Every finding on record at Powder River Manor

Based on observation and interview, the facility failed to label, date, and store food in a manner to maintain food safety and prevent foodborne illness by failing to ensure all open items were dated. This deficient practice had the potential to affect all residents who ate at the facility. Findings include:During an observation and interview on 4/21/26 at 7:40 a.m., the initial kitchen walkthrough showed the following items were stored on the open shelving to the right of the grill and stovetop. The containers were opened for use, and not marked with the date they were opened:- large plastic bottle of cooking oil, capped,- large plastic bottle of butter-flavored oil, capped,- large container of parsley flakes, capped,- large container of dry, chopped onions,- round container of Quaker oats, capped- box of Malt-O-Meal hot breakfast cereal,- box of instant mashed potatoes,- large container of ground ginger, capped- large container of ground coriander, capped, and- large container of whole sesame seeds, capped.Staff member H stated she had been the kitchen manager for 12 years. Staff member H stated she tried to get the staff to date items when they were opened. Staff member H stated it was hard to get and keep good workers. Staff member H stated she was aware that the staff did not date food items when they were opened.During an interview on 4/22/26 at 2:00 p.m., staff member H stated she did not have a lot of storage space, so she felt she went through food items quickly enough to be safe. Staff member H stated she periodically checked food items for an open date. Staff member H stated that all staff were responsible for dating food items, and the facility had never had an outbreak of a foodborne illness due to food items being used beyond a safe use-by date.

Based on observation, interview, and record review, the facility failed to protect from sexual abuse 1 (#13) by resident #4; and failed to protect from physical abuse 1 (#5) by resident #8 of 12 sampled residents. Findings include:1. Sexual AbuseReview of the facility investigation for the incident reported to the State Survey Agency on 1/26/26, showed resident #4 was found by staff with his hand down resident #13's brief in a common area. Resident #13 did not have capacity to consent. The facility investigation did not show other residents were interviewed or assessed for potential to be affected by similar sexual abuse incidents.During an interview on 4/21/26 at 4:22 p.m., staff member A stated the incident between residents #13 and #4 was reported to the wrong facility type license as they were unaware, they had an adult day care service license as well as the skilled nursing facility license. Staff member A stated the two residents were assessed and many interventions were put in place, but for the investigation no other residents were present, so no others were asked or assessed for potential similar incidents.During an interview on 4/22/26 at 12:26 p.m., NF2 stated he was notified when the incident happened and was told it was resident #13 and the perpetrator, and no other incidents have happened. He understood the interventions in place.During an interview on 4/22/26 at 3:04 p.m., staff member K stated he was the one who walked into the common area where he found resident #4 with his hand to his wrist inside the brief of resident #13. Resident #4 put his hands up when staff member K told him to stop. Staff member K stated he called the nurse to come, and the residents were immediately separated. Staff member K stated resident #4 was under constant supervision since the incident, and resident #13 had no change in her behavior.2. Physical AbuseReview of a facility incident reported to the State Survey Agency on 2/2/26 showed resident #8 was upset at his wife, resident #5, for being tired at dinner together in the dining room. He proceeded to shake her head to wake her. Staff intervened and took resident #5 to the nurses' station as she was agitated by the event, and resident #8 went back to their shared room. Resident #8 returned to the nurses' station with a spray bottle filled with water, and after staff asked him to give them the spray bottle, he continued and sprayed resident #5 in the face with the water until staff could remove the bottle from resident #8.During an observation on 4/21/26 at 7:56 a.m., resident #8 went into his room, which had the nameplates for resident #5 and resident #8. The belongings of both residents were in the room.During an interview on 4/21/26 at 4:22 p.m., staff member A stated the facility self-reported the incident of spouses due to resident #8 shaking resident #5's head and spraying her in the face with a water spray bottle to wake her up to eat dinner. Staff member A stated resident #5 was always out in the common areas.During an interview on 4/22/26 at 11:41 a.m., NF1 stated she was notified of the incident between resident #8 and #5. NF1 stated resident #8 was just being 'old school' and was just trying to get resident #5 to do what he thought was needed. NF1 stated it was the history of their relationship as spouses. NF1 stated that, for the most part, the two residents were kept away from each other when up, and resident #5 slept in a recliner by the nurses' station most of the time.During an interview on 4/22/26 at 2:49 p.m., staff member K stated resident #5 was rarely in her room, only when resident #8, her husband, was not. Staff member K stated resident #5 spent her time in her wheelchair and slept in a recliner by the nurse's station or common room, and ate at an assisted table away from resident #8 due to behaviors between the two.Review of resident #5's Care Plan, last updated on 4/9/26, showed she was not to be in the room when resident #8 was in the room unless they both wanted to be there during the day. The door had to be open, and staff had to intervene if yelling was occurring due to an incident of resident #8 shaking her head and using a spray bottle on 2/2/26.

Based on observation, interview, and record review, the facility failed to ensure the accuracy of MDS assessments for 2 (#s 1 and 7) of 12 sampled residents. Resident #1 had a history of pneumonia and resident #7 had limited range of motion to her left arm and shoulder. These were not accurately shown in the resident's MDS assessments. The deficient practice had the potential to affect resident care as the resident's current status was inaccurately documented. Findings include: 1. During an observation on 4/21/26 at 12.41 p.m., resident #1 was seated in the dining room eating lunch. The resident showed no shortness of breath, no cough, or any other respiratory symptoms. The resident was not using oxygen.Review of resident #1's Quarterly MDS assessment, with an ARD of 2/27/26, showed an active diagnosis of pneumonia. Review of resident #1's EHR, accessed on 4/21/26 and 4/22/26, failed to show any treatment, medication, or provider notes related to a pneumonia diagnosis during the past six months.Review of resident #1's diagnoses list in the EHR, accessed on 4/21/26, showed the resident had a history of pneumonia in 2022.During an interview on 4/22/26 at 11:41 a.m., staff member B stated the MDS system auto-populated diagnoses from the EHR to Section I. Active Diagnoses. Staff member B stated that the nurse completing the MDS remotely should have manually corrected the diagnosis list to show no current diagnosis of pneumonia. Staff member B stated she did not review the MDS for accuracy before it was submitted.2. During an observation and interview on 4/21/26 at 10:59 a.m., resident #7 was unable to lift her left arm above her shoulder.Review of resident #7's admission MDS assessment, with an ARD of 3/17/26, showed the resident had no limited range of motion.During an interview on 4/22/26 at 11:41 a.m., staff member B stated the nurse who had been doing MDS assessments for some time had left the facility. Staff member B stated the facility had hired a nurse to remotely complete the MDS assessments while she and another staff member completed MDS assessment training. Staff member B was not able to say why the remote nurse completed the range of motion information incorrectly. Staff member B stated resident #7 had been at the facility in 2022, and those assessments showed no limited range of motion.

Based on observation, interview, and record review, the facility failed to ensure direct care staff were aware of a resident's wandering behaviors and the need to increase monitoring when the weather warmed up for 1 (#6) of 12 sampled residents. This deficient practice increased the risk the resident would leave the facility unaccompanied. Findings include: Review of resident #6's dementia care plan, initiated on 4/7/21, showed the resident had memory problems due to her dementia. An intervention, initiated on 7/2/25, showed, Sometimes I attempt to go outside on my own repeatedly so a wander guard bracelet was put on my walker to alert staff .and also have history of going outside alone to try to check the bird feeders . [sic]During an observation on 4/22/26 at 8:00 a.m., resident #6 was seated in the dining room eating breakfast. When the resident had finished eating, she used her wheeled walker to ambulate back to her room.During an interview on 4/22/26 at 8:10 a.m., staff member F stated she had worked at the facility for several years. When asked about resident #6's wandering behaviors, staff member F stated resident #6 was not a wander risk and did not have a wander guard on her person or her walker. Staff member F did not remember resident #6 having any wandering or elopements in the past.During an interview on 4/22/26 at 9:56 a.m., staff member E was asked about resident #6's wandering behaviors. Staff member E stated resident #6 was not a wanderer. She stated the resident had occasional confusion but did not try to leave the facility.During an interview on 4/22/26 at 11:56 a.m., staff member B stated resident #6 went outside when the weather was nice. Staff member B stated the activities department provided bird seed for resident #6 to use when she wanted to fill the bird feeders. Staff member B stated the activities staff accompanied resident #6 outside to fill the bird feeders. Staff member B was not able to explain why the care plan did not include these warm weather outings and why some staff were unaware of resident #6's wander risk.Review of the facility's policy titled, Elopements and Wandering Residents, dated 8/26/24, showed, Monitoring and Managing Residents at Risk for Elopement or Unsafe Wandering . 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.

Based on observation and interview, the facility failed to ensure readily available results of surveys completed by the State Survey Agency were located in a publicly accessible area. This failure would affect any person wishing to view the survey results. Findings include:During an observation on 9/8/25 at 1:18 p.m., the facility had a wall-mounted file holder viewable upon entrance into the facility's building, located on the wall of the common area TV room. The holder had a label with the words printed on it, SURVEY RESULTS. The holder did not have any binder or documents to view.During an observation on 9/10/25 at 8:22 a.m., the facility did not have any binder or documents to view in the same entry area wall-mounted file holder.During an interview on 9/10/25 at 10:12 a.m. staff member D stated she did not realize the binder with results from surveys was not available in the file holder. Staff member D stated she would check to see where it might be.During an interview on 9/10/25 at 10:51 a.m. staff member D stated she did not know why the binder had not been available in the file holder. Staff member D stated it could have been pulled to the nurses station for something and just not returned. Staff member D stated, It's one of those things, just in walking by it every day, you forget to think of that being there or not.

