication(s) addressed for resident #10. Resident #10 had been on Buspar for nine months with no gradual dose reductions attempted. The physician signed a declination on 4/21/25, without documenting why resident #10 needed to continue taking the psychotropic medications. During an interview on 5/8/25 at 12:07 p.m., staff member B said the Ativan contributed to resident #10's falls, and the medication was not appropriate for him. Staff member B said resident #10 said he was scared, but he wanted company or comfort and didn't need that much Ativan. The Ativan dose decreased on 5/6/25, but it was too late to help prevent the last fall that caused his hip fracture. Staff member B said if it was not for the psychotropic medication, resident #10 would not have fallen and fractured his hip. Review of the State Operations Manual, Appendix PP, shows: A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: (i) Anti-psychotic; (ii) Anti-depressant; (iii) Anti-anxiety; and (iv) Hypnotic. 41952 2. A request was made on 5/6/25 for monthly pharmacist reviews for the last year for resident #'s 3, 24, and 35. The monthly pharmacist medication regimen reviews were not provided by the end of the survey for the three residents. During an interview on 5/8/25 at 7:33 a.m., staff member A stated the facility was having issues with the prior pharmacy locking them out of the system utilized and not providing the information, including pharmacy reviews, and recommendations. They had no historical documentation to provide. Staff member A stated the facility started with a new pharmacy provider 4/1/25 and were still working things out. a. Review of resident #3's current physician orders showed: - Duloxetine HCL delayed release particles 60 mg, one time a day for depression, with a start date of 3/1/25. - Mirtazapine 30 mg at bedtime, for depression, with a start date of 2/28/25. - Depakote delayed release 500 mg two times a day, for aggression, with a start date of 2/28/25 - Hydroxyzine 25 mg as needed every 8 hours for itching with a start date of 2/28/25 b. Review of resident #24's current physician orders showed: - Fluoxetine HCL oral tablet 40 mg for major depressive disorder with a start date of 1/25/25 - Zyprexa Oral tablet 10 mg at bedtime for paranoid delusional disorder with a start date of 1/21/25 - Zyprexa oral tablet 2.5 mg one time a day for paranoid delusional disorder with a start date of 1/22/25 - Depakote Sprinkles delayed release 125 mg give two capsules by mouth three times a day for mood stabilizer with a start date of 1/21/25 c. Review of resident #35's current physician orders showed: - Duloxetine HCL delayed release sprinkles 60 mg one capsule one time a day for depression with a start date of 12/31/24 - Buspirone HCL 5 mg one tablet two times a day for depression with a start date of 3/4/25 46400 d. A request was made on 5/6/25 for all monthly pharmacist medication reviews for the last four months for resident #22. Nothing was received by the end of the survey. During an interview on 5/7/25 at 2:40 p.m., staff member B stated [Pharmacy Provider] had been with the facility until March 31 (2025), before the contract was terminated, and a new provider sought. Staff member B stated they were unable to access any of the past reviews.

Based on interview and record review, the facility failed to report an allegation of residen to resident abuse, as it was not identified as abuse for 2 (#s 47 and 53); and failed to report two injuries of unknown origin for a resident, one of the injuries was a major injury, for 1 (# 10) within 24 hours of the incidents of 17 sampled residents for abuse reporting. Findings include: 1. Review of resident #10's nurse progress notes, dated 4/25/25 at 12:56 a.m., showed, resident continues with fading bruising scattered purple/blue in color to left lower back. Voiced c/o pain to area. Review of nursing progress notes, from 4/18/25 through 5/25/25, showed resident #10 did not have any falls or sustain injuries. The cause of the bruising was unknown and not identified by the facility. During an interview on 5/7/25 at 4:57 p.m., staff member A said she was not aware of any bruising on resident #10. Staff member A said there was no investigation completed into the cause of the bruising of unknown origin, which is reportable to the State Survey Agency. Staff member A said the facility tried to read the progress notes every day, but we were stretched too thin (staff available for the task). Staff member A said she was still investigating to see if more information was available for the bruising. Review of resident #10's nursing notes, dated 5/7/25 at 4:39 p.m., showed, RN walked past resident's room and he was lying on his left side in bed. When RN and CNA met at 100/200 nurses station, yelling out was heard coming from the resident's room. All available staff were called to come to the resident's room for assistance. Vital signs obtained. Neuro checks started. ROM was provided to all extremities. Resident c/o increased pain to LLE with range of motion. Upon transferring him from the floor to his bed resident expressed increased pain to L hip . Review of resident #10's nursing notes, dated 5/7/25 at 7:00 p.m., showed resident #10 sustained a fractured hip. During an interview on 5/8/25 at 7:52 a.m., staff member A said resident #10 fell and fractured his hip. Staff member A said the fall with injury, which was not witnessed, and the resident was an unreliable reporter, but sustained a fractured hip, was not reported to the State Survey Agency as an injury of unknown origin. 2. Review of resident #53's nursing note, dated 3/28/25, showed resident #53 was agitated and threatening physical harm to her roommate, resident #47. The nurse's note showed, according to roommate, the resident had already hit her at this point. This was not witnessed by staff. However, the roommate was laughing and taunting resident #53 despite being reprimanded. The intervention put into place was to remove the roommate. During an interview on 5/6/25 at 2:20 p.m., staff member A said the event on 3/28/25 involving residents #47 and 53 was not abuse. The event was investigated as abuse, and it was determined there was no abuse. Staff member A said the investigation revealed no abuse, so the allegation was not reported. Staff member A said she was not alerted by staff member M when this incident occurred. During an interview on 5/6/25 at 3:25 p.m., resident #47 said she did not remember if her roommate got physical and hit her, but her roommate did get verbally aggressive, and she was going through her things. Resident #47 said she did not like roommates yelling or going through her property. Review of the State Survey Agency abuse portal did not show the facility reported the incident between resident #53 and her roommate resident #47 on 3/28/25, and did not report the bruise of unknown origin for resident #10 on 4/25/25. Review of the facility's policy titled, Abuse, Neglect and Exploitation Policy undated and taken from the Compliance Store with a 2024 Copyright, showed, alleged violation is a situation or an occurrence that is observed or reported by staff, resident, relative, visitor or others but has not yet been investigated and, if verified, could be indication of noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property. The abuse policy showed all allegations would be reported to the administrator, to the State Survey Agency, and other required agencies.

Based on interview and record review, the facility failed to ensure the required elements of education, physician and management notifications, and documentation of an AMA discharge, were completed for 1 (#55) of 17 sampled residents. Findings include: Review of a closed record EHR for resident #55 showed discharge on 3/8/25 as AMA. The resident had admitted on [DATE]. Resident #55's care plan did not have discharge planning until 3/5/25. The care plan only showed the resident wished to go back to the community. No other discharge planning was documented. No information on education and the risks was documented for an AMA discharge, other than they could not give him medications, to take with him on discharge. No notifications were in the EHR of the provider being notified. There was no recapitulation of the residents stay from the provider, or documentation of the facility contacting other entities related to the resident leaving AMA due to risks with the discharge. Review of resident #55's discharge evaluation, dated 3/12/25, showed, Resident left facility AMA and had a friend pick him up. Facility was called after a few days and advised resident was looking for placement again. Facility will not accept resident back after leaving AMA. Review of a form titled, Against Medical Advice release form, dated 3/8/25, showed predefined text and signature of the nurse and resident, no second witness signature. A hand written note of, Going to Belgrade. Friend [friends name] coming to pick. He left at 0900 [9:00 a.m.]. [sic] During an interview on 5/8/25 at 11:38 a.m., staff member B stated resident #55 had come to her upset and wanting to leave earlier in the week of his AMA discharge. She stated she educated resident #55 on needing to stay until a safer place was found, due to conversations with family, that his prior living situation was not suitable. She told resident #55 his provider would be there to see him the next week to evaluate the resident and make a plan. Staff contacted her on the day of the resident's AMA, and she directed them to educate and sign the AMA paperwork. Staff member B stated all of the education and contact with family should have been documented. Review of a facility provided policy titled, Transfer and Discharge (including AMA), listed as Copyright 2025 The Compliance Store LLC, showed: 11. Discharge Against Medical Advice (AMA) . b. The resident and family/legal representative should be informed of the risks involved, the benefits of staying at the facility, and the alternatives to both. Under no circumstances will the facility force, pressure, or intimidate a resident into leaving AMA. c. The physician should be notified of the intended AMA discharge and be encouraged to speak with the resident to encourage them to stay at the facility. d. Documentation of this notification should be entered in the nurses' notes by the nursing department . e. Notify Adult Protection Services, or other entity as appropriate, if self-neglect is suspected. Document accordingly.

Based on interview and record review, the facility failed to ensure residents transferring or discharging to the hospital were provided the transfer discharge notice and bedhold for 1 (#3) of 17 sampled residents. Findings include: During an interview on 5/8/25 at 7:57 a.m., staff member A stated the facility did not have the transfer discharge notice for resident #3. Staff member A stated the transfer discharge notices and bedholds were a problem they were working on. Review of resident #3's census showed a hospitalization from [DATE] to 3/4/25. There was no documentation of a transfer discharge notice or bedhold form in the resident's record or provided.

Based on interview and record review, the facility failed to ensure a baseline care plan was developed and implemented within 48 hours after admission to reflect the resident's care needs, for 1 (#10) of 17 sampled residents. This increased the risk of staff not providing necessary care and services due to the lack of the baseline care plan. Findings include: Review of resident #10's baseline care plan evaluation showed the resident was admitted on [DATE]. Resident #10's baseline care plan failed to identify the resident's code status. Section F, active diagnoses contributing to the resident's admission were left blank. Resident #10's base line care plan did not identify his risk associated with dementia, weakness, and the use of psychotropic medications. Resident #10's baseline care plan showed the resident had no history of falls. There was no date for completion of the care plan. Section 5. B, on the baseline care plan form, showed a signature and date line for the resident and the representative to sign. This section was blank. Section seven of the care plan showed it was to have a signature, title, and date of the staff completing the care plan. Section seven was blank. During an interview on 5/6/25 at 4:31 p.m., staff member A, I, and Q were present for the interview. Staff member A said the care plan process was an interdisciplinary process that began at the resident's admission. Staff member I said there was an evaluation assessment which was completed by each discipline. Staff member A said this evaluation was the base line care plan. Staff members A, I, and Q were unsure if the baseline care plan assessment sent information to a Kardex or care plan that was accessible by the certified nursing assistants. Staff member Q said the CNAs could always ask the nurse how to take care of the resident. During an interview on 5/7/25 at 8:40 a.m., staff member H said resident #37's base line care plan was not completed because the evaluation was not completed, and there were no staff signatures on the care plan. During an interview on 5/7/25 at 9:08 a.m., staff member K said he was not aware of how to look at the resident's baseline care plan. Staff member K said the only care information available to him was the sheet of paper the DON completed with information about the resident.