Based on interview and record review, the facility failed to ensure a completed POLST form with physician signature was readily accessible in the hard chart and the electronic medical record for 1 (#5) of 5 sampled residents. Findings include:During a record review of resident #5's POLST, dated [DATE], showed No CPR and selective treatment was selected, and the form was filled by the resident's responsible party. The form was not signed by resident #5's responsible party. The form was not signed by the provider, it was without a date, and there was not a printed name of the provider.During an interview on [DATE] at 11:23 a.m., staff member F stated admission forms, including POLST forms, were reviewed by staff member F, the resident or responsible party, and or family member. Staff member F stated some forms were given to the resident or responsible party to fill out ahead of time, before entering the facility. Staff member F stated she was not sure why resident #5's POLST had not been completed and filled out with the responsible party signature, provider signature, and date.Review of a facility policy titled, Advance Directives, revised [DATE], showed: . The facility defines the following in accordance with current OBRA definitions and guidelines:. a. Advance care planning - a process of communication between individuals and their healthcare agents to understand, reflect on, discuss, and plan for future healthcare decisions for a time when individuals are not able to make their own healthcare decisions. h. Physician Orders for Life-Sustaining Treatment (or POLST) . form - a form designed to improve patient care by creating a portable medical order form that records patients treatment wishes so that emergency personnel know what treatments the patient wants in the event of a medical emergency .Review of a document provided by the facility, Directions for Health Care Professionals, revised [DATE], showed: Completing POLST . 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.

Based on interview and record review, the facility failed to ensure staff were performing cares within their scope of practice; failed to ensure sufficient supervision; and failed to ensure nursing staff performed adequate pain assessment and ongoing monitoring for the application of a heat pack for 1 (#9) of 16 sampled residents. The facility's failures resulted in the development of a partial thickness facial burn for one resident and increased the risk of serious injuries for any resident in need of heat pack application. Findings include: During an interview on 3/11/25 at 10:12 a.m., resident #9 reported he received a burn to his left face approximately five or six months ago when he reported a toothache. During an interview on 3/12/25 at 1:45 p.m., staff member D stated, We don't use hot packs here at all. There was an incident with one in the past. During an interview on 3/12/25 at 2:40 p.m. regarding the 7/1/25 burn incident reported by resident #9, staff member A stated, The CNA went back to physical therapy without permission and got a heat pack from the hydrocollator. As an OT (occupational therapist), I have had to have specialized modality training on how to use a hydrocollator heat pack. Those packs can get up to 165 degrees (Fahrenheit) or so. That was a bad deal. During a telephone interview on 3/12/25 at 3:28 p.m., staff member G stated the CNA staff did occasionally use heat packs, as needed. She had been shown how to access and use the hydrocollator, located in the physical therapy department. Staff member G was unable to recall who trained her on the use of the hydrocollator. Staff member G stated on the day of the injury, she notified staff member H of resident #9's request for a heat pack for his dental pain, and she would get one from the physical therapy department. Staff member H stated Okay. Staff member G obtained the heat pack from physical therapy, and applied it to resident #9's face. Staff member G stated she then became busy and did not get back to remove the pack until 30-40 minutes later. Staff member G did not know if staff member H had assessed or monitored the resident before, during, or after the heat application. Staff member G stated when she removed the heat pack, resident #9' face was reddened, and reported the redness to staff member H. Staff member G stated she thought the redness would go away after the removal of the pack. The following morning, staff member G noted there was blistering on resident #9's face. Staff member G stated she knew the burn was from the heat pack application the day prior and reported it to the nurse on duty. Staff member G stated the staff were no longer allowed to use heat packs in the facility because of resident #9's burn injury. An interview attempt with staff member H was made by phone on 3/12/25 at 3:18 p.m. No return call from staff member H was received by the end of the survey period. During an interview on 3/12/25 at 4:00 p.m., staff member C stated the heat pack policy was being updated to show only therapy can use the hydrocollator, but it had not yet been updated, due to administrative staff changes. Staff member C stated all staff were educated by email and instructed to no longer apply heat packs to any resident. Review of resident #9's nursing progress notes, dated 7/1/25, showed, . No c/o mouth/gum pain. No request for prn medication. There were no additional notes on this date to show the assessment, application of heat, monitoring, or follow-up. Review of resident #9's nursing progress notes, dated 7/2/25, showed, . NOC nurse reported to this RN at 0600 (6:00 a.m.) that resident had blisters on the left side of his cheek from a heat pack that was put on his face to help with oral pain. Heat pack was on too long and resident has developed blistering. Assessment of site Revealed the entire area from the left jaw to above his ear was red. Blisters noted from left cheek to left jaw line. All intact. Resident did allow this RN to place a cool compress on the left side of his face for pain and swelling. Will pass this onto the night nurse and DON. [sic] Review of a facility document, titled, Policy: Hydrocollator and Moist Heat Pack Usage, with an effective date of 3/8/23, showed, Only PT, OT, or CHARGE NURSE are permitted to utilize hydrocollator and/or MHPs . [sic]

Based on observation, interview, and record review, the facility failed to ensure proper hand hygiene was used for 3 (#s 5, 12, and 18); failed to ensure clean medical equipment (lifts) between resident uses for 2 (#s 12 and 18); failed to properly clean blood glucose monitor for 1 (#5); failed to provide effective education related to enhanced barrier precautions (EBP) throughout the facility, and failed to implement the appropriate use of enhanced barrier precautions (EBP) for 1 (#9) of 16 sampled residents. The deficient practices increases the risks of infection for all residents receiving care within the facility. Findings include: 1. During an observation on 3/11/25 at 3:58 p.m., staff member E and F were toileting resident #18, using the sit-to-stand lift. Staff member E began by gloving, without hand hygiene, and moved resident #18 over the toilet. Both staff member E and F removed the soiled brief. Resident #18 urinated. and without removing the dirty gloves, staff members E and F replaced resident #18's brief on and dressed him, while he was in the lift. Staff member E moved resident #18 back to his chair by the nurses' station. After transferring resident #18 out of the sit-to-stand lift, staff member E and F removed their gloves and headed to the next resident without cleaning the sit-to-stand or washing their hands. 2. During an observation on 3/11/25 at 4:05 p.m., staff member E and F entered the room of resident #12 to toilet the resident. Staff member E and F put on gloves, without hand hygiene, between resident #18 and resident #12. Staff member E and F placed resident #12 in the sit-to-stand lift and moved her to the toilet. Staff member E removed resident #12's soiled brief, and then left the room to grab supplies, touching the door handle and stop sign on the door, without degloving, until she returned to the room. Staff member F continued to use the same gloves while staff member E and F placed a clean brief on resident #12 and dressed her. Staff member E and F then moved resident #12 back to the recliner in her room. Wearing the same gloves from the beginning, staff member F assisted resident #12 with a sip of her drink, adding blankets, and clipping her call light to the blankets. Staff member E and F degloved and completed hand hygiene as they exited the room and entered the room of resident #13 with the sit-to-stand lift, without cleaning it first. During an interview on 3/11/25 at 5:00 p.m., staff member E stated hand hygiene should be completed before and after entering or leaving a room, start of shift, when handling trash, and before putting gloves on and after taking gloves off. Staff member E stated she and staff member F talked after the surveyor observation and they knew better, but they were busy. During an interview on 3/11/25 at 5:03 p.m., staff member F stated hand hygiene should be completed before and after meals, using the restroom, after resident care, when blood contact occurs, when leaving the room, and between dirty and clean tasks. Staff member F stated she, Just forgot to, when asked about hand hygiene and cleaning the lift during the surveyor observations. 3. During an observation and interview on 3/12/25 at 10:58 a.m., staff member D went to the activity room to administer Tresiba Flexpen 100 units/ml, 36 units subcutaneously to resident #5. Staff member D completed hand hygiene and gloved, administered the Tresiba to resident #5, then recapped the needle, took the needle off the pen, and placed the pen and capped needle in the white medication tray. Still gloved, staff member D placed her dirty, gloved hand, into the supply tray and pulled out cotton, a lancet, and a glucose monitor. Staff member D completed the blood sugar check and took her gloves off, cleaned the glucose monitor with a mini alcohol pad with her bare hands, placed the monitor back in the supply tray with the lancets, and cotton balls. Staff member D stated she usually used a mini alcohol pad to wipe the glucometer because that was what the facility provided. Review of a facility policy, Handwashing/Hand Hygiene, revised October 2023, reflected: - Hand hygiene is indicated: - a. immediately before touching a resident; - .c. after contact with blood, body fluids, or contaminated surfaces; - d. after touching a resident; - .f. before moving from work on a soiled body site to a clean body site on the same resident; and - g. immediately after glove removal. Review of the facility policy titled, Patient Lifts Safety Guide, no date, reflected: - . Always clean lift before and after each patient use. Disinfect all lift surfaces. Wipe off traces of disinfectant. Review of the facility's policy, Cleaning and Disinfection of Resident-Care Equipment, dated 2024, reflected: - . d. Multiple-resident use equipment shall be cleaned and disinfected after each use. - . h. Use only EPA-registered disinfectants with kill claims for the common organisms found in the facility . 48268 4. During an observation and interview on 3/11/25 at 3:45 p.m., resident #9 was observed in his recliner with his feet elevated. A wound wrap and dressing were noted to resident #9's right lower leg, and a dressing to the left forefoot and heel, covered with a padded dressing. Resident #9 said staff do not wear gowns when they change the dressing, stating, Only gloves. During an observation and interview on 3/12/25 at 4:15 p.m., staff member D was observed changing the dressings on resident #9's wounds. Staff member D was observed wearing gloves, but no gown. When asked about wound precautions, staff member D stated, He used to have MRSA in this wound, but I don't think it's been tested in a long time. When asked about enhanced barrier precautions (EBP), staff member D stated, What is that? During an interview on 3/12/25 at 4:22 p.m., staff member J stated she was not familiar with the terms enhanced barrier precautions or EBP. Staff member J stated there were no residents in the facility at this time that required a gown for cares. During an interview on 3/12/25 at 4:50 p.m., staff member E was asked if she was familiar with enhanced barrier precautions or EBP. Staff member E stated, What is that? No I have never heard of it! Review of resident #9's care plan entry for skin impairment, initiated on 10/15/24, and revised on 3/10/25, showed, I have had MRSA in my ankle wound. Dressing changes and treatment will be done as ordered by provider. Use enhanced barrier precautions for my care if large amounts of drainage from the site. Review of a facility-provided email communication, dated, 3/21/24, from the facility's infection preventionist to licensed nursing staff, showed, . If they are doing usual cares/toileting and the wound remains covered then there is no need for gowning. [sic] Review of facility provided, CMS document, titled, QSO-24-08-NH, dated 3/20/24, showed: . EBP are indicated for residents with any of the following: . Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO . For residents for whom EBP are indicated, EBP is employed when performing the following high-contact resident care activities: -Dressing -Bathing/Showering -Transferring -Providing hygiene -Changing linens -Changing briefs or assisting with toileting -Device care or use -Wound care: any skin opening requiring a dressing. This document was attached to the email as noted above, which was sent to all licensed nursing staff by the infection preventionist as education. A request for staff education on EBP was requested on 3/11/25 at 4:24 p.m. No additional evidence was provided by the end of the survey period to show EBP training for CNAs, or other department staff, and no additional education for licensed nursing staff other than the email dated 3/21/24.