Based on observation, interview, and record review, the facility failed to review and provide the needed ADL assistance for dining for 1 (#3) of 17 sampled residents. Findings Include: During an interview on 5/6/25 at 9:59 a.m., resident #3 was in her room sitting in her wheelchair, and she was clearing her throat and coughing, and stated the facility staff 'don't feed me right.' Resident #3 stated she had a hard time with a regular fork and spoon, and she had tried built up (adaptive) silverware in the past, but they had not been tried in a while. Resident #3 stated she was to get a walled (adaptive plate) plate but it did not always happen. During an observation on 5/7/25 at 12:37 p.m., resident #3 was in the assisted dining room at a table with another resident, and a staff member facing away from resident #3. Resident #3 had a large bowl with a mix of food and dinner roll on top. There were three drinks with straws in double handled sippy cups, without lids. Resident #3 was trying to grab the dinner roll from the bowl and could not get her hand to turn the correct way to grasp the roll. She openly stated to she could not grab it, but no one responded. The dinner roll was not eaten. Resident #3 was observed through the meal attempting to feed herself by holding her right hand steady with her left hand to try to bring a regular spoon to her mouth. Resident #3 was observed only getting two bites of food from the bowl during the meal. Resident #3 was also observed leaning towards the cups on the table, and she was trying to grab the straws with her mouth (as the straws kept moving around) to get a drink, because there were no lids on the cups, to hold the straws in place. During an interview on 5/7/25 at 4:46 p.m., staff member D stated resident #3 used to have a high wall plate, and they had attempted a heavy spoon, but resident #3 needed more assistance so staff were to feed her. When resident #3 came back from her hospitalization she did not have orders for the adaptive equipment, and there had not been any new orders written for adaptive meal equipment. The facility staff had not yet identified and addressed the issue with the resident's struggles when eating to ensure she was able to fully eat and drink at her meals safely. During an observation on 5/8/25 at 9:24 a.m., resident #3's breakfast was left on a table in the assisted dining room. A divided plate with two English muffins, cut in half, two sausage patties cut in chunks, and scrambled eggs, all not eaten, all were left on the plate. There were three sippy cups with straws, with no lids. There was a bowl with a straw that was empty. During an interview on 5/8/25 at 9:32 a.m., staff member R stated the last time therapy worked with resident #3 for meals and eating was before her hospitalization (when she had orders for adaptive equipment) when she was having a lot of behavioral problems and refusing to participate if she did not get her wheelchair back. At the time resident #3 attempted the long utensils, the kind that wrapped around her arm, but the resident did not like them. Resident #3 was to have a walled plate, and sippy cups with the concave lids, with straws. This was because she could not hold the cups. Resident #3 was to be fed by staff due to her decline. Review of resident #3's care plan for ADL self-care performance showed a revision on 1/29/25, with the intervention of, Eating: [Resident #3] needs assist of 1 with eating.

Based on interview and record review, the facility failed to crush medications as ordered by the physician, for 1 (#1) of 5 sampled residents with a diagnosis of difficulty swallowing. This resulted in the resident being transferred to the emergency department and hospitalized for aspiration pneumonia. Findings include: During an interview on 12/4/24 at 2:37 p.m., staff member G said resident #1 was at risk for choking and the resident eats in the dining room. She had never witnessed resident #1 to have problems with swallowing but the resident has her food cut up into small bites. During an interview and record review on 12/5/24 at 7:50 a.m., staff member D said she was a travel nurse and had received education on medication administration and abuse by her travel company, prior to starting her 13-week contract. Staff member D said the facility provided information on each resident and their preferences, in a binder, at the nurse's station. Staff member D provided a document, labeled with the resident's name, the hall, and the room number, and how each resident takes their medications. This included the code status, primary physician name, and any notes that are specific to the resident. Review of the document showed resident #1's medication was to be given whole. Staff member D said she had not checked the specific medication order but followed the information on the document. Staff member D said resident #1 has difficulty swallowing and eats in the dining room where she could be observed. During an interview on 12/5/24 at 8:15 a.m., staff member E said she was familiar with resident #1 and her medications were administered whole, not crushed. Staff member E said she had not checked the medication order. She said she had not given resident #1 her medications crushed, and if she had crushed the medications, resident #1 would probably refuse to take them. During an interview on 12/5/24 at 10:29 a.m., staff member B said the facility did not currently have a DON, but had a clinical nurse resource filling the position until a replacement was found. Staff member B said it was her expectation that staff document any interventions offered or refused by a resident within the medical record. During an interview on 12/5/24 at 11:00 a.m., staff member H said on the night of 11/24/24, she had received report from the previous nurse that resident #1 had been off during the day. Later that night, she went into resident #1's room to dispense her medications, she was sleeping. Staff member H had asked resident #1 if she was wanting to go into the ED for evaluation and resident #1 refused and said she wanted her medication. Staff member H said resident #1 was awake and alert, she dispensed the medication to resident #1 in applesauce or something, and resident #1 seemed to have swallowed them without difficulty. Shortly after taking the medications, resident #1 began to cough and became unresponsive. Staff member H then tried to take out as many pills as she could get out of resident #1's mouth but was aware she had not gotten all the pills out. Staff member H said after attempting to contact the physician and the resident's daughter, without success, she contacted emergency medical services. Resident #1 had remained unresponsive. Staff member H said she was aware resident #1 had a history of difficulty swallowing and had been noted to choke on day shift. She had not seen the resident choke before this incident. Staff member H said she had listened to resident #1's lungs after her coughing episode, and the lungs sounded terrible (not clear). Staff member H said she was not aware of resident #1 had an order to crush her medication. She said resident #1 was not compliant with pureed food, so she did not think resident #1 would be compliant with crushed medication. She had never attempted to give her crushed medications. During an interview on 12/5/24 at 11:54 a.m., staff member J said resident #1 was very independent. Staff member J said resident #1 would not take her medication crushed. When asked if staff member J had documented resident #1's refusal of crushed medication, staff member J smiled and shrugged her shoulders, she did not provide and answer. During and interview on 12/5/24 at 12:09 p.m., staff member I said resident #1 was at the assistive table, she requires assistance at every meal. Staff member I said she had witnessed resident #1 choking on liquids, but the resident was able to clear her lungs. Staff member I said she had not seen an incident where she believed resident #1 had aspirated. Staff member I said she had not received a report of resident #1 had any difficulty with swallowing food or pills. Record review of resident #1's electronic medical record health status note, dated 11/25/24 at 1:31 a.m., showed: Resident coughed after pills were taken, LPN got out any pills that were visible in mouth at the time. Resident then became lethargic and not responsive. Review of a facility document, Order Recap Report, dated 1/1/24 through 12/31/24, showed resident #1 had airway clearance therapy ordered as needed and three times a day for increased secretions, order date 10/1/24 and an end date of 11/24/24; May crush all crushable medications and open capsules until contraindicated, order date 7/29/24 and an end date of 11/24/24. 11/24/24 was the date resident #1 was admitted to the hospital for aspiration pneumonia. Review of resident #1's care plan, with a print date of 12/4/24, showed a diagnosis of Dysphagia, oropharyngeal phase, and pneumonia due to other specified infectious organisms. Review of a facility Emergency Provider Note, dated 11/25/24, showed: . presents to the ED for evaluation of hypoxia and altered mental status.patient is nonverbal at time of initial assessment.per facility report she has been not herself for 2 days, but claimed she was awake when they gave her her nightly meds . . On EMS arrival patient was on her baseline nasal cannula at 5 L through a concentrator, satting 82% . On presentation to the ED she will blink her eyes on command but is not responding verbally and has very weak attempts at motor responses to verbal stimuli. . RT at bedside, managing high flow and administering DuoNeb treatments, was performing oropharyngeal suctioning and continues to get chunks of partially dissolved pills and possibly food from pt's oropharynx after she coughs . [sic] Review of a facility H&P, dated 11/25/24, showed: . A/P: 1. Severe sepsis 2. Acute on chronic respiratory failure, hypoxia 3. Aspiration PNA . -Food and pill material evident in ED with suctioning - CXR with B/L PNA findings .

Based on observation, interviews, and record reviews, the facility failed to ensure an ongoing systemic approach was utilized for managing a resident with a known history of elopement attempts, by failing to ensure the resident was evaluated timely and as needed throughout his stay, for future elopement prevention as the resident continued to attempt to elope; and the facility failed to ensure staff were made aware of the resident's risk for elopement and process utilized for residents who were an elopement risk, and resident #1 eloped, sustained an injury, and was hospitalized for monitoring, for 1 (#1) of 12 sampled residents. Findings include: During an interview on 8/26/24 at 11:15 a.m., staff members A and B stated resident #1 was sitting in the dining room with his wife, having his morning coffee before breakfast, at approximately 8:20 a.m. Staff noticed the resident was not at his dining room table while serving breakfast, at approximately 9:00 a.m. Staff immediately alerted other staff and started to look for resident #1. Resident #1 was not found in the courtyard outside the dining room or in the building. Facility leadership was immediately notified, and a search on foot occurred. At approximately 10:00 a.m., a staff member alerted staff member A that their car had been stolen (from facility parking lot), and the staff member had left the keys in the car. The facility staff believed resident #1 had taken the car. Resident #1 was found at approximately 10:00 p.m. The vehicle he had taken from the facility parking lot, was rolled onto the passenger side, and the resident was not wearing a seatbelt. The resident was immediately transported to the hospital with complaints of neck pain. The resident was then admitted to the hospital over the weekend to monitor elevated troponin levels (a troponin test measures the levels of troponin T or troponin I proteins in the blood). These proteins are released when the heart muscle has been damaged, such as what occurs with a heart attack. The more damage there is to the heart, the greater the amount of troponin T and I there will be in the blood) which was believed to have occurred during the wreckage of the vehicle. Staff members A and B stated the dining room door did not alarm, and staff believed resident #1 had removed his Wander guard from his walker, which resulted in the dining room door not alarming, when he left the building. During an interview on 8/26/24 at 11:30 a.m., staff member D stated the dining room door did not lock until 9:00 p.m. The dining room door exits into a courtyard which has a patio and gazebo, but the yard is not secured. Staff member D stated, the dining room door should alarm if a resident with a Wander guard attempts to exit the door. The door would not alarm if the resident was not wearing a Wander guard. Staff member D stated the residents who utilize the unsecured courtyard were not always supervised. During an observation at 12:15 p.m., the dining room door was not locked. Upon exiting the dining room door, the egress opens onto a patio and a sidewalk which leads into an enclosed grassed courtyard with a gazebo at the center. The courtyard is enclosed with a chain-link fence. The gate off the side of the courtyard, which leads to where staff and visitors park, was not secured. During an observation on 8/26/24 at 1:45 p.m., a resident without a Wander guard alarm went outside through the dining room door. The door did not alarm. The resident held the door open for resident #11 so she could go outside. The Wander guard alarm sounded, and staff turned off the alarm. Resident #11 went outside and attended the garden. 1. Failed to Ensure the Resident at Risk of Elopement was Evaluated Timely: A review of resident #1's nursing Progress Notes Reflected the following: - On 8/11/24 at 6:30 p.m., Note Text: Resident witnessed to be walking out of his room screaming at his wife that they are leaving, all their clothes and belongings packed into bags stacked up onto his walker and he stated, We are leaving. This nurse walked with resident down hallways trying to redirect him back to his room, but patient refused and continued onto the common day room at 100/200 hall. He presented to the front door and re-directed to the chair in the front room. The other nurse called his son and phone was handed over to resident. - On 8/12/24 at 7:18 p.m., Note Text: Resident found 2 blocks away by another staff member Resident stated he was waiting for the Bus. Notified Resident nurse that he is outside and refusing to come back in. This elopement was not reported. A new elopement assessment was not completed after this elopement. - On 8/15/24 at 9:40 a.m., Note Text: resident is convinced he is going to leave the facility today, has been packing things out of his closet. piled up a bunch of clothes on top of his walker then tried to sit on it. he slipped off the walker and fell to floor. fall was unwitnessed. neuro checks started. increased confusion noted. [sic] - On 8/16/24 at 6:33 p.m., Note Text: resident is convinced he is going to leave the facility today. Resident has packed things out of his closet. He has piled up his clothes on top of his walker and attempted to leave his room. Resident was re-directed, clothes taken off of his walker and walked to the dining room for dinner. - On 8/16/24 at 1:14 p.m., Late Entry Note Text: Discussed with IDT about resident and his wife rooming together and the possibility of separating them because they are known to [NAME]. Followed up with resident and asked why he is wanting to leave facility. He stated he is just looking for something to do. Asked if he would like to move rooms. Resident chuckled and stated no. Will follow up with POA. - On 8/16/24 at 8:10 a.m., Late Entry Note Text: Resident is an elopement risk r/t dementia diagnosis and poor safety awareness. Wander guard issued as intervention. - On 8/17/24 at 7:10 a.m., Late Entry Note Text: Resident witnessed by this nurse to have bags on his walker and stating he was leaving the facility, resident was re-directed by this nurse back to his room, walker was unloaded in his room and resident laid back in bed. - On 8/17/24 at 8:25 a.m., Late Entry Note Text: This nurse was passing medications to a resident in the dining room prior to breakfast. [Resident #1] was not in his regular dinning chair awaiting his breakfast tray, this nurse looked around the dining room, in the resident's room/bathroom, in the 100/200 halls and asked CNAs and other nurses if they had seen [Resident #1], everyone had denied at this time, resident is a smoker and goes to designated smoking area often, resident was not found in smoking area and back gate out of designated smoking area opened. Code Yellow called over the walkie talkie. Administration notified, and POA next of kin notified at this time. [sic] A review of resident #1's Social Services Behavior Notes, reflected the following: - Effective Date: 8/13/24 at 8:10 a.m., with a Created Date of 8/17/24 at 5:27 p.m., Resident is an elopement risk r/t [related to] dementia diagnosis and poor safety awareness. Wander guard issued as intervention. - Effective Date: 8/13/24 at 9:43 a.m., with a Created Date of 8/19/24 at 9:47 a.m., Resident removed wander guard from person. Resident has a sitting walker with a lift seat for storage area. Wander guard was taken and placed inside his walker to prevent further tampering. Resident does not open storage area. A review of resident #1's Elopement Risk Assessments showed an elopement assessment was completed on admit on 7/8/24 and a second elopement assessment was completed on 8/21/24 after the resident's second and final elopement. There was no elopement assessment completed after the resident's elopement on 8/12/24. A Wander guard was not placed on the resident until 8/13/24. Social Service documentation showed the resident continued to remove his Wanderguard bracelet. No additional interventions were implemented to prevent further tampering of the bracelet by the resident. A review of the resident #1's IDT notes failed to show an IDT meeting was held to review the resident's elopement on 8/12/24. A review of resident #1's Medication Administration Record for July and August 2024 reflected the Wanderguard was applied to the left ankle due to poor safety awareness, with a start date of 8/19/24 at 6:00 p.m. This entry was after the second elopement on 8/17/24. A review of resident #1's Treatment Administration Record for July and August 2024, reflected staff were to check the Wanderguard nightly for proper functioning, with a starting date of 8/20/24. This entry was after the second elopement on 8/17/24. A review of resident #1's KARDEX failed to show the resident was an elopement risk and failed to show he had a Wanderguard in place. 2. Failed to Ensure Staff were Made Aware of the Resident's Risk for Elopement: During an interview on 8/26/24 at 11:00 p.m., staff member B stated she had implemented a form which identifies all the residents and has the term alarm next to any resident who is an elopement risk and wears a Wanderguard. She stated before the elopement of resident #1, there would be a notation on the treatment record or the Kardex for the aides. During an interview on 8/26/24 at 12:47 a.m., staff members F and G stated the nurses would let them know who wears a Wanderguard and was an elopement risk. She stated if they could not see the Wanderguard or were not sure if a resident was an elopement risk, she would ask the nurse or would have to log onto the computer and thought it might be on the Kardex. During an interview and observation on 8/26/24 at 1:00 p.m., staff member N stated she was not sure how to tell if a resident was at risk for wandering or elopement. She stated she would look for a Wanderguard and if could not see one, she might check the treatment record. Staff member N was only able to identify one of the three residents in the dining room who were elopement risks. During an interview on 8/26/24 at 1:15 p.m., staff member H stated they were not sure how to tell if a resident was a high risk for elopement. She stated hopefully it was shared during report. She stated she was not sure if it was on the treatment record or not but would check. She stated she was not aware of the form which identified the residents with alarms. A review of a facility's policy and procedure, titled Elopements and Wandering Residents, with no date, reflected: . 3. The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. 4. Monitoring and Managing Residents at Risk for Elopement or Unsafe Wandering a. Residents will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary care plan team. b. The interdisciplinary team will evaluate the unique factors contributing to risk in order to develop a person-centered care plan. c. Interventions to increase staff awareness of the resident's risk, modify the resident's behavior, or to minimize risks associated with hazards will be added to the resident's care plan and communicated to appropriate staff. d. Adequate supervision will be provided to help prevent accidents or elopements. e. Charge nurses and unit managers will monitor the implementation of interventions, response to interventions, and document accordingly. f. The effectiveness of interventions will be evaluated, and changes will be made as needed. Any changes or new interventions will be communicated to relevant staff .