Based on observations and interviews, the facility failed to ensure opened facility-wide use medications were labeled with an expiration date when stored in the medication cart; and expired products in the medication room were disposed of. This deficient practice increased the risk of adversely affecting any resident who was taking these medications or using an inaccurately calibrated glucose monitor. Findings include: During an observation on 3/11/25 at 4:37 p.m., with staff member I, the following items were found: - Robafen DM with no open date, almost empty, - Maxtussin Mucus and chest congestion with no date and was half empty, - Mintox Max antacid with no open date and almost empty, - Cholestyramine 4 gm with no open date, - Metrix level 2 3ml Control solution, expired on 2/28/25, and - 8 IV extension tubing set, expired 4/2021. During an interview on 3/12/25 at 8:13 a.m., staff member D stated all medications were to be marked with an open date, once opened, and disposed of when expired. During an interview on 3/12/25 at 11:40 a.m., staff member C stated all medications were required to be labeled with open dates, and the medication cart and medication room were regularly checked for expired medications and products. Staff member C stated she was unable to locate a policy for medication storage and disposal.

Based on observations, interviews, and record review, the facility failed to ensure medication error rates were under 5% for 2 (#s 9 and 13) of 6 sampled residents for medication errors. The calculated medication error rate was 7.69%. Findings include: 1. During an observation and interview on 3/11/25 at 12:58 p.m., staff member I was administering medications to resident #9. Staff member I administered a pea size amount of Voltaren gel to each knee. Staff member I stated she did not usually apply the gel to his ankles because he usually had compression wraps on from his knees to his toes, and she did not want to create more work for the nurse. Staff member I stated she was aware of the plastic measuring tool to ensure enough gel was applied but forgot to grab it when prepping resident #9's medications. When asked, staff member I was unable to determine how much other nurses would have administered during the day because this was not included on the MAR as an option. Review of resident #9's medication order reflected, Voltaren External Gel 1%. Apply to knees/ankles topically three times a day for pain. The sticker order on the medication tube reflected: - Apply topically to affected areas three times daily ***Max 32 GM daily*** 2. During an observation and interview on 3/12/25 at 8:22 a.m., staff member D was preparing resident #13's medications. Staff member D stated she crushed his medications and added the powder to applesauce. One of the medications she prepped was Guaifenesin 400 mg. Staff member D crushed the Guaifenesin and added it to the applesauce. Staff member D then administered the medications with the applesauce. Staff member D stated she had not noticed the DO NOT CRUSH sticker on the pill card, and she was trained to crush his medications, or he would not take them. Review of Drugs.com Guaifenesin, accessed on 3/17/25, at https://www.drugs.com/guaifenesin.html, reflected: - Do not crush, chew, break, or open a controlled-release, delayed-release, or extended-release tablet or capsule. Swallow it whole. Breaking or opening the pill may cause too much of the drug to be released at one time. Review of the facility's policy, Medication Administration, dated 2024, reflected: - 17. Administer medication as ordered in accordance with manufacturer specifications. - . c. Crush medications as ordered. Do not crush medications with do not crush instructions.

Based on observations, interviews, and record review, the facility failed to complete a baseline care plan for 1 (#77) of 16 sampled residents. This deficient practice put the resident at risk for bedside staff to be unaware of resident care needs and providing effective, person-centered care. Findings include: During an observation on 3/10/25 at 3:15 p.m., resident #77 was in her room, with no name on the door, and was not listed in the census list provided. During an interview on 3/10/25 at 3:30 p.m., staff member C stated resident #77 was a respite patient, who entered the facility on 3/7/25, and the facility did not fully admit respite patients. Staff member C stated a care plan was not necessary because the census was small, and everyone knows the residents who were at the facility for respite stays. Review of resident #77's paper chart did not include a baseline care plan. Review of the facility's policy, Baseline Care Plans, dated August 2024, reflected: - 1. The baseline care plan will: a. Be developed within 48 hours of a resident's admission. b. Include the minimum healthcare information necessary to properly care for a resident including, but not limited to: i. Initial goals based on admission orders. ii. Physician orders. iii. Dietary orders. iv. Therapy orders. v. Social services .

Based on interview and record review, the facility failed to accurately document an event sent to the State Survey Agency regarding a resident-sustained facial burn and the resident had pain, due to the application of a heat pack, and failed to provide accurate documentation of the facility's investigative findings, for 1 (#9) of 16 sampled residents. Findings include: During an interview on 3/11/25 at 10:12 a.m., resident #9 reported he had received a burn to his left cheek and ear, approximately five or six months ago, from a heat pack applied for a toothache. During a phone interview on 3/11/25 at 4:15 p.m., NF6 stated he received a complaint from resident #9 pertaining to receiving a burn. NF6 stated he saw the facial burn approximately one week after the incident. At the time of his visit, NF6 stated, There was no blistering remaining, but the entire cheek, from top of the ear to the left jawline, was quite red, inflamed, and was reported by [Resident #9] to be painful. During a phone interview on 3/12/25 at 1:15 p.m., NF5 stated resident #9's left face was red and blistered from the hairline above the ear to the jawline. NF5 stated, His (Resident #9's) face was so red, blistered, and sore looking, that I thought maybe he had shingles, until they (staff) told me what happened. Review of a Facility-Reported event, submitted to the State Survey Agency on 7/2/25, showed resident #9 sustained a . red area on residents left upper cheek and ear . We did not have to do any medical treatment to the area. [sic] Review of the facility's report of findings, submitted to the State Survey Agency on 7/3/25 showed, No need for treatment as there were only a couple small blisters less than 2mm in size on one ear. Review of resident #9's nursing progress notes, dated 7/2/25, showed, . the entire area from the left jaw to above his ear was red. Blisters noted from left cheek to left jaw line. Review of resident #9's electronic medical record, dated 7/2/25, showed a verbal order was requested by nursing for aloe vera topical cream for the burn. Review of resident #9's nursing progress notes, dated 7/5/25, showed, .Cheek and upper neck are swollen and hot to the touch with more blistering than noted yesterday. Aloe applied to burn and surrounding areas. Ice pack applied for 10 minutes to help with swelling. Resident stated, 'My jaw feels swollen and puffy. It kind of hurts a little too.' Contacted DON to have someone look at the area. Review of resident #9's physician progress notes, dated 7/8/25, showed . 1. Burn of second degree of head, face, and neck, unspecified site, initial encounter - T20.20XA (Primary) . Notes: Will monitor skin closely. I question the start of impetigo to some of the burn, but will see how he responds to the oral antibiotic I am giving him for the oral infection. Will recheck patient on Wednesday. RN staff can continue topical aloe vera. [sic] Review of the facility policy titled, Incident Reporting, dated 8/26/24, showed, Procedure for Filing an Initial Report . 10. The extent of any injuries: and . the outcome of your investigation.

Based on observations, interviews, and record review, the facility failed to implement equal practices during the admission process, by failing to complete admissions on residents entering the facility for respite care for 1 (#77) of 16 sampled residents. This deficient practice placed residents at risk for staff providing effective, person-centered care. Findings include: During an observation on 3/10/25 at 3:15 p.m., resident #77 was in her room, with no name on the door, and was not listed on the census list provided by the facility. During an interview on 3/10/25 at 3:30 p.m., staff member C stated resident #77 was a respite patient, and the facility did not fully admit respite patients. Staff member C stated residents who were on respite stays would not be included in the census. Staff member C stated the facility accepted respite patients regularly and did not admit them the way they did for regular admissions. Staff member C stated a paper chart was started for respite patients, including a paper MAR, a facility contract, an initial assessment, and nursing notes. Staff member C stated respite patients were not in the facility long enough to warrant a full admission. Staff member C stated a care plan and emergency preparedness were not necessary because the census was small, and everyone knows the residents who were at the facility for respite stays. Review of resident #77's paper chart reflected: - A respite care contract between the facility and resident #77 for Full Day-$203.00 all-inclusive services; - A POLST; - An initial Nursing Assessment; - Nursing Progress Notes dated 3/7/25 through 3/10/25; -MAR listing seven medications; and - Contact List The paper chart did not include physician orders, history & physical, discharge summary, emergency preparedness documents, or baseline care plan. During an interview on 3/11/25 at 12:06 p.m., staff member C stated the facility did not have any policies related to respite services. Review of the facility's policy, Admission of a Resident, with a revision date of 2025, reflected: - The admission process is intended to obtain all possible information regarding the resident for the development of the comprehensive plan of care, and to assist the resident in becoming comfortable in the facility. Residents are admitted to the facility under orders of the attending physician. Request for a policy and procedure for respite admissions was made on 3/11/25 at 11:22 a.m. Staff member C reported back at 12:00 p.m., there was no policy or procedure related to respite care.