Based on observation, interview, and record review, the facility failed to identify the root cause of falls for the implementation of individualized interventions; and failed to ensure resident care plans were updated with interventions addressing the residents' current medical, physical, and cognitive limitations for 2 (#s 42 and 49) of 2 residents sampled for falls. Findings include: 1. During an observation and interview on 5/21/24 at 9:42 a.m., resident #42 was attempting to stand up out of his wheelchair. He was part way in the door of his room. He stepped forward and tripped on the foot pedals of his wheelchair. A member of the survey team reached out to catch resident #42 to keep him from falling to the ground. Resident #42 stated he needed to get his dresser packed. Resident #42 continued to attempt to stand up. Staff member H came to assist the surveyor and stated the resident had already fallen that morning and thanked the surveyor for catching him. Staff member H said it was common for her to have to work both the 300 hall and the 400 hall and there were two residents (#s 42 and 49) who required very close supervision because they fell frequently. Staff member H said resident #42 had his room changed at the facility and kept trying to go back to his old room. He was packing and focusing on getting back to his old room. Staff member H said his behavior made it harder to keep him from falling and made him more impulsive. Staff member H said she wanted to put resident #42 back to bed, but was reluctant for fear of the resident attempting to get up on his own and falling again. Staff member H stated resident #42 was not [cognitively] there enough to use his call light for help. During an interview on 5/21/24 at 10:35 a.m., staff member I stated the staff had a busy morning and hadn't had time to document resident #42's 5/21/24 morning fall in the electronic medical record yet. Staff member I stated they did a verbal round with staff when there were new interventions for residents since not everyone had time to read the care plans or Kardex. Staff member I stated the facility had stopped doing the falling star indicators on resident doors and wheelchairs mentioned in their fall protocol when they were told in the past it was dignity/HIPAA issue. Review of resident #42's nursing progress notes, dated January 2024 - current, showed the resident had 17 falls in a five-month span. Two of these falls resulted in trips to the emergency department for a head contusion and broken nose. Eight of these falls occurred while the resident had an infection and/or was on antibiotics. Review of resident #42's nursing progress notes, dated January 2024 - current, showed the following falls and antibiotic orders: a. Resident #42 had an order for the antibiotic Bactrim twice daily dated 1/27/24 - 2/6/24 for a UTI. - 1/27/24 fall while on antibiotics. - 2/2/24 fall in the bathroom resulting in a left forehead contusion and broken nose. He was sent to the E.R. He was still on antibiotics at this time for a UTI. - 2/5/24 fall while walking in his room. He was still on antibiotics at this time for a UTI. b. Resident #42 was hospitalized for sepsis caused by pneumonia from 3/5/24 - 3/7/24 after presenting with weakness the previous days. - 3/3/24 Resident was assessed after fall by this nurse resident did have swelling on front left side of face goose egg with a laceration at top of swelling, resident also had skin tear to left rear elbow, skin tear also to left front of knee. c. Resident #42 had antibiotic orders for Bactrim dated 4/28/24 - 5/5/24 for cellulitis, Amoxicillin 5/8/24 - 5/18/24 for pneumonia, and Levofloxacin dated 5/9/24 - 5/12/24 for a UTI. - 5/5/24 fall and was then hospitalized [DATE] - 5/8/24 for sepsis. - 5/9/24 fall in the hallway, still on antibiotics. - 5/10/24 fall while on antibiotics. - 5/12/24 fall while on antibiotics. Review of resident #42's care plan, with an initiation date of 2/28/24, showed a focus area, [Resident name] is high risk for falls r/t Confusion, Deconditioning, Gait/balance problems, Unaware of safety needs. Interventions, all dated 2/28/24, included: - Anticipate and meet needs . - .call don't fall sign in room to help remind resident to use call light for assistance . - Follow facility fall protocol . There was no identification of the resident's increased weakness and risk for falls when he had an infection and/or was on antibiotics. Review of resident #42's care plan, with an initiation date of 5/10/24, showed a focus area, [Resident name] has a behavior of self-transferring. Interventions included: - Staff will re-educate as needed about the risks of self-transferring. - Staff will remind [Resident name] that it is unsafe for him to transfer himself. There was no identification of the resident's impulsivity and cognitive limitations on calling for help. Review of resident #42's Significant Change MDS, with an ARD of 4/3/24, showed under Section C, Cognitive Patterns, the resident scored a 7, severe cognitive impairment. 44770 2. During an interview on 5/21/24 at 9:42 a.m., staff member H said she did not know if there was a fall committee or any kind of fall prevention program. She stated if there was a fall committee she did not know about it and the CNAs were not involved. Staff member H said she did not know of any interventions specific to residents to help keep them from falling. Staff member H said she did not know where to find interventions and she stated there was no discussion regarding residents and interventions to prevent falls. During an interview on 5/21/24 at 9:55 a.m., staff member G said when a resident falls at the facility, the nurses should do a rapid assessment of the resident if the fall was not witnessed the nurses should start neuro assessments. The neuro assessments should be documented on an assessment sheet and then sent to medical records to be scanned into the resident's medical chart later. Staff member G said staff are supposed to fill out an incident report in the EMR. Staff member G said the nurses are not involved in a fall committee or any meeting where they assist in coming up with interventions specific to resident's needs. Staff member G was not aware of any conversations regarding specific residents and preventing falls. When asked if the residents with a high fall risk should have a star on their door or on their wheelchair as per the fall prevention policy, staff member G stated he was not aware of that. During an observation on 5/20/24 at 1:02 p.m., resident #49 did not have a star on her wheelchair or on her door. During an observation on 5/21/24 at 10:22 a.m., resident #49 was at the nurse's station next to the day room. She was in a wheelchair and was scooting herself to the edge of her wheelchair. She had her hand on the countertop of the nurse's station and attempted to stand up. A staff member who just walked around the corner was able to catch her and assist her back in the chair. During an observation on 5/21/24 at 10:45 a.m., resident #49 climbed out of her wheelchair and stood up, the resident was leaning backwards with her hands on the arm bars of her unlocked wheelchair. There were no staff present. The surveyor intervened and called for staff. The housekeeping supervisor came to assist the resident. Review of resident #49's EMR showed she was admitted on [DATE], she had a fall assessment completed on 4/20/24 after she had four falls. The assessment showed a score of 15 indicating she was a high fall risk. On 5/17/24 another fall assessment was completed after 4 additional falls. The assessment showed a score of 16 indicating she was a high fall risk. The EMR showed documentation of falls on 4/2/24 at 3:15 p.m., 4/13/24 at 11:17 a.m., 4/18/24 at 10:35 a.m., 4/20/24 at 10:30 p.m., 5/13/24 at 3:55 a.m., 5/13/24 at 4:14 a.m., 5/14/24 at 3:15 a.m., and 5/17/24 at 5:23 p.m. The fall on 5/14/24 at 3:15 a.m. resulted in the resident being sent to the emergency department for a laceration on her head requiring sutures. Review of a facility document titled Fall Prevention Program, not dated, showed: .Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls . 2. Upon admission, the nurse will complete a fall risk assessment along with the admission assessment to determine the resident's level of fall risk. 3. The nurse will indicate on the (specify locations) resident's fall risk and initiate interventions on the resident's baseline care plan, in accordance with the resident's level of risk . 6. High Risk Protocols: a. the resident will be placed on the facility's Fall Prevention Program . ii. Place Fall Prevention Indicator (such as star, color coded sticker) on the name plate to the resident's room. iii. Place Fall Prevention Indicator on resident's wheelchair . 9. When any resident experiences a fall, the facility will: a. Assess the resident. b. Complete a post-fall assessment. c. Complete an incident report. d. Notify physician and family. e. Review the resident's care plan and update as indicated. f. Document all assessments and actions. g. Obtain witness statements in the case of injury .

Based on interview and record review, the facility failed to document the basis for a resident's facility-initiated immediate transfer and discharge, for 1 (#2) of 1 resident sampled for discharge concerns. This deficient practice resulted in the resident being improperly discharged from the facility, to the hospital, and then the facility would not accept the resident for readmission. This resulted in the resident being discharged to a location 4 hours away. Findings include: Review of resident #2's nursing progress notes, dated 2/1/24, showed, .she (resident #2) rounded the nurses station and went into the med room . I tried to calm her down and she grabbed my throat and tried to shove me out of the way. I pried her fingers off my throat . she tried to head butt me . Following this incident, resident #2 was sent to the hospital via police and ambulance services where she was admitted for medication adjustment. Review of resident #2's MDS Discharge Assessment-Return not anticipated, dated 2/1/24, showed the facility intended to discharge the resident. However, resident #2 returned to the facility on [DATE]. Review of resident #2's nursing progress notes, dated 2/5/24, showed the resident was again sent to the hospital after an aggressive behavioral incident. Review of resident #2's MDS Discharge Assessment- return not anticipated, dated 2/6/24, showed the facility intended to discharge the resident. The resident was not permitted to return after this transfer, although discharge arrangements were not in place. Review of resident #2's EMR, accessed on 2/26/24, did not show a discharge summary, physician note, nursing notes or social services notes related to a suitable discharge location, nor the required transfer/discharge notices or required information for an immediate facility initiated transfer, to include: - Appropriate information communicated to the receiving health care institution or provider. - The basis for the transfer. - The specific resident need(s) that cannot be met. - Facility attempts to meet the resident needs, and the service available at the receiving facility to meet the need(s). - Documentation required by the resident's physician when transfer or discharge is necessary in emergent facility-initiated disharges. - Required documentation by the physician on the discharge. - Contact information of the practitioner responsible for the care of the resident. - Resident representative information including contact information - Advance Directive information - All special instructions or precautions for ongoing care, as appropriate. - Comprehensive care plan goals; - All other necessary information, including a copy of the resident's discharge summary, and other documentation to ensure a safe and effective transition of care. Review of resident #2's care plan, with an initiation date of 1/17/24, did not show any attempts were made by the facility to find alternate placement for the resident during her stay, to include as her behaviors became more unmanageable for facility staff. During an interview on 2/26/24 at 3:41 p.m., staff member B stated staff member E had taken calls on resident #2, but did not come see the resident, and did not write a discharge summary. She stated the resident had since been moved from the hospital to another facility, which was now four hours away. During an interview on 2/26/24 at 5:10 p.m., staff member A stated discharging resident #2 had been a matter of safety for staff and other residents, but the medical record information lacked evidence to support a proper discharge, either facility initiated or planned.

Based on observation, interview, and record review, the facility failed to identify, address, and correct concerns related to the declining nutritional status for a resident who had a a severe weight loss of 28 pounds in a month, for 1 (#58) of 2 residents sampled. Findings include: A review of resident #58's electronic medical record showed resident #58 had lost 16.67% of his body weight, a total of 28 pounds, in 30 days from the resident's admission, which is considered to be a severe weight loss. During an observation on 5/9/23 at 12:15 p.m., resident #58 was in the dining room during lunch service. He had his head laying on the table and appeared to be sleeping. He was not observed eating any of his meal. No staff were observed encouraging the resident to eat his meal. During an observation on 5/10/23 at 12:40 p.m., resident #58 was observed in the dining room during lunch meal service. Resident #58 did not eat his meal, except for his ice cream cup. The meat on his plate appeared to be in strips 1 by 3 long. No alternative were offered to the resident to determine if he would attempt to eat something else, and staff did not encourage him to eat what was served. Review of resident #58's care plan showed his food should be .cut into bite sized pieces . and Ensure BID; sub equivalent supplement PRN . and .Encourage oral intakes . During an interview on 5/10/23 at 1:48 p.m., staff member I stated the kitchen had food cards that showed how the food should be served to each resident. The kitchen staff should have cut resident #58's food into bite sized pieces before it came out to the dining room and served to him. Staff member I stated the facility had been having trouble getting nutritional supplements for the residents. They had not been receiving them as ordered. During an interview on 5/10/23 at 3:12 p.m., staff member H stated she had not been in the facility for over a year, and she relied on communication from the facility staff for concerns regarding the residents, which she received by phone and e-mail. Staff member H stated she had recommended nutritional supplements for resident #58, but the retailer had been out of stock, so they were unable to get them. Staff member H stated she was not notified, even when in the building, of weight concerns unless residents were on her list to evaluate. Staff member H stated she was frustrated because resident weights were not being done when they should have been, and they were not always done accurately. Staff member H stated this makes it very difficult to assess the residents. Review of the facility policy titled, Evaluation of Weight Nutritional Status Policy and Procedure showed staff should be .implementing interventions for maintaining or improving nutritional status that are consistent with resident needs, goals, and recognized standards of practice .

Based on interview and record review, the facility failed to identify risks and hazards related to a resident's previous falls and medical history, and implement interventions, for the prevention of falls or risks/hazards, for 1 (#8) of 4 sampled residents; and, the resident had a fall and sustained significant injuries from the fall, to include a punctured lung. After being admitted to the hospital, it was determined by the physician and responsible party, that end of life care was in the best interest of the resident, due to the extent of the injuries and status. Findings include: An Immediate Jeopardy was announced on [DATE] at 2:30 p.m., for F689 Accidents and Hazards, with the severity and scope of J, which would be lowered to a G upon removal of the immediacy of harm. One resident was identified to be involved with the IJ (#8). Review of resident #8's history and physical, for the hospital, dated [DATE], showed the resident had a fall at home and was admitted to the hospital for back pain, and left sided pain. Review of resident #8's discharge summary, from the hospital, dated [DATE], showed resident #8 had active diagnoses of intractable low back pain, falls, chronic left shoulder pain, confusion, inability to care for self, and dementia with behavioral disturbance. Review of resident #8's fall risk assessment tool, dated [DATE], showed the resident scored 9 out of 10. A score of 4 or more was considered at risk for falling. Review of resident #8's progress notes, dated [DATE] at 6:30 a.m., showed the resident had been found on the floor in the doorway of her room. After the fall, the nurse failed to document the completion or outcome of neurological checks, and failed to show how the resident's pain, increased pain, and change in pain level, were addressed after the fall. The nurse on duty failed to address potential injuries the resident may have had from the fall. Review of resident #8's baseline care plan failed to show a focus, goals, or interventions for falls or fall prevention for the resident, eventhough the resident was at risk for falls and had a history of falls. During an interview on [DATE] at 8:42 a.m., staff member C said information regarding resident #8's falls at home should have been added to her baseline care plan. Staff member C said resident #8's high fall risk should have been placed on the resident's baseline care plan with appropriate goals and interventions. Staff member C said All the staff in the facility knew of resident #8's fall risk, and her .fall at home, by word of mouth . During an interview on [DATE] at 2:33 p.m., staff member B said the nurse on duty at the time of resident #8's fall ([DATE]) should have notified the resident's representative. The nurse should have started neurological checks per facility protocol. The nurse should have monitored resident #8's pain continually; and the nurse should have completed a full assessment of the resident after her fall. Staff member B did not know why the nurse on duty failed to do these things. During an interview on [DATE] at 11:30 a.m., staff member J said resident #8 had sustained multiple fractures from the fall on [DATE]. Review of the facility's policy titled, Fall Prevention Program, not dated, showed: - . 9. When any resident experiences a fall, the facility will: a. Assess the resident. b. Complete a post-fall assessment. c. Complete an incident report. d. Notify the physician and family. e. Review the resident's care plan and update as indicated. f. Document all assessments and actions. g. Obtain witness statements in the case of injury. A review of resident #8's hospital documentation, dated [DATE] and [DATE], which was documented after resident #8 was sent to the emergency room , later in the day, and after her fall in the morning, showed the following: a. Emergency department triage notes: They (facility) reported she (#8) had a fall this morning but seemed fine all day. This evening she had increased pain in leg and back. b. Documentation of a progress note, completed by staff member J, on [DATE], showed, Fax states that staff found patient sitting on the floor in the doorway of her room (at facility) without injuries noted. They were unable to obtain vital signs due to resident movement. c. The hospital imaging (xray) results showed the resident was found to have the following injuries upon being admitted to the ER, from the facility: - Fractures of right 8th through 10th ribs with moderate size right pneumothorax (collapsed lung) with bibasilar airspace - Right introchanteric fracture (hip fracture) - Right fracture of inferior pubic ramus - Remote fracture of left inferior scapula (The scapula, or shoulder blade, is the bone located in the back of your shoulder between the shoulder and the spine) d. Review of the provider progress notes for the History and Physical, dated [DATE], showed, Patient is admitted with comfort measures and end-of-life care. Given moderate right pneumothorax, patient not expected to survive hospitalization . e. Review of the hospital discharge summary showed the resident was admitted to the hospital for . end of life care related to the multiple injuries she sustained with a fall . and died peacefully in the evening .

Based on interview and record review, the facility failed to protect 6 (#s 1, 2, 3, 4, 5, and 8) from staff abuse and neglect, and resident #8 had significant injuries related to a fall that were neglected by the nurse on duty after the fall and not addressed timely; and failed to protect 1 (#7) of 9 sampled residents, from physical abuse by a staff member. Findings include: 1. During an interview on 12/13/22 at 1:25 p.m., NF1 said she talked to staff and was told resident #8 had fallen that morning. NF1 said resident #8 told her that her stomach hurt. NF1 said she placed a teddy bear on resident #8's stomach in an effort to comfort resident #8. NF1 said resident #8 screamed in pain, saying Get it off me, my stomach hurts! NF1 talked to staff member B around 3:30 p.m., asking for someone to call resident #8's doctor to get some help. NF1 stated, Yes, she (Resident #8) calls out all the time, but this time it was different. I could tell she was really in pain. NF1 said staff member B finally called resident #8's doctor around 4:25 p.m. and was directed to send resident #8 to the emergency department. Review of resident #8's progress notes, dated 11/16/22 at 6:30 a.m., showed the resident had been found on the floor, in the doorway of her room, yelling. The progress note showed resident #8 had range of motion to all four extremities. No documentation was found of neurological checks being performed on resident #8. No documentation was found showing pain assessments were conducted on resident #8. No documentation was found showing resident #8 was monitored for increasing as the day went on, or how pain complaints were addressed. Review of resident #8's history and physical, dated 10/14/22, which was prior to the resident's fall at the facility, showed the hospital completed imagining of the resident's left shoulder, left side, and left hip. No new fractures were noted at any of the imaged sites. A CT of the thoracic and lumbar spine was completed. The CT showed diffuse, severe, osteoporotic compression fractures of the lumbar spine, mostly unchanged, since 11/25/2013. Review of resident #8's discharge summary from the hospital, dated 10/18/22, showed the resident continued to have significant back pain and shoulder pain with any movement with the active diagnoses of intractable low back pain, falls, chronic left shoulder pain, confusion, inability to care for self, and dementia with behavioral disturbance. Review of resident #8's nursing admission assessment document, dated 10/18/22, showed: The resident hurt a little bit more in left shoulder and lower back, and she was receiving Diclofenac to the left shoulder three times a day, a lidocaine patch to her lower back twice a day, and Tylenol 500 milligrams every eight hours. The questions related to onset/duration, quality (description of pain), coping (pain interventions), and lifestyle (affect on sleep, mood, socialization, activities of daily living, and physical activity/mobility) were blank, no responses had been entered. During an interview on 12/14/22 at 1:16 p.m., staff member I said she stopped to wish resident #8 a good morning, on the day of the resident's fall, and see how she was feeling. Staff member I said resident #8 refused to eat saying My stomach hurts. Staff member I said resident #8's complaints of pain were different than her previously expressed complaints of pain. Staff member I said she felt resident #8 was expressing acute complaints of pain at that time. During an interview on 12/14/22 at 1:23 p.m., staff member D said resident #8's complaints of pain on 11/16/22 were different than her usual calling out. Staff member D said she thought resident #8 was in acute pain on 11/16/22. During an interview on 12/14/22 at 1:24 p.m., staff member G said resident #8 cried out in pain when she (staff member G) put resident #8's shoes on her feet. Staff member G said resident #8's expressions of pain on 11/16/22 were acute complaints of pain. During an interview on 12/14/22 at 2:33 p.m., staff member B said the nurse on duty at the time of resident #8's fall (11/16/22) should have notified the resident's representative. The nurse should have started neurological checks per facility protocol. The nurse should have monitored the resident #8's pain continually, and the nurse should have completed a full assessment of the resident after her fall in an attempt to identify injuries. Staff member B did not know why the nurse on duty failed to do these things. During an interview on 12/15/22 at 11:30 a.m., staff member J said she was not in the office on 11/16/22. Staff member J said she received a text from facility staff at 3:45 p.m., which was nine hours after the resident's fall, notifying her of resident #8's increased pain. Staff member J said she responded to the facility, telling them she was out of the office, and to contact the on-call physician. Staff member J said she saw resident #8 at the hospital the next day (11/7/22). Staff member J said resident #8 had multiple new fractures, including a fractured rib, which had punctured the resident's lung. Review of resident #8's hospital imaging (xray) results showed the resident was found to have the following injuries upon being admitted to the ER, from the facility: - Fractures of right 8th through 10th ribs with moderate size right pneumothorax (collapsed lung) with bibasilar airspace - Right introchanteric fracture (hip fracture) - Right fracture of inferior pubic ramus - Remote fracture of left inferior scapula (The scapula, or shoulder blade, is the bone located in the back of your shoulder between the shoulder and the spine) Refer to F689 Accidents and Hazards, and F697 Pain Management, related to resident #8's fall. 2. Review of complaint documents, submitted to the State Survey Agency, for an abuse/neglect investigation, showed the following: a. Resident #1 did not receive a shower on 10/7/22 by night shift staff. The complaint showed, When we went in to get [Resident] up for the morning, he was found to be soaking wet with urine to the extent that all of his bedding needed to be changed. He did not appear to have been recently showered as his hair was oily and disheveled, and his fingernails were dirty. Resident #1 was no longer at the facility. b. Resident #2 did not receive a shower on 10/7/22 by night shift staff. The complaint showed, I spoke with [Resident name] at breakfast and asked if he was showered the night before. [Resident name] said that he requested a shower and one of either [staff name] or [staff name] threw a towel at him and told him to do it himself. Review of resident #2's Quarterly MDS (minimum data set), with an ARD (assessment reference date) of 10/13/22, showed the resident required physical assistance with bathing. During an interview on 12/14/22 at 8:20 a.m., resident #2 said all he wanted was a staff member in the bathroom with him when he took his shower. He said staff did not have to help him. Resident #2 said he was afraid of falling in the bathroom, and he wanted staff to make sure he was safe. c. Resident #3 had requested ice water on 10/6/22 and 10/7/22, from the night shift staff. The staff member told resident #3 the ice machine was broken so he could not have ice water. Staff member F said the ice machine was not broken at that time. During an interview on 12/14/22 at 8:25 a.m., resident #3 said he remembered the incident with the ice water. He said that staff member was no longer at the building. Resident #3 said everything has been good, since they (staff) left. d. Resident #4 had requested assistance from a night shift employee on 10/7/22. Resident #4 had a urinary incontinence issue while she was in bed. Resident #4 used the call light, and when staff responded, she asked the staff to help her change her brief, and to change her soaked bedding. The staff member refused to help her. During an interview on 12/14/22 at 8:35 a.m., resident #4 said the staff member involved was no longer working in the building. She did recall the incident, and remembered being upset that the staff member would not help her. Review of resident #4's Annual MDS, with an ARD of 10/12/22, showed the resident needed extensive assistance of two staff for toileting and was frequently incontinent. e. Resident #5 requested night staff assist her with toileting, and changing her clothes at bedtime, on 10/7/22. A night shift employee told the resident to do it yourself. Review of resident #5's Quarterly MDS, with an ARD of 10/12/22, showed the resident required limited assistance with toileting and dressing. During an interview on 12/14/22 at 11:36 a.m., staff member H said the two night shift contract staff only worked two or three shifts before they were gone. During an interview on 12/14/22 at 12:46 p.m., staff member A said concerns were voiced related to the two contracted staff members, who worked the night shift, regarding lack of care for several residents. Staff member A said the facility did not get a chance to interview the two contracted staff members. Staff member A said, two staff members called off from a scheduled shift, without notice, and they never came back to work at the facility. Staff member A said the facility did initiate training for all staff on abuse and neglect. Staff member A said the identified concerns were not brought forward to QAPI (quality assurance performance improvement), for further review or action. 3. Review of a facility reported incident, dated 11/13/22, showed resident #7 voiced concerns of verbal and physical abuse by staff member L. Resident #7 also contacted the police and filed a complaint with the city police department. Review of the facility's abuse investigation for resident #7 showed the following: a. The typed written statement from the city police department, date 11/13/22, showed resident #7 made statements to a city police officer regarding physical and verbal abuse by staff member L. The police report showed the resident had a bruise on the back of her hand. Resident #7 said the bruise came from staff member L ripping the call light from her grasp, or from when staff member L pushed her into the bathroom to toilet her. The police officer asked resident #7 if she was on blood thinners. Resident #7 told the police officer she was not. The police report showed the incident was still under investigation. b. The typed written statement, dated 11/14/22, showing resident #7 stated, She (resident #7) said that [staff name] 'terrorized' her the previous night and said that [staff name] mocked her (resident #7) by saying that she needs to start doing things for herself so she can discharge home soon. She (resident #7) said that [staff member] was physically rough with her, shoving her in her wheelchair, and in and out of the bathroom. [Resident #7] claims [staff member] pulled up her brief so hard that it ripped, and then had to get a new one.Resident #7 asked that [staff member] never be allowed near her. c. Review of a facility document, which was on the facility's letterhead, dated 11/16/22, showed, I, [staff name], agree that my responses and the behaviors could at times lead to patients feeling offended, and sometimes to the level that they do not want me to provide care for them. The document was signed by staff member L. d. Review of a facility document titled, Termination Form, dated 11/16/22, showed staff member L was voluntarily terminated from the facility position, due to an allegation of abuse and neglect which was being investigated by the facility's administration and law enforcement. Review of the facility's policy, titled, Abuse, Neglect, and Exploitation, not dated, showed, Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.