Based on observations, interviews, and record review, the facility failed to complete timely revisions to comprehensive fall care plans for 1 (#18) of 16 sampled residents. The failure to update the fall care plan caused staff confusion and increased the risk of additional falls resulting in injuries. Findings include: During an observation on 3/11/25 at 7:32 a.m., resident #18 was in his bed wearing white crew socks without grips, there were no grip strips on floors, the bedside table was next to his bed, and the door to the hallway was closed. The ghost alarm was turned off. No Falling Star magnet (visual tool for staff to know when a resident had frequent falls) was on the door. During an observation on 3/11/25 at 12:09 p.m. through 3:20 p.m., resident #18 was in his wheelchair without foot rests, by the nurses' station, slumped over. Resident #18 was wearing white crew socks without grips on the bottoms. Resident #18 did not move from the nurse's station during the observation period. During an observation on 3/11/25 at 3:58 p.m., resident #18's chair alarm wire was not connected to the chair alarm device, rendering the device inoperable. During an interview on 3/11/25 at 12:48 p.m., staff member G stated resident #18's care plan fall interventions were a fall mat next to the bed, a ghost alarm for when he is in his room, and a tabs alarm on his wheelchair. Staff member G was not aware of any other interventions. Staff member G stated the interventions changed frequently, so it was hard to keep track of what was current. During an observation on 3/12/25 at 7:10 a.m., resident #18 was sitting by the nurses' station sleeping in his wheelchair, without foot rests, with white crew socks on his feet. During an observation on 3/12/25 at 7:30 a.m., resident #18 was located in the dining room, and his chair alarm wire was not connected to the chair alarm device, rendering the device inoperable. During an interview on 3/12/25 at 7:34 a.m., staff member C stated, The alarms only work if the alarm wire is connected. Review of resident #18's Fall care plan, with a revision date of 6/20/24, reflected: - CURRENT INTERVENTIONS: - 3/6/25 put dycum non slip mat in seat of wheelchair and between sensor pad and gel pad in the wheelchair seat and gel pad is to be only cushion in wheelchair, put non slip socks on. - .1/22/24: Make sure bed alarm pad is connected to alarm box, - 7/23/24: Bed pad (sensor pad) alarm to be used while resident is in bed. - 6/16/24: grip strips were placed in front of my bed and recliner to help prevent my feet from slipping. - 5/10/24: continue with ghost alarm, staff will loudly announce presence and P.T. suggested having staff walk him to and from meals and any time he wants to use walker to help build back some strength and stamina, - 12/5/23: Wake resident every two hours starting at midnight to toilet. Remove bedside table from room to decrease clutter on resident's side of room. - 10/9/23: Falling star program. [sic] During an interview on 3/11/25 at 4:05 p.m., staff member E stated resident #18 had not walked for months, had a bedside table since admission, and she had not seen anyone use the bed alarm. Staff member E stated she also thought the staff was supposed to use a fall mat on the floor when he was in bed, but she had not seen it the last few days.

Based on observation, interview, and record review, facility staff failed to uphold professional standards by not following the physician orders to check the wanderguard function daily, for 1 (#20) of 16 sampled residents. The failure increased the risk for elopement and serious harm to the resident. Findings include: During an observation on 3/11/25 at 3:25 p.m., resident #20 was observed wandering the halls, peering into resident rooms, staff offices, and peering out of the exterior door window. Resident #20 was wearing a wanderguard bracelet at the time of the observation. During an interview on 3/12/25 at 2:12 p.m., staff member D stated resident #20 had eloped at some time in the past, and so she had the wanderguard on to prevent another elopement. Staff member D stated the wanderguards were tested daily by the nurses. During an interview on 3/12/25 at 3:50 p.m., staff member C stated she placed the wanderguard checks on the TARs specifically to prevent them from being overlooked. Staff member C stated the EHR system flags the nurses for incomplete orders during their shift, and therefore it would be difficult to forget to follow or complete an order because, all they have to do is log in, and it flashes at them. Review of resident #20's physician order, dated 3/8/24, showed, Check wanderguard function daily. Review of resident #20's treatment administration records for the period of 12/1/24 through 2/28/25, showed staff failed to follow the physician's order on 24 separate dates within the three month review period, which represented a 27% failure rate. Review of a facility document titled, Elopements and Wandering Residents, dated 8/26/24, showed, 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 . Review of wanderguard operating instructions, located at https://www.manualslib.com/manual/1339810/Wanderguard-18029.html#manual, accessed on 3/20/25, showed . [Wanderguard] Bracelets must be tested daily. IMPORTANT: Failure to replace the bracelet 'on time' could result in injury to or the death of a person in your care.

Based on observations, interviews, and record review, the facility failed to ensure fall interventions were followed by staff for 1 (#18); and failed to ensure staff followed needle safety techniques for 1 (#5) of 16 sampled residents. These deficient practices placed the resident at risk for increased falls for #18 and staff needle injuries. 1. During an observation on 3/11/25 at 7:32 a.m., resident #18 was in his bed wearing white crew socks, not non-skid socks. There were no grip strips on floors, the bedside table next to his bed, and the door to the hallway was closed. The ghost alarm (motion alarm) was turned off. No Falling Star magnet (visual tool for staff to know when a resident had frequent falls) was on the door. During an observations on 3/11/25 from 12:09 p.m. through 3:20 p.m., resident #18 was in his wheelchair without foot rests, by nurses' station, slumped over. Resident #18 did not move from the nursing station during the observation period. During an observation on 3/11/25 at 3:58 p.m., resident #18's chair alarm wire was not connected to the chair alarm device, rendering the device inoperable. During an interview on 3/11/25 at 4:05 p.m., staff member E stated resident #18 had not walked for a long time, had a bedside table for months (at least before Christmas), and no one was using the bed alarm, as far as she knew. Staff member E stated she was not aware no one had taken resident #18 to the toilet since before 12:09 p.m. During an observation on 3/12/25 at 7:30 a.m., resident #18 was located in the dining room and his chair alarm wire was not connected to the chair alarm device, rendering the device inoperable. During an interview on 3/12/25 at 7:34 a.m., staff member C stated, The alarms only work if the alarm wire is connected. During an observation and interview on 3/12/25 at 11:40 a.m., staff member A stated, The team (management) was aware the alarms not being turned on was a problem, and we are going to be restarting audits. Staff member A and this surveyor went to the fireside room, where resident #18 was sleeping in a manual recliner, with his feet up on the footrest, no dycum in the chair, no bell to call for assistance, his tabs alarm not attached, and he did not have non-skid socks on. Staff member A stated this was not acceptable, and she would reeducate the CNAs. Staff member A stated resident #18 would not be able to lower the footrest on his own. Review of resident #18's Fall care plan, with a revision date of 6/20/24, reflected: - CURRENT INTERVENTIONS: - 3/6/25 put dycum nonslip mat in seat of wheelchair and between sensor pad and gel pad in the wheelchair seat and gel pad is to be only cushion in wheelchair, put non slip socks on, - .1/22/25: Make sure bed alarm pad is connected to alarm box, - 1/7/25: Use tabs alarm in wheelchair d/t sensor pad not working with WC cushion, - 9/14/24: Sensor alarm placed in wheelchair, tabs can be used if sensor alarm box is not functioning or if parts are on order, - 8/12/2024: 2-hour toileting program 24/7 to prevent resident from self-transferring to bathroom, - 7/30/2024: fall mat to be placed next to bed when resident is in bed (Removed in December 2024). CNA and Nurses will also be educated on alarm use at their monthly meetings in August. - 7/23/24: Bed pad (sensor pad) alarm to be used while resident is in bed. - 6/20/2024: The falls team tracked and trended my recent falls and put into place the following interventions: hourly checks, shorten my TABS alarm string, have the RNA help me with dressing in the morning, and place me in a Geri chair after supper. - 6/16/24: grip strips were placed in front of my bed and recliner to help prevent my feet from slipping. - 6/3/24: TABS alarm on my wheelchair because I am unsteady on my feet and like to self-transfer. - 5/10/24: continue with ghost alarm, staff will loudly announce presence and PT suggested having staff walk him to and from meals and any time he wants to use walker to help build back some strength and stamina. - 5/9/2024: Remind resident to remain seated while changing or putting on clothes. - 5/8/2024: Ghost alarm to be placed under my bedside table when I am in my room because I am unsteady on my feet after my recent hospitalization . - 12/5/23: Wake resident every two hours starting at midnight to toilet. Remove bedside table from room to decrease clutter on resident's side of room. - 10/9/23: Falling star program. [sic] Review of resident #18's fall history reflected resident #18 had 18 falls in a 12-month period from 3/30/24 to 3/6/25. 2. During an observation and interview on 3/12/25 at 10:58 a.m., staff member D administered 36 units of Tresiba FlexTouch Subcutaneous Solution Pen-injector 100 UNIT/ML to resident #5. After administration, staff member D recapped the Tresiba pen and placed the pen in the tray with clean supplies. After leaving the room, staff member D stated the facility did not supply sharps containers to carry around to the room while obtaining blood sugars and administering medications requiring needles. Staff member D stated she recaps the needles and puts the needles in the sharps container when she returns to the medication room. During an interview on 3/12/25 at 12:05 p.m., staff member A stated the staff should never recap needles due to the risk of accidental needle sticks. Staff member A stated the facility would be ordering mini sharps containers for the staff to use. Review of a facility policy, Regulated (Biohazard) Medical Waste, dated 2024, reflected: - . 8. Contaminated needles and other contaminated sharps will not be bent, recapped, or removed. - 9. Contaminated sharps will be placed in appropriate sharps containers located at the point of use .

Based on observations, interviews, and record review, the facility failed to ensure a resident in respiratory distress, who was coughing and unable to breathe, and afraid he was dying due to it, was provided respiratory care and assessed as needed, for 1 (#23) of 16 sampled residents. Findings include: During an observation and interview on 3/10/25 at 2:44 p.m., resident #23 was in his bed coughing and gurgling, and coughing up phlegm. Staff member B entered the room and sat resident #23 up in bed and went to get medications for the cough. Staff member H entered the room and stated she was giving resident #23 cough syrup, cough drops, and his inhaler. Staff member H stated all of resident #23's vitals were normal, so the doctor was not notified. Staff member B stated vitals are done weekly unless a resident is on daily vitals orders. No respiratory assessment was done for the resident during this observation. Resident #23 asked if the surveyor could find him a way to the hospital because he was dying. During an interview on 3/11/25 at 12:20 p.m., NF2 and NF3 visited resident #23. NF3 stated the doctor saw resident #23 a few weeks ago, and had concerns about aspiration of food leading to pneumonia. NF3 stated she had voiced concerns about the long wait to be seen for a swallow evaluation, but was told due to the rural area, the wait would be another month out (April). NF3 stated resident #23 had been coughing and getting worse for a few weeks and nothing was being done. During an observation on 3/11/25 at 2:11 p.m., staff member D entered the room of resident #23. Resident #23 stated, I'm congested in my lungs and I'm coughing a lot. I've been using the inhaler quite a bit, but it's not helping. It usually helped in the past but isn't helping this time. Staff member D offered resident #23 his inhaler and some cough syrup. Resident #23 declined the medications stating they did not help. During an interview on 3/11/25 at 2:15 p.m., staff member D stated vitals were not taken because the protocol for resident #23 did not include daily vitals. When asked, staff member D stated she did not do a respiratory assessment of resident #23's lungs because she felt resident #23 simply needed to use his inhaler. Staff member D stated she did respiratory assessments when she worked at the hospital but long term care facilities do not do respiratory assessments. During an observation on 3/11/25 at 2:21 p.m., staff member D entered resident #23's room and completed a set of vitals to include: blood pressure 111/57, pulse 63, temperature 97.5, oxygen saturation 89%. Staff member D assessed resident #23's lungs and stated the following: Upper lungs were clear, right mid-line wheezing, and lower bilateral lungs had coarseness. Staff member D stated she would notify the physician's office and put resident #23 on the list of residents to be seen when the doctor comes to the facility on [DATE]. During an interview on 3/11/25 at 3:43 p.m., staff member C stated she reviewed resident #23's chart, and the nurses should be doing more assessment than what was in the chart. Staff member C stated a respiratory assessment should be done and vitals completed each shift. Staff member C stated the CNAs put vitals on a worksheet and turn them into the nurse, and she was not sure why the oxygen saturations were missing in the EHR vitals from 2/28/25 through 3/11/25. During an interview on 3/11/25 at 4:40 p.m., staff member B stated resident #23 was assessed by the physician a few weeks ago and a chest x-ray was done. Staff member B stated the x-ray was clear on 2/18/25 and guaifenesin was ordered for his cough and wheeze. Staff member B stated the swallow evaluation was ordered on 2/28/25, and the appointment was made for mid-April. Staff member B stated the rural area created a barrier to obtaining a swallow evaluation any sooner. Staff member B stated a nursing assessment would be the standard for any change in resident #23's condition, and she had not been informed of a change in his condition. Staff member B stated resident #23's complaints of not being able to breathe, oxygen saturations of 87-89%, and coarseness in the lower lobes would constitute a change in condition and would warrant further assessment and notification to the physician. During an observation and interview on 3/12/25 at 3:30 p.m., NF1 was in the facility and entered resident #23's room. Resident #23 told NF1 the cough was coming and going, but when it came, he could not stop it, and some days it (the cough) was just continuous all day. Resident #23 stated, I feel like I'm choking when I eat, and I have to get up from the dining room and cough up my meal. It's really scaring me. I seem better during the middle of the day and when I'm up for the day. Last night I woke up and simply could not breathe, doc you got to help me. NF1 stated she was concerned with possible postnasal drip and potential aspiration risks. NF1 stated she would be ordering a chest x-ray, would check on the swallow evaluation appointment, a nasal spray for the nasal drip, head of bed elevation, and remaining up for 60-90 minutes after meals to allow for stomach emptying. Resident #23 stated he was grateful for her visit. Review of the facility policy titled, INTERACT CARE PATH Symptoms of shortness of breath, revision date 8/21, reflected: - . Evaluate Symptoms and Signs for Immediate Notification* - Cough with or without sputum production - Inability to eat or sleep due to SOB - Abnormal lung sounds (wheezing, rales, rhonchi, etc. ) - Edema - Change in mental status - New irregular pulse - Cardiovascular - Respiratory - Signs and symptoms suggest possible sepsis** .

Based on interview and record review, the facility failed to provide COVID-19 vaccinations for residents requesting the vaccine for 2 (#s 9 and 10) of 5 residents sampled for vaccinations. This deficient practice increased the risk of COVID-19 infections for residents in the facility. Findings include: 1. During an interview on 3/11/25 at 3:31 p.m., staff member C stated two of the five sampled residents did not receive their COVID-19 vaccine, as requested. During a phone interview on 3/12/25 at 1:15 p.m., NF5 stated she did sign an approval for the COVID-19 vaccine for resident #9 last fall, and assumed the vaccine had been administered. Review of a facility document titled, Vaccine Intake and Annual Consent, dated 10/28/24, showed NF5's signed approval for resident #9 to receive the COVID-19 vaccine. 2. Review of a facility document titled, Vaccine Intake and Annual Consent, dated 10/23/24, showed resident #10's POA's signed approval for resident #10 to receive the COVID-19 vaccine. Review of a facility written statement, undated, provided by staff member C to the surveyors on 3/11/25, showed, We did not get all the flu vaccinations done until first week of November 2024. We decided to wait at least a month before giving the COVID-19 booster shots. With holidays and staffing changes and illnesses going through the facility staff and residents, the COVID-19 booster shots have not been given yet for [resident #9] and [resident #10]. [sic] The delay for administration of the requested COVID-19 vaccines was greater than five months at the time of the survey. Review of the facility document titled, Resident COVID-19 Vaccination, dated 2/7/23, showed, . To minimize the risk of residents acquiring, transmitting, or experiencing complications from COVID-19 by ensuring that each resident . has the opportunity to receive the COVID-19 vaccine, unless medically contraindicated, refused, or has already been immunized .

Based on interview and record review, the facility failed to ensure all allegations of neglect by staff were reported to the administrator and State Survey Agency within the required timelines for 2 (#s 1 and 4) of 7 sampled residents. Findings include: During an interview on 12/30/24 at 12:39 p.m., staff member B stated she had witnessed staff member H pushing resident #4 down the hall towards his room. Staff member B stated the resident was sitting on a bath chair and wrapped in a blanket. Staff member B stated staff member H took resident #4 into his room and left him there. Staff member B stated resident #4 began, hollering and yelling for help. Staff member B stated she witnessed staff member G go into the resident's room. Staff member B stated she did not remember how much time elapsed between when staff member H left resident #4 in his room and when staff member G entered the resident's room to help him. During an interview on 12/30/24 at 6:28 p.m., staff member G stated she was working with staff member H on a day shift. Staff member G stated staff member H had given resident #4 a bath and was returning him to his room. Staff member H put resident #4 in his room and left him sitting in a bath chair wrapped up in a blanket. Staff member G stated she heard resident #4 yelling for help, and when she entered the resident's room, she observed resident #4 sitting in the middle of his room, without a call light or any way to summon help. Staff member G stated she asked staff member H why she left the resident alone in his room without a call light. Staff member H stated another CNA was supposed to have gone in and helped him. Staff member G stated she followed the chain of command and reported the incident to staff member I. Staff member G stated she expected staff member I to investigate the incident. During an interview on 12/31/24 at 7:55 a.m., staff member J stated she remembered a day when staff member G gave resident #4 a bath and then left him in his room unattended. Staff member J stated the resident was sitting in a bath chair wrapped in a blanket and had no call light within his reach. Staff member J stated she did not know how much time had passed before resident #4 began yelling for help. Staff member J stated she saw staff member I walking in the hallway when the resident began yelling for help. When asked if she had witnessed any other incidents of possible neglect of care involving staff member H, staff member J stated she had followed staff member H on a day shift. Staff member J stated when she did 2:00 p.m. rounds, she found resident #1, who had been taken care of by staff member H from 6:30 a.m. to 2:00 p.m., in a heavily saturated brief which also contained a large bowel movement. Staff member J stated the brief was an overnight brief. Staff member J stated the BM had dried to his skin. Staff member J stated she followed the chain of command and reported the incident to the nurse on duty. During an interview on 12/31/24 at 9:15 a.m., staff member G stated she had assisted staff member J with caring for resident #1. Staff member G stated she found the resident in an overnight brief which was very, very wet. Staff member G stated the overnight briefs were used during the night because they were more absorbent than the regular briefs. Staff member G stated she followed the chain of command and reported the incident to staff member I and was told, Other people do that. During an interview on 12/31/24 at 10:10 a.m., staff members A and K stated when direct care staff came to them regarding complaints about staff member H, they referred them back to staff member I. Staff member I told staff member A she would take care of it. Staff member A stated she trusted staff member I to deal with the issues. Staff member A stated she began to become concerned with staff member I's job performance when the complaints involving staff member H continued and other staff were refusing to work with staff member H. Staff member A stated she was not aware of the incidents of possible neglect with resident #1 and resident #4 until they were identified during the survey. Staff member A stated staff member H and staff member I were very close friends, and she (staff member A) believed nothing was ever done because of the friendship. Staff member A stated the incidents with the two residents should have been reported and investigated as possible neglect. When asked what, if anything, had been done regarding the complaints associated with staff member H, staff member A stated she decided it was best not to renew staff member H's contract. Staff member A stated staff member H had not worked since before Christmas. When asked if staff member I had kept any notes or records related to the incidents involving resident care, staff member A stated they were not able to find any helpful documentation after staff member I left the facility in late October of 2024. Review of the facility policy titled, Abuse prevention, investigation, and reporting of resident abuse, dated 2/7/23, showed, All allegations of resident abuse (neglect) will be investigated and reported to the proper authorities. The policy also showed, . All suspected incidents of abuse (and neglect) shall be reported . An incident report shall be forwarded to the Administrator . In any case in which the facility's administrator does not respond to reports from its employees of suspected abuse or neglect, those employees who have knowledge of possible abuse or neglect are required to report this information directly to DPHHS . Staff members H and I were no longer employed by the facility and were not available to interview.