Based on interview and record review, the licensed nursing staff failed to assess and monitor a resident's pain, and change in level/type of pain, specifically after a fall, for 1 (#8) of 2 sampled residents. Findings include: 1. During an interview on 12/13/22 at 1:25 p.m., NF1 said she came in to visit resident #8 on the afternoon of 11/16/22, around 2:00 p.m. NF1 said she placed a teddy bear on resident #8's stomach, and resident #8 screamed at NF1 to take it off, it hurts! NF1 stated the resident yelled out often, but . this time it was different . I could tell she was really in pain. NF1 said she spoke to staff member B at around 3:30 p.m., asking staff member B to contact resident #8's physician. NF1 said she wanted resident #8 transported to the hospital for further evaluation. NF1 said staff member B finally called resident #8's doctor around 4:25 p.m. and was directed to send resident #8 to the emergency department. Review of resident #8's progress notes, dated 11/16/22 at 6:30 a.m., showed the resident had been found on the floor. Resident #8's medical records failed to show the post fall nursing assessment or any pain assessments were started or completed after resident #8's fall. No documentation was found showing any pain assessments were conducted for resident #8, or that the resident's pain was monitored, at any point after her fall, on 11/16/22. Review of resident #8's history and physical, from the hospital, dated 10/14/22, showed the resident was admitted to the hospital for back pain, and left sided pain (after fall). Resident #8's discharge summary, from the hospital, dated 10/18/22, showed the resident continued to have ongoing significant back pain and shoulder pain with any movement. Review of resident #8's nursing admission assessment document, to the facility, dated 10/18/22, showed the resident hurt a little bit more in her left shoulder and lower back, and she was receiving Diclofenac to the left shoulder three times a day, a lidocaine patch to her lower back twice a day, and Tylenol 500 milligrams every eight hours. The questions related to onset/duration, quality (description of pain), coping (pain interventions), and lifestyle (affect on sleep, mood, socialization, activities of daily living, and physical activity/mobility) were blank, no responses had been entered. Review of resident #8's baseline care plan failed to show a focus, goals, or interventions for pain for the resident. During an interview on 12/14/22 at 8:42 a.m., staff member C said information regarding resident #8's pain should have been added to her baseline care plan. During an interview on 12/14/22 at 11:06 a.m., staff member D said resident #8 was complaining of pain after the fall. During an interview on 12/14/22 at 11:27 a.m., staff member G said she assisted resident #8 out to the dining room for breakfast on 11/16/22. Staff member G said resident #8 was complaining of pain. Staff member G said she told the nurse about resident #8's complaints of pain. The nurse told staff member G she would assess resident #8's pain. Staff member G said she did not know if the nurse assessed resident #8's complaints of pain or not. Staff member G stated she notified the nurses of resident #8's pain throughout the shift. During an attempted interview on 12/14/22 at 12:07 p.m., a voice mail was left for staff member K who was the nurse on duty on 11/16/22 for resident #8's fall. Staff member K did not return the phone call. During an interview on 12/14/22 at 1:16 p.m., staff member I said she had provided therapy services to resident #8, since her admission to the facility, on 10/18/22. Staff member I said resident #8 refused to eat saying my stomach hurts. Staff member I said resident #8's complaints of pain were different than her previously expressed complaints of pain. Staff member I said she felt resident #8 was expressing acute complaints of pain at that time, which was approximately seven hours after the fall. During an interview on 12/14/22 at 1:23 p.m., staff member D said resident #8's complaints of pain on 11/16/22 were different than her usual complaints/calling out. Staff member D said resident #8 was in acute pain on 11/16/22. During an interview on 12/14/22 at 1:24 p.m., staff member G said resident #8 cried out in pain when she (staff member G) put resident #8's shoes on her feet. Staff member G said she was going to stop, but resident #8 told her to hurry up and put them on. Staff member G said resident #8 cried out several more times during the process. Staff member G said resident #8's expressions of pain on 11/16/22 were acute complaints of pain. During an interview on 12/14/22 at 1:40 p.m., staff member A stated, Unfortunately the only pain assessment was the one done on the Admission Assessment (10/18/22) for resident #8. During an interview on 12/14/22 at 2:33 p.m., staff member B said the nurse on duty at the time of resident #8's fall (11/16/22) should have monitored resident #8's pain continually, and the nurse should have completed a full assessment of the resident after her fall. Staff member B did not know why the nurse on duty failed to do these things. During an interview on 12/15/22 at 11:30 a.m., staff member J said she received a text from the facility on 11/16/22 at 3:40 p.m., saying resident #8 had complaints of increased pain. Staff member J said she found out on 11/17/22, when she returned to the office, resident #8 had been admitted to the hospital on 11/16/22. Staff member J said resident #8 had multiple fractures including a rib fracture which had punctured resident #8's lung. A review of resident #8's hospital documentation, dated 11/16 and 11/17/22, which was documented after resident #8 was sent to the emergency room , showed the following: a. Emergency department triage notes: They (facility) reported she (#8) had a fall this morning but seemed fine all day. This evening she had increased pain in leg and back. b. Documentation of a progress note, completed by staff member J, on 11/17/22, showed, Fax states that staff found patient sitting on the floor in the doorway of her room (at facility) without injuries noted. They were unable to obtain vital signs due to resident movement. c. The hospital imaging (xray) results showed the resident was found to have the following injuries upon being admitted to the ER, from the facility: - Fractures of right 8th through 10th ribs with moderate size right pneumothorax (collapsed lung) with bibasilar airspace - Right introchanteric fracture (hip fracture) - Right fracture of inferior pubic ramus - Remote fracture of left inferior scapula (The scapula, or shoulder blade, is the bone located in the back of your shoulder between the shoulder and the spine)

Based on interview and record review, the licensed nurse providing care to a resident, after the resident had a fall, failed to competently assess and address the resident's multiple injuries, which included fractures, and the resident was found to have a change in her pain/activity level throughout the day, for 1 (#8), of 2 sampled residents. Findings include: Review of resident #8's progress notes, dated 11/16/22 at 6:30 a.m., showed the resident had a fall and was found in the doorway of her room. A review of resident #8's medical record lacked evidence of neurological checks being performed on resident #8, by staff member K, after her fall; failed to show how pain or pain assessments were addressed; how pain was monitored closely after the fall; or how the resident's ongoing care throughout the day addressed the resident's significant change in behavior/comfort. During an attempted interview on 12/14/22 at 12:07 p.m., a voice mail was left for staff member K who was the nurse on duty on 11/16/22. Staff member K did not return the phone call. Review of a written statement, from staff member G, undated, showed the staff member assisted putting the resident back to bed after the fall, but the resident would scream in pain when touched, and the nurses were notified throughout the shift, of the resident's pain/behavior. During an interview on 12/14/22 at 2:33 p.m., staff member B said the nurse on duty at the time of resident #8's fall (11/16/22) should have started neurological checks per facility protocol. The nurse should have monitored resident #8's pain continually, and the nurse should have completed a full assessment of the resident after her fall. Staff member B did not know why the nurse on duty failed to do these things. A review of resident #8's hospital documentation and imaging results, dated 11/16/22, showed the resident had multiple fractures and a punctured lung, and was admitted for end of life care. Also, documentation of a progress note, completed by staff member J, on 11/17/22, showed, Fax states that staff found patient sitting on the floor in the doorway of her room (at facility) without injuries noted .