Based on observation, interview, and record review, the facility failed to prevent the development and progression of a pressure wound, for 1 (#4) of 1 sampled resident with a Stage 3 sacral pressure wound. Findings include: During an observation and interview on 3/12/24 at 2:10 p.m., resident #4 was seated in a recliner in her room, leaning toward the left arm of the chair. A pressure relieving chair pad was observed on the chair. An air mattress was observed on resident #4's bed. Resident #4 stated she had a butt sore, which made it hard to sit up straight in the chair. Resident #4 stated, I got that new (air) mattress on the bed and this (pressure relieving chair pad) thing not too long ago, but I don't think they are helping much. Resident #4 stated, It's uncomfortable, how would you feel if you had a hole in your butt? During an interview on 3/13/24 at 9:35 a.m., staff member F stated resident #4's wound care had already been completed for the day and was completed by mid-morning, daily. Staff member F stated, I told them (nursing leadership) that she needed specialized wound management . It (resident #4's pressure wound) has gotten a lot worse. Review of resident #4's physician progress note, dated 12/13/23, showed, Patient reported soreness to the left buttock, starting to have an area of redness. Concern for start of pressure sore. Did talk to DON about condition. Discussed having her lay in lateral decubitus position, getting a new cushion for recliner. Monitor closely. Review of resident #4's EMR document, titled, Braden Scale for Predicting Pressure Sore Risk, showed, resident #4 was determined to be AT RISK for pressure wounds on Quarterly assessments, dated 9/9/23, 12/8/23, and 3/4/24. Review of resident #4's medical record, showed no documentation from 12/14/24 through 1/28/24 monitoring resident #4's area of redness on the left buttock, as identified in the 12/13/23 physician progress note. Review of resident #4's medical record, dated 1/29/24, showed a closed wound had developed on resident #4's sacrum. This was the same wound identified on the left buttock. Review of resident #4's medical record, showed no documentation of wound observations or dressing changes on 1/30/24, 1/31/24, 2/1/24, 2/2/24, and 2/3/24. Review of resident #4's medical record, dated 2/4/24, showed the sacral wound had opened. Review of resident #4's care plan first showed the presence of the pressure wound on 2/5/24, and showed, Keep a pressure reducing cushion in my recliner or wheelchair when I am sitting in them. Nurse will keep a dressing on to cover and protect my bottom, treat as ordered by doctor. Date Initiated: 02/05/2024. No pressure relieving devices were identified on the care plan prior to 2/5/24. Review of resident #4's physician progress note, written by staff member P, dated 2/8/24, showed, Pressure ulcer of sacral region, stage 2 ., and the following treatment order, ORDER FOR MEDIHONEY TO BE PLACED ON WOUND WITH EACH DRESSING CHANGE. [sic] Review of resident #4's physician progress note, written by staff member O, dated 2/9/24, showed, Pressure ulcer of sacral region, stage 3. Review of resident #4's nursing progress note, dated 2/17/24, showed the first application of Medihoney as ordered by staff member P on 2/8/24 which reflected a nine-day delay (2/8/24 through 2/17/24). Review of resident #4's physician progress note, dated 2/28/24, showed the following: - Slow healing, but concern for depth of pressure sore. No sign of infection. Continue with daily inspection and application of Medihoney. Review of resident #4's TAR for January 2024, February 2024, and March 2024 showed no sacral wound treatments listed until 3/6/24.

Based on observation, interview, and record review, the facility failed to have a proactive beneficial system in place for the prevention of falls for all residents, to include specifically those at heightened risk of falls, due to their past history of recurring falls, and: - failed to identify the direct root causes of falls for the implementation of individualized interventions; - failed to assess fall events and details comprehensively and ensure fall documentation was in place and consistent across disciplines; - failed to ensure staff had the necessary tools and knowledge to provide fall prevention interventions on an ongoing daily basis; - failed to ensure resident care plans were updated with interventions related to fall safety and address the resident's current medical, physical, or cognitive limitations, for 8 (#S 4, 6, 7, 8, 9, 17, 19, and 22) of 8 sampled residents. These falls included falls with major injury with fractures for 3 (#s 4, 7, and 22), and a hospitalization for 1 (#22) of 8 sampled residents, leading to the deterioration of the resident's condition, and the resident passed away within a month of the last fall with major injury. Findings include: IMMEDIATE JEOPARDY On 3/1/23 at 2:10 p.m., the facility's Director of Nursing and MDS Coordinator, in the absence of the facility administrator, was notified an Immediate Jeopardy existed in the area of 689 - Prevention of accidents and hazards. The Severity and Scope identified for the Immediate Jeopardy was identified to be at the level of a K, and upon removal of the immediacy, was lowered to an H. 1. Review of resident #22's Significant Change MDS, with an ARD of 5/7/22, showed under Section G, Functional Status, the resident was marked as, 0 = Independent - no staff help or oversight at any time for the following ADLs: - Bed mobility - Transfer - Walk in room - Walk in corridor - Dressing Resident #22 was marked as 1 = Supervision - oversight, encouragement, or cueing for the following eating, toilet use, and personal hygiene. Review of resident #22's diagnoses, from the 5/7/23 Significant Change MDS, included Dementia, a history of left hip fracture, and Glaucoma. Review of resident #22's Brief Interview for Mental Status exam, dated 5/7/22, showed she scored a 0, reflecting severe cognitive impairment. a. Review of resident #22's nursing progress notes, dated 6/21/22, showed: - An unwitnessed fall occurred outside of the dining room. - Resident #22 was observed by staff, 1/2 laying and 1/2 sitting on her left side about a foot away from dining room doorway. - Resident #22's walker was noted to be parked just inside the dining room door. It was concluded she was walking without it (the walker), again. - Resident #22 denied pain. Vital signs taken after the fall showed a blood pressure of 73/41 (low blood pressure). She was identified as, drowsy, but responds well to (the) penlight. Review of resident #22's hard copy paper care plan for falls, with a print date of 7/1/22, did not show fall prevention interventions related to her walking without a walker, vision impairments, or the potential impact these had on falls. An intervention related to resident #22's blood pressure showed: - Remind me when I am changing positions that I do so slowly so my blood pressure adjusts slowly with the change, and the intervention had not been revised since 3/18/19, and failed to address the resident's advancement in dementia, and if the intervention was evaluated as being successful, due to her severe cognitive deficit and recall ability. B. Review of resident #22's nursing progress notes, dated 7/25/22, showed: - An unwitnessed fall occurred when she was walking near her door without her walker. - Resident #22 was observed laying on the floor. - RN and OT assessed resident, .asking where it hurt, all resident said was 'owe, owe, owe.' When I touched her right hip she complained of an increase in pain. - Resident was sent to the hospital where a UTI and closed right femur fracture were diagnosed . After the fall on 7/25/22, and the subsequent hospital admission for the hip fracture, resident #22 was admitted back to the facility for comfort care and services. Review of resident #22's Significant Change MDS, with an ARD of 8/4/22, showed under Section G - Functional Status, the resident was marked as, 4 = Total Dependence - full staff performance every time during the entire 7-day look back period, for the following ADLs: - Bed mobility - Eating - Tilting - Personal hygiene Resident #22 was marked as 8 = for the ADL activity itself did not occur during entire period for the resident walking in the room and corridor. Review of the investigation file for resident #22's fall on 7/25/22, was requested during the entrance conference on 2/28/23. It was found no new interventions were added to her care plan related to the fall. During an interview on 3/1/23 at 2:17 p.m., staff member A and B stated resident #22 had been completely ambulatory before the fall, in which she sustained the fracture, on 7/25/22. Resident #22 passed away on 8/21/22. She had a change and decline in condition after her fall with significant injury, and passed away approximately one month after the fall. 2. Review of resident #7's nursing progress notes, dated 9/22/22 - 12/10/22, showed the resident had five falls, two with minor injury, and one fall with major injury. a. Review of resident #7's nursing progress notes, dated 9/2/22, showed: - Resident had an unwitnessed fall in the bathroom. - Staff was alerted to the resident by her roommate turning on the call light and yelling for help. - Resident #7 was found, . head between the toilet and the wall .laying face down more on the left shoulder .both legs were facing the doorway. - Resident #7 stated she had gotten herself out of bed, and used her walker to go to the bathroom, but slipped and fell . - Bruising was noted on the left side of the resident's head. Review of resident #7's fall care plan, printed on 2/28/23, showed [Resident #7] was reminded to call for help, for the 9/2/22 fall. The care plan failed to address ensuring the resident's call light was within reach, environmental factors were addressed, or that she was walking to the bathroom in the dark and if it was a concern or risk related to the fall. b. Review of resident #7's nursing progress notes, dated 10/30/22, showed, Resident has experienced moderate - severe confusion over past 48 hours. Visual hallucinations of seeing people and things that are not present. These hallucinations continued to be documented through review of the resident's electronic medical record. Review of resident #7's nursing progress notes, dated 10/30/22, showed: - Resident #7 had an unwitnessed fall in the doorway between her room and hallway. - She was found with her feet on the transitional strip on the floor, and her head facing her recliner. She hit her shoulder and elbow during the fall. - Resident #7 stated her walker had caught the transitional strip as she was turning around. - Resident #7 was diagnosed with a right shoulder fracture. Review of resident #7's fall care plan, printed on 2/28/23, showed the intervention for the fall on 10/30/22 included, Remind me to walk out so that I am clear from the doorway before turning around, and Ghost alarm . because of increased confusion and hallucinations. The care plan failed to address the residents ADLs or transfer status, maneuvering the walker safely, the contributing factor of catching on the transitional strip, or updated for increased risk of falling once her arm had been fractured and placed in a sling. c. Review of resident #7's nursing progress notes, dated 11/21/22, showed: - Resident #7 fell while walking out of the bathroom with a CNA. - The resident was lowered to the ground, by the CNA, with the gait belt. Review of resident #7's fall care plan, printed on 2/28/23, showed the intervention added after the 11/21/22 fall was, ONLY USE WHEELCHAIR TO TAKE [RESIDENT #7] TO TOILET FROM NOW ON. Review of resident #7's nursing progress notes, dated 12/4/22, showed: - Resident #7 fell while being assisted from the bathroom by a CNA. - The resident was lowered to the ground as she started to fall. - Resident #7 received a skin tear from the walker to her left forearm. Review of resident #7's care plan failed to show when the previous intervention of only taking the resident to the bathroom with a wheelchair had been discontinued, or if the facility modified the level of staff assistance needed for ADL care when using a walker and one arm in a sling. d. Review of resident #7's nursing progress notes, dated 12/10/22, showed: - Resident #7 fell in her room and was found sitting on the floor next to her bed. - Resident #7 stated she was moving from the recliner to her bed. As I started to sit on the edge of the bed I saw my sister on or near the other side of the bed. Review of resident #7's fall care plan, printed on 2/28/23, showed the intervention added after the 12/10/22 fall included, Reminded [Resident #7] she has to use call bell and have staff assist her to transfer. The care plan failed to address the effectiveness and whether reminding the resident would be beneficial since the resident had cognitive deficits and was hallucinating. 3. During an observation of resident #6's room, on 3/1/23 at 8:42 a.m., there was a large wardrobe next to the doorway entrance. The bottom drawers were at floor level, which would require someone to bend far over to reach and open the drawers. Resident #6 was sitting in his recliner, with a bedside table next to him, and his walker on the other side of the table. Review of resident #6's diagnoses, as of 3/1/23, showed: - Unspecified macular degeneration, - BPH, - Unspecified mononeuropathy or right and left lower limbs, - Muscle weakness, - Benign Paraxysmal Vertigo . Review of resident #6's Morse Fall Scale, dated 2/17/23, showed the resident, overestimates or forgets limits. Review of resident #6's fall worksheets, dated 9/19/22 - 1/6/23, showed the resident had ten falls in a four-month period. a. Review of resident #6's fall worksheet, dated 9/19/22, showed: - Resident #6 had an unwitnessed fall in his room during shift change. - He was found by the housekeeper, in a half-seated position, with his right knee bent under him. - The Resident stated he was getting clothes out of his closet, and tripped over the door stop, near the bathroom door. - His walker was noted to be beside his bed. - Eyesight and hearing were both marked as impaired for the resident. - Resident #6 experienced a sore right knee and pain during ambulation which required the temporary use of a wheelchair. Review of resident #6's care plan, initiated 9/5/18, showed the updated intervention after the fall was, [Resident #6] was reminded he needs to be using the walker everywhere in his room. The door stop was not addressed. b. Review of resident #6's fall worksheet, dated 9/30/22, showed: - Resident #6 had an unwitnessed fall in his room. - He was found sitting next to his closet with his back to the bathroom door. - The resident stated he was trying to pick up a hanger he had dropped on the floor. - His walker was noted to be under his TV, about 6ft away. - Resident #6 had a bruise to his left elbow. Review of resident #6's care plan, initiated 9/5/18, showed the updated intervention after the fall was, [Resident name] was reminded that he is supposed to call for staff to pick things up from the floor because he gets off balance. The facility did not identify the trend in falls occurring with resident #6 getting objects from his closet. c. Review of resident #6's fall worksheet, dated 10/23/22, showed: - Resident #6 had an unwitnessed fall in the dining room. - He stated he was holding onto the dining chair while moving his walker away. - Resident #6 had a skin tear to his right elbow from the fall. Review of resident #6's care plan, initiated 9/5/18, showed the updated intervention post fall: - [Resident #6] was educated that he should keep the walker next to the table but he refuses. d. Review of resident #6's fall worksheet, dated 10/31/22, showed: - Resident had an unwitnessed fall in his room. - He was found lying on the floor on his right side. - Resident #6 stated he was trying to go from the bathroom to his chair, and the walker got caught on the transitional strip on the floor. The incident report for resident #6 showed predisposing environmental factors marked as, none. There was a failure to identify this was the second fall in under two months the resident had tripped over environmental pieces in his room. e. Review of resident #6's fall worksheet, dated 11/6/22, showed resident #6 had a witnessed fall in the dining room, and he stated he was just walking and lost his balance, tipping over the walker as he fell . Review of resident #6's nursing progress notes, dated 11/8/22, showed the IDT had discussed a wheelchair, but decided against it as the resident, does not follow direction on safety and positioning. f. Review of resident #6's fall worksheet, dated 11/22/22, showed: - Resident #6 had an unwitnessed fall in his bathroom. - He stated he had been trying to pull up his clothes and lost his balance. - Eyesight and hearing were marked as impaired. - Resident #6 had a reddened area to the back of his head. Review of resident #6's care plan, initiated 9/5/18, showed the updated intervention post fall was: - Reminded him to call for help if dizzy. There was a failure to identify eyesight had been marked as impaired on multiple fall worksheets and the potential impact it was having on repeated falls, and the facility did not address the dressing or loss of balance. g. Review of resident #6's fall worksheet, dated 11/25/22, showed resident #6 had an unwitnessed fall in his room. He stated he, .was moving my pillows on my bed, and I was gonna lean back against my walker, but it's not that sturdy. He reported he fell and then, had to skootch on my butt to call light. The incident report for resident #6 showed predisposing factors of furniture, crowding, and improper footwear. Review of resident #6's care plan, initiated date 9/5/18, showed the updated intervention post fall: - Reminded not to sit on his walker. The facility did not address the safety with the walker, crowding in the room, improper footwear, or furniture, but instead provided another reminder for the resident who who had cognitive deficits, and the care plan interventions did not address or identify the residents positioning when on the bed or pillow placement for future prevention. h. Review of resident #6's fall worksheet, dated 12/6/22, showed: - Resident #6 had an unwitnessed fall in his room. - He was found with his back against the bathroom wall, his right leg bent at the knee. - Resident #6 stated he was going back to his recliner and his foot slipped. - Resident #6 had a second fall 90 minutes later and stated his knee gave out. Review of resident #6's care plan, initiated date 9/5/18, showed the updated intervention post fall: - Reminded him that he needs to stay closer to the walker. The care plan was not updated to address the knee giving out, safety when using the bathroom, or increased monitoring or observations, but again the facility directed staff to remind him to stay closer to the walker when it was shown he did not have the ability to recall all staff directions or recommendations for safety. i. Review of resident #6's fall worksheet, dated 1/2/23, showed: - Resident had an unwitnessed fall in his room. - He stated he was getting socks out of his drawer and lost his balance. - Resident #6 had a contusion to his left forehead and skin tear to his right forearm. He also complained of right hip soreness. Review of resident #6's care plan, initiated date 9/5/18, showed the updated intervention post fall: - Reminded him that he can call for staff to get anything for him that he has to bend down for. The care plan interventions or modifications after this fall did not address the loss of balance, retrieving items from the drawer, or staff assisting with dressing for fall safety and prevention. j. Review of resident #6's fall worksheet, dated 1/6/23, showed: - Resident had an unwitnessed fall in his room. - Resident #6 stated he was sitting on a stool