Based on interview and record review, the facility failed to immediately report suspicion of drug misappropriation to the State Survey Agency, failed to protect residents from drug misappropriation over an extended period of time, and failed to implement prevention interventions from drug misappropriation. This affected 2 (#s 2 and 7) of 7 sampled residents. Findings include: During an interview on 2/2/21 at 3:50 p.m., staff member C stated during the investigation of drug misappropriation it showed NF4 had written on the narcotics books and signed out medications at times not ordered or days NF4 did not work, made changes to the medication numbers given, wasted a lot of medications, and the MAR indicated [REDACTED]. The investigation started with the similar medication as the resident had reported to the facility; but led to other residents because of the documentation discrepancies. Staff member C stated other than resident #2 stating he could not sleep; the facility could not determine if other residents were affected as it went back months. Staff member C stated nurses are to have two nurses sign off on wasted medications, and sign off at shift change when medication cards were counted for narcotics, because years prior they had an issue with drug misappropriation of stealing whole cards of medications. During an interview on 2/3/21 at 4:10 p.m. staff members B and D stated, the nurses had not been given any training on medication protocols, misappropriation, or done return demonstration in the last 3 months. Staff members B and D stated the nurses were to sign-off on the narcotics books each time there was a change of nurse. Staff members B and D stated, if there was an issue with the medication count they would have to stay on until the narcotic count issue was rectified. Staff members B and D stated, they hadn't had any recent issues of medication counts and stated they would need a second nurse to sign off if they needed to waste a medication. Staff members B and D stated as they worked the day shift they didn't have an issue of getting a second nurse to verify if that occurred. Staff members B and D stated they did not know what management oversight of the medication administration process was done. During an interview on 2/4/21 at 11:30 a.m. staff member C stated, she could not recall what day it was reported to her about the suspicion of medication misappropriation, but that it would have been the day she reported it to the administrator to submit to the state reporting portal. Staff member C stated the facility realized NF4 did not have a current nurse license at the time of the investigation. NF4 was put on suspension for the investigation on 1/18/21 because the facility could not get in contact with NF4. Staff member C stated there was no regular reconciliation or review of medication management procedures by nursing management to identify or prevent issues, only the nurses signing off on shift change by counting the cards, and the ADON sometimes working the floor, to ensure there was no drug misappropriation. A. During an interview on 2/3/21 at 9:55 a.m., resident #2 stated he reported on the morning after NF4 worked to the staff member on medication pass that when NF4 passed his pills, she would leave the cup on his (#2's) table, and the little orange one (pill) was not there. Resident #2 stated he could not sleep at all those nights. Resident #2 stated he would become agitated at all the noise at night and stare at the ceiling, and the day after he would not feel like eating or participating in anything. Other nights, he could get a few hours of sleep when other nurses passed his night medications with the orange pill and it made a big difference. During an interview on 2/4/21 at 10:48 a.m. staff member I stated, resident #2 told her that the night nurse, NF4, would pass his pills, and he would not get a little orange/pink one (pill), and he would not get any sleep. Staff member I stated resident #2 explained when the other night nurse would pass his bedtime pills, he would get the orange/pink pill, and he could get a few hours of sleep. Staff member I stated resident #2 had made comments like this many times before, but this was the first time resident #2 specifically mentioned the specific pill, NF4, and not sleeping directly because of it. Staff member I stated she reported the information later on the same shift to staff member C and had written a statement. Resident #2's Narcotic log, for February 2020, of [MEDICATION NAME], 1/2 tab TID for 15 days (2/1-2/15) then 1/2 tab BID x 14 days (2/16-2/29) then stop. Examples of NF4 and how the employee signed out the medication inappropriately: - Signed out 2/16, 1 at 2100 to have 27 left - Signed out 2/17 1at 0600 to have 26 left and at 2100 for 2tabs, then crossed out as 1 and from 25 crossed out to 24 then written over to 25 with the note corrected - Signed out 2/18 1 at 0600 with 24 scratched out and put 25 and 23 scratched out and 24 written, and the note of corrected with initials - Signed out 2/21 at 2100 from 18 to 17 - Signed out 2/22 at 0500 from 17 to 16 with a note wasted and another signed out at 0500 from 16 to 15, another signed out at 2200 from 15 to 14, and another signed out at 0600 from 14 to 13 - Signed out 2/27 at 2200 and 0600 1 each time - Signed out 2/28 at 2100 and 0530 1 each time B. During an interview on 2/3/21 at 3:21 p.m., resident #7 stated her nights had been bad for a long time with pain, as nurses would give her night pain medications; but they did not seem to help. Resident #7 stated lately she seems to feel a little better through the night, after her medications are given. Resident #7's Narcotic logs for September and October 2020 showed times for [MEDICATION NAME], 1 tablet, PO, PRN @ 0800, 1200, 1600, + 2 tab @HS signed out when not ordered, corrections or writing over, crossed out and wasted by NF4. Examples are: - Signed out 9/8/20 - 1 each at 0030 and 0545 - Signed out 9/10 at 2116 2 tablets, and again at 2230 1 tablet and 0530 1 tab - Signed out 9/19 at 0400 and 0621 and 2127 with a 2 written over 1 for how many tablets given - Signed out 9/20 at 0430 and 0640 and at 2156 a 2 written over a 1, and 22 crossed out and 21 written for how many tabs given - Signed out 10/14 at 1932 1 tablet then written over with 2 and 47 left crossed out to 46 - Signed out 10/15 at 0345 and 0642 1 each time, but had 47 crossed out to 46, 46 to 45, and 45 to 44 left - Signed out 10/28 at 2023 a 2 written over 1 given and 6 crossed out to show 5 left - Signed out 10/29 at 0330 and at 0600 twice. The count is crossed out from 6 to 5, 5 to 4, and 4 to 3, and the second 0600 entire entry is crossed out and has a note of wasted - Signed out 11/1 at 0235 and 6000 and at 2045 a 2 is written over the 1 and 44 is written over 45 left - Signed out 11/2 at 0533 Record review of the facility investigation showed: - A complaint form for the Montana Department of Labor and Industry showed the suspicion of drug misappropriation was reported to the DON on 1/12/21. - Staff member I's written statement, dated 1/12/21, regarding the allegation of drug misappropriation by resident #2 - The facility identified 11 residents where ordered medications were misappropriated by NF4 and documentation that was not completed correctly by NF4 as far back as February 2020. - The facility reported the suspicion of drug misappropriation to the State Survey Agency on 1/16/21, 4 days after the initial allegation. The final five-day investigation was submitted on 1/21/21. - Resident #2's Narcotic logs showed for 1/11/21 the [MEDICATION NAME] .5 mg was signed out, but the resident reported it was not given. Record review of the facility January Nurse actual worked schedule showed NF4 last worked on 1/11/21 from 7 p.m. to 7 a.m. This was the shift before resident #2 reported he couldn't sleep from not getting his sleeping pill. Record review of facility nurse education, at the time of survey, showed the nurses had not been educated on medication administration procedures and expectations, signs to watch for drug misappropriation, or reporting and return demonstrations, as noted in the facility reported incident. Record review of NF4's employee file showed: -RN license expiration of 12/31/20 and had not been renewed. -NF4 had been given a verbal warning regarding medication administration in June of 2020 -NF4's hire date of 1/27/19 -NF4's termination date as of 1/20/21

Based on observation, interview, and record review, the facility staff failed to failed to implement and monitor interventions to reduce falls, to include falls which caused injury, for 2 (#s 4 and 9) of 11 sampled residents; and, staff failed to utilize a gait belt when transferring and ambulating 2 residents (#s 8 and 13) of 18 sampled and supplemental residents. Findings include: 1. Review of the facility Falls Detail report showed resident #9 fell two times: 4/12/17 and 4/16/17. The report showed circumstances were unknown, and resulted in a laceration and a skin tear. The falls on 4/4/17, 5/11/17, and 5/13/17, were not included in the report. Review of resident #9's Post-Fall investigation, dated 4/4/17, showed he slid off of the bed, head on and above the mattress. The resident did not hit his head. The Staff's 10 Questions at the Time of a Patient Fall was blank, which was part of the new format for the team huddle. The bed was in a low position. Continue with alarm on the bed and wheelchair. Review of resident #9's Post Fall investigation, dated 4/14/17, for the fall on 4/12/17 showed steri strips to left hand skin tear, hematoma on head, 3 cm, ice to this and neuro checks. The floor mat was not in place, however he fell beyond the the floor. Review of the IDT Fall Meeting note, dated 4/14/17, for the 4/12/17 fall, showed Resident fell on [DATE] a non- witnessed fall, there was an injury, physician notified family notified resident fell in his room found lying on his abdomen with left for (sic) head on the floor. Resident was ambulating independently, patient was alone in room wearing stockings. The tab alarm and landing strips were removed from room. Staff will be doing frequent room check for 4 IP's; pain, positioning, potty and placement. Information regarding the reason for the removal of the alarm and strips, and evidence of the frequent room checks were not documented. Review of resident #9's IDT Fall Meeting note, dated 4/18/17, for the fall on 4/16/17, showed Resident rolled out of bed, unwitnessed fall. Obtained a skin tear on nose. Resident was sleeping had taken medications, pillow placed behind his back, facing the wall. This is the resident's 3rd fall, he is in a low bed, scoop mattress, mat on floor. Will place a pool noodle under the Mattress to push the mattress up. The Post Fall Investigation report was requested, but not provided for the fall on 4/16/17. Review of #9's Post Fall Investigation Report, dated 5/14/17, for the fall on 5/10/17, showed the resident slid out of his wheelchair, and had no injuries. He had on slippers, and the fall was unwitnessed. Another fall was reported by the facility on 5/13/17, written on a note by staff member A. Review of resident #9's Care Plan showed 2 new interventions: 4/5/17 - Scoop Mattress to bed, and 5/17/17 - Do not leave unattended in wheel chair or on toilet. During an interview on 5/18/17 at 9:55 a.m., NF1 stated resident #9 was now on hospice, and she felt he had a big decline after he hit his head. 2. Review of the facility Fall Detail Report, and the Post Fall incident Reports, showed resident #4 fell 11 times from 8/30/16 through 5/11/17. The Fall Detail Report did not include a fall on 3/27/17. Resident #4's falls included: 8/30/16 - fell in room, unwitnessed fall. 9/28/16 - fell in hallway, witnessed fall. 10/18/16 - fell in room, unwitnessed fall, with injury. 10/23/16 - fell in room, unwitnessed fall, with injury. 1/7/17 - fell in hallway, witnessed fall, with injury. 1/20/17 - fell in hallway, witnessed fall, with injury. 3/1/17 - fell in room, unwitnessed fall. 3/27/17 - fell in dining room, witnessed fall. 4/23/17 - fell in dining room, witnessed fall. 4/28/17 - fell at nurses station, witnessed fall. 5/11/17 - fell in common area, witnessed fall. Review of resident #4's Care Plan for potential for falls, dated 4/1/16, showed two new interventions were added for 2017, New cup holder for walker to prevent unsteady balance and Staff to ensure that room around bed and floor are clutter free. Review of resident #4's Post Fall Investigation, dated 10/18/16, showed he was wearing stockings, had a pain level of 6 and he fell as he was sitting down. There was an unidentified injury and first aid was provided. Contributing Conditions included an unsteady gait and noncompliance. Review of resident #4's Post Fall Investigation, dated 10/23/16, showed he fell in front of his TV, was wearing socks, and had pain level of 5 with an abrasion to the left knee. Contributing conditions included an unsteady gait and noncompliance. Review of resident #4's IDT Fall Meeting notes, dated 10/25/16, for the falls on 10/18/16 and 10/23/16, showed the resident did not use the walker, and the resident was wearing socks. On the second fall, the resident's leg gave away. No root cause analysis, interventions, or monitoring for effective interventions were documented. Review of resident #4's IDT Fall meeting, dated 11/1/16, showed 2 x 2 cm abrasion to left front knee. Periodic pain; regular pain med effective, this is a result of a fall on 10/23/16, independently walking in his room. No root cause analysis, interventions, or monitoring for effective interventions were documented. Review of resident #4's Post Fall Investigation, dated 1/7/17, showed the resident had a witnessed fall in the hall and sustained an abrasion. Review of resident #4's IDT Fall meeting dated 1/10/17, for the fall on 1/7/17, showed the resident had an abrasion to his knee. He was walking with a walker and became wobbly, and fell to his knees. Wearing glasses, using walker. History of fall non-steady gait. Resident has adequate shoes. Resident has had 13 falls in the past 6 months. No root cause analysis, interventions, or monitoring for effective interventions were documented in the meeting note. Review of resident #4's Evaluation Summary note, dated 1/20/17, showed that the resident had a history of [REDACTED]. The resident was carrying his coffee mug, ambulating down the hall. Review of resident #4's Post Fall Investigation, dated 1/20/17, did not identify the coffee mug as the cause of the fall, but did show the facility would ask for a coffee cup holder for his walker. It showed he had shoes on and was using his walker. Review of resident #4's Incident Note, dated 3/7/17, showed the resident had a fall on 3/1/17. He stated he lost his balance while making his bed. The resident was wearing shoes, and the area around the bed was dry and uncluttered. Last therapy services were discontinued on 10/7/16. Falls are unavoidable due to traumatic brain injury-impulsiveness. No changes made to current care plan. Review of resident #4's Post Fall Investigation, dated 3/1/7, showed he fell by the bed, lost his balance, and had on shoes. Review of resident #4's Post Fall Investigation, dated 3/27/17, showed he fell in the dining room from a chair. The Incident Investigation Directives Post Fall form was blank. No root cause or interventions were documented regarding the fall. Review of resident #4's IDT Fall meeting note, dated 3/28/17, showed the resident had a fall on 3/27/17, when getting up from table, and included Unsteady on his feet. fell and quickly got up. No seizure activity noted, labs current. Care plan updated. No root cause analysis, interventions, or monitoring for effective interventions were documented. Review of resident #4's Care Pan for did not show any updates for fall interventions for the 3/27/17 fall. Review of resident #4's Post Fall Investigation, dated 4/23/17, showed he fell in the dining room and appeared weak. Contributing conditions included history of falls, and non-compliance. Review of resident #4's IDT Fall Meeting note, dated 4/26/17, showed the resident had a fall on 4/23/17, while getting up from table. Clammy and disoriented and stated he had a seizure. Uses walker and has erratic gait pattern. He becomes angry and pulls away if offered assistance. No root cause analysis, interventions, or monitoring for effective interventions were documented. Review of resident #4's IDT Fall Meeting note, dated 5/2/17, showed the resident had a fall on 4/28/17. New non-skid soled shoes will be ordered by social services. Resident continues to ambulate in a fast manner even with interventions to encourage and remind resident to slow down with ambulation. Review of resident #4's Post Fall Investigation, dated 4/28/17, did not identify his shoes as the cause for the fall. It showed the resident was ambulating in his normal fast pace pushing the walker. He appeared to lose balance and fell to his knees. He was wearing his shoes and using his walker. Review of resident #4's Post Fall Investigation, dated 5/11/17, showed the resident had another fall, in the day room. No root cause analysis, interventions, or monitoring for effective interventions were documented. The facility had not conducted an IDT meeting for this fall. During an interview on 5/17/17 at 10:05 a.m., staff member B stated the facility started a new fall program in October (2016), and the weekly meeting would be documented, with interventions to reduce falls. She stated a team huddle occurred for each fall. Fall documentation did not show team huddles were implemented or documented. During an interview on 5/18/17 at 8:50 a.m., staff member A stated the facility talked about falls each day, and at the monthly Performance Improvement meeting. She said the amount of falls had been reduced in the past six months, and it was a matter of reeducating the nurses, for the process to be improved. During an interview on 5/18/17 at 9:20 a.m., staff member B stated the facility had not found any interventions that worked for resident #4. He does not allow stand by assist. She stated the Fall Prevention Program was a work in progress. 3. During an observation on 5/17/17 at 7:45 a.m., staff member C assisted resident #8 to transfer from his bed to his w/c. Staff member C did not utilize a gait belt during the transfer. During an interview on 5/17/17 at 7:45 a.m., staff member's C and E, said resident #8, Can stand and ambulate himself on his own. Staff member E said, He can walk all the way down the hall if he wants too, it just depends on how tired he is at the time. During an observation on 5/17/18 at 7:58 a.m., staff member E assisted resident #8 to ambulate to the Restorative Dining Room from his room. Resident #8 used a walker as an aid to stabilize himself, and staff member E pulled a wheel chair along behind him. Resident #8 did not wear a gait belt during the ambulation. Resident #8 walked about 1/2 the distance to the dining room before he became tired and had to sit in the wheel chair, and be wheeled the remainder of the distance to the dining room. A review of the Care Plan for resident #8 showed he was at risk for falls. One of the fall prevention interventions on the care plan was, Walk to Dine using 2WW and gait belt follow with w/c as resident tolerates (sic). 4. Resident #13 was admitted to the facility on [DATE] with history of a right humerus fracture, vascular dementia, and more. A review of the 30-day MDS, with an ARD of 5/2/17, showed resident #13 required an extensive assist of one for transfers and for toileting. Resident #13 had not ambulated during the seven-day look-back period prior to 5/2/17. A review of the Care Plan showed staff should have used a gait belt when they assisted resident #13 with toileting and transferring. During an observation of care on 5/16/17 at 1:00 p.m., resident #13 was transferred from her w/c to the toilet, and back to her wheel chair by staff member D. Staff member D had not placed a gait belt on resident #13. After resident #13 completed the use of the toilet, she was assisted back to her wheel chair. Staff member D rolled resident #13 to her bedside in her wheel chair. Staff member #13 placed a gait belt under resident #13's arms, at the level of her arm pits. Staff member D then lifted resident #13 to her feet, using the gait belt. She used the gait belt to pivot resident #13, and sat resident #13 down on the bed. Resident #13 exerted very little weight bearing effort during standing and pivoting to the bed. No instructions were provided to resident #13 prior to, or during, the transfer. Staff member D did not follow the protocol of rocking the resident back and forth to help overcome resistance to standing (see policy below). During an interview on 5/16/17 at 1:00 p.m., staff member D said, I put the gait belt on a little higher because sometimes she doesn't like it lower. When I am transferring her (resident #13) to her bed from the w/c, I do have to lift her to a stand. She said, But in the bathroom, she can grab the rails and she stands right up. A review of the care plan for resident #13 showed, (Resident #13) requires extensive staff assistance of 1 with transfers using gait belt to toilet, bed and w/c. A review of the Gait Belt policy provided by the facility, showed the employee should: -Implementation; 8. Apply the belt around the patient's waist snugly enough to eliminate the possibility of sliding up on the ribs; -Transferring the Patient; 3. While firmly gripping the gait belt, keep your back straight, bend your knees slightly and position your feet in a wide stance to maintain proper body mechanics and begin rocking back and forth to overcome forces resisting transfer. Provide the necessary instructions for hand/foot placement prior to push-off. Use the gait belt to stabilize the patient by grasping the belt firmly in a position that allows patient movement in a chosen direction and allows for a firm safe hold of the belt, . 5. Instruct the patient to pivot and to bear as much weight as possible on the unaffected side. Support the affected side to resist loss of balance to this side; and, -Ambulating the patient: 4. Place one hand under the gait belt on the back of the patient. If the patient is weaker on one side, make sure to walk on that side while ambulating. 5. Walk closely behind and slightly to the side of the patient, or as appropriate for the gait pattern.