and trying to look in his drawers to find his checkbook when the stool tipped over. - Injuries included a skin tear to his right wrist described as, skin torn completely off. Review of resident #6's care plan, initiated date 9/5/18, showed the updated intervention post fall: - [Resident #6] was told not to be reaching down for things if sits on the stool. The plan did not address the resident's loss of balance off the stool, the use of the stool in general, or items being kept in areas where the resident would have to bend over in some capacity, which increased the risk of the resident falling. Review of resident #6's nursing progress note, dated 1/12/23, showed, [Resident #6's daughter] mentioned possibly having clothes left out for him, as that seems to be when he is at higher risk for falls. There is also mention of him limiting his fluids to avoid incontinence and this possibly contributing to dehydration (and dizziness). None of these identified concerns voiced by the the family member's comments were identified by IDT as fall risks. Over the course of these ten falls, resident #6 sustained five injuries to the right side of his body including: skin tears, bruises, knee, and hip pain. He had two falls with head injury. There was a failure to identify the trend in the resident's right sided injuries, or the resident being found on his right side, as reoccurring. All the interventions, identified by the IDT, were reminders. No new interventions were initiated based on the resident's predisposing factors, the environment, the resident's cognition or physical disabilities or limitations, or his medical status. There was not root cause analysis of the actual fall details for any of the falls, or a means to prevent future falls from occurring using a proactive approach. The facility did not increase monitoring or observations of the resident, have the staff increase ADL assistance, or consider optional placement of furniture or belongings. During an interview on 3/1/23 at 10:32 a.m., staff members A and B stated reminding residents to call for help had become a go to intervention. They stated they were at a loss for interventions with the non - complaint residents (specifically resident #6). During an interview on 3/1/23 at 1:00 p.m., staff member C stated there was a report sheet with important information about each resident for staff who were new. Review of this sheet did not list any interventions for fall prevention for resident #6. 4. During an observation on 2/28/23 at 8:01 a.m., resident #19 was asleep in her room. A tabs alarm was noted in her wheelchair nearby, and a motion alarm (ghost alarm) was on the floor next to her bed. Review of resident #19's Annual MDS, with an ARD of 9/6/22, showed the resident scored a four on the BIMS; reflecting severe cognitive impairment. a. Review of resident #19's nursing progress notes, dated 4/25/22, showed: - Resident #19 had an unwitnessed fall in her room. Her alarm sounded. - She was found on her left side with her wheelchair to the right and walker between her wheelchair and her bed. - Resident #19 stated she was trying to get up but didn't know where she was going. b. Review of resident #19's nursing progress notes, dated 9/15/22, showed: - Resident had an unwitnessed fall in her room. Her alarm sounded. - She was found laying on her left side behind her wheelchair in the bathroom doorway. - Resident #19 had bruising on her right cheek, a laceration under her right chin, skin tear to her right hand with bruising. c. Review of resident #19's nursing progress notes, dated 11/6/22, showed: - Resident #19 had an unwitnessed fall in her room. - She was found seated on the floor with her walker out of reach. Resident #19's fall worksheet showed poor lighting as a predisposing factor. Review of resident #19's fall care plan, printed on 2/28/23, the following interventions: - 4/25/22: Resident brought to common area for observations, alarms re-attached and on. - 9/15/22: Was reminded she needs to call for help .continue with the ghost alarm. - 11/6/22: Staff will check alarm after family leaves. No new interventions were initiated for #19's falls, based on predisposing factors, the environment, medical equipment, resident's health status or physical limitations, and a root cause analysis of the actual fall to identify direct root causes, was not completed for future fall prevention. Reminders were given to the resident who had cognitive deficits, and alarms continued to be used, which were a reactive alert for staff, rather than a proactive approach of anticipating the resident's needs to prevent a fall before it occurred. 32997 5. During an observation on 3/1/23 at 3:23 p.m. resident #4 wheeled herself into the dining room. No staff were in the dining room at that time. Resident #4 had a coffee cup in her hand and a string clipped to the back of her shirt. She wheeled herself over the the sink, stood up from her wheel chair, the string was attached to a chair alarm, and the string was pulled tight, but did not come loose from the alarm. The alarm did not sound. Resident #4 dumped her cup in the sink, rinsed the cup out, and sat back down in her wheel chair. The chair alarm sounded. Resident #4 reached around behind her, grabbed the alarm while saying she hated it. Resident #4 then pulled the alarm around to in front of her, shut the alarm off, and then tossed it back over her left shoulder. Resident #4 said how annoying the alarm was. No staff members came to check on resident #4 while her alarm was sounding off. The alarm was active for about 20 seconds. Review of resident #4's electronic medical record showed diagnoses including: - pathological fracture of the left femur, - displaced intertrochanteric fracture of the right femur, - right humerus fracture, - fractures of the right pubis, - impaired mobility, - chronic pain, and - arthritis. Review of resident #4's Annual MDS, with an ARD of 12/16/22, showed: - Resident #4 was moderately cognitively impaired. - Resident #4 needed the assistance of one staff member for transfers, walking in her room, walking in the hallway, with getting dressed, using the toilet, her personal hygiene, and her bathing. - Resident #4 had a range of motion impairment to the upper and lower sections of both sides of her body. - Resident #4 was not steady when moving from a seated to standing position, when walking, and when moving on and off the toilet. She was only able to stabilize herself with human assistance. - Resident #4 used a walker and or a wheelchair for mobility. - Resident #4 had a fall with a major injury. a. Review of resident #4's fall worksheet, dated 10/2/22 at 10:30 a.m., showed: - An unwitnessed fall occurred in the resident's room. - Resident #4 was found on the floor, on her left side. - Resident #4 said she was trying to get something out of her closet, saying she just fell . - No injuries or complaints of pain were documented on the fall worksheet. The fall worksheet showed the staff member completing it did not identify predisposing environmental or physiological factors. No interventions were put into place to prevent further falls, and a root cause analysis was not completed for the identification of the direct cause of the fall, and the facility did not address concerns related to the resident's dressing abilities, obtaining clothing from closet safely, or the current level of ADL assistance and if the resident needed more help. Review of resident #4's nursing progress note, dated 10/2/22, showed: 10/2/22: The resident had an unwitnessed fall in the doorway of her room. The resident had complaints of increasing pain to her arm and shoulder area. An assessment of resident #4's right shoulder showed edema, and the head of the humerus was outside of normal placement. The resident was sent to the clinic. After examination at the clinic it was identified the resident also had a fracture of the right humerus. The right shoulder displacement was adjusted, and the resident was placed in a right arm sling. No further treatment was identified. b. A fall worksheet for resident #4 was requested on 2/28/23 for a fall the resident had on 10/2/23. Staff member A said a fall worksheet had not been completed for that fall. Staff member A did provide some documentation in place of the fall worksheet. Review of resident #4's unidentified document, dated 2/10/23 at 5:35 p.m., showed: - Resident #4 was assisted to stand up, assisted to her recliner, and was given Tylenol at 6:00 p.m. - An injury was observed to the front of resident #4's left shoulder to include swelling and bruising, and the resident had complaints of pain at a level 10. - The resident was ambulating without assistance, at the time of the fall. The unidentified document failed to show interventions put into place to prevent further falls, and a root cause analysis was not completed for this fall to identify the direct room cause(s). Review of resident #4's nursing progress note, dated 2/10/23, showed: - 2/10/23: Resident #4 had an unwitnessed fall in her bathroom. Approximately 45 minutes after the fall, a lump appeared on resident #4's left collar bone, and the resident had increased complaints of pain. The resident's pain was treated with as needed Tylenol, as ordered by the physician. The family did not wish to send the resident to the ER. The resident was sent to the clinic on 2/13/23, and an X-ray was taken. No acute fractures were identified. Review of resident #4's care plan, with a print date of 2/28/23, showed the resident's care plan focus included a history of falls at home with bilateral hip fractures, and falls at the facility with arm and pelvis fractures. The resident's goals included she would have no further injuries from falls through the next review date. This goal was initiated on 12/24/18, and last revised on 3/4/19. The resident's interventions included: when toileting she is to have someone with her because she is not steady, she is to have a stand-by assist with a gait belt and walker because she is unsteady at times, chair alarm, and motion sensor alarm. 6. During an observation on 2/28/23 at 10:32 a.m., resident #17 was in bed sleeping. Resident #17's room was located at the end of the hallway, furthest from the nursing station. During an observation on 3/1/23 at 3:52 p.m., resident #17 was seated at the nursing station. The resident was not interviewable. A wheeled, non-locking, bedside table had been placed in front of him. Some (toy) tractors, and a drink cup, were on the table. Resident #17 was watching television. Review of resident #17's electronic medical record showed diagnoses including: - epileptic disorder, - generalized idiopathic epilepsy and epileptic syndromes, - pathological fracture of the left femur, and - fracture of the neck of the left femur. Review of resident #17's Quarterly MDS, with an ARD of 1/13/23, showed: - Resident #17 was not able complete the cognitive status assessment. - Resident #17 needed the assistance of two staff member for transfers. - Resident #17 needed extensive assistance of two staff for dressing. - Resident #17 needed extensive assistance assistance of one staff for toileting and personal hygiene. - Resident #17 was totally dependent on one staff for bathing. - Resident #17 was not steady when moving from a seated to standing position. - Resident #17 used a walker for mobility. a. A fall worksheet for resident #17 was requested on 2/28/23 for a fall the resident had on 11/6/22. Staff member A said a fall worksheet had not been completed for that fall. No other information was provided by the facility for this fall. Review of a nursing progress note, dated 11/6/22, showed resident #17 had a witnessed fall. The resident was getting undressed and ready for bed with the assistance of a staff member. Resident #17 was taking off a sock and attempting to place it on his walker. The resident lost his balance and fell to the floor. The resident hit his head on the floor sustaining a bruise to his left temporal region. Nursing staff did initiate neuro checks, and they were within normal limits. The document failed to show interventions were put into place to prevent further falls, or if the resident needed more hands on assistance from staff, what caused the resident to be unbalanced, or if he received the level of help identified necessary at the time from the staff member present at the time of the fall. A root cause analysis was not completed for the fall. b. Review of resident #17's fall worksheet, dated 11/24/22 at 1:15 p.m., showed: - An unwitnessed fall occurred in the hallway. - Resident #17 was found on his bottom and leaning against the wall. - Resident #17 showed he as trying to walk, leaned against the wall and slid down to a seated position. - Resident #17's walker was in front of him. - Resident #17 had no documented injuries. The fall worksheet failed to show predisposing environmental or physiological factors. No interventions were put into place to prevent further falls, and a root cause analysis was not completed for this fall. Review of resident #17's nursing progress notes, dated 11/24/22, showed resident #17 had an unwitnessed fall. The resident was able to show a staff member he had leaned against the wall and slid down it. The facility failed to identify this as a fall concern. No injuries were noted. c. A fall worksheet for resident #17 was requested on 2/28/23 for a fall the resident had on 2/11/23. Staff member A said a fall worksheet had not been completed for that fall. Staff member A did provide a document, not titled, which showed the following information: - Nursing description, dated 2/11/23, At 1003 [Resident name] fell at the nurses station. He was standing with his walker facing the nurses' counter with one hand of the walker and the other holding his juice cup and other papers. I was at the med room door and the activity assistant was handing me the box for eye drops. We both heard a thud, turned and saw [Resident name] on the floor facing away from the counter with part of the walker above his head. His glasses were ajar. He did not hit his head on the floor or counter. Somehow he held it up. - Immediate action taken: . took his vitals. The assistant and I sat him in his chair. and, - Predisposing physiological factors: gait imbalance. The facility failed to use a root cause analysis process for determining the direct cause of the fall, and did not address his actions of trying to hold many things in one hand and holding to the walker with the other, or if staff could have prevented the fall by verbally instructing the resident at the time to perhaps put the items down or place both hands on the walker. Review of resident #17's care plan, with a print date of 2/28/23, showed the resident's focus as being unsteady and had a history of falls. Resident #17's goal was to have no new [TRUNCATED]

Based on observation, interview, and record review, the facility failed to revise interventions on the resident's plan of care after multiple falls for 8 (#s 4, 6, 7, 8, 9, 17, 19, and 22) of 8 sampled residents. This deficient practice affected half of the facility resident population, and had the potential to further increase the risk of falls, with or without injury, for the vulnerable or non vulnerable residents, and act proactively for preventing the falls vs being reactive and responding to the falls. Findings include: Refer to F689 - Free of Accident Hazards/supervision/devices for detailed fall information. 1. Review of resident #22's Brief Interview for Mental Status exam, dated 5/7/22, showed she scored a 0, for severe cognitive impairment. Review of resident #22's diagnoses, from the 5/7/22 Significant Change MDS, showed: - Dementia - History of left hip fracture - Glaucoma a. Review of resident #22's nursing progress notes, dated 6/21/22, showed: - An unwitnessed fall occurred (for #22) outside of the dining room. - Resident #22 was observed by staff, 1/2 laying and 1/2 sitting on her left side about a foot away from dining room doorway. - Resident #22's walker was noted to be parked just inside the dining room door. It was concluded she was walking without it, again. - Resident #22 denied pain. Vital signs taken after the fall and showed a blood pressure of 73/41 (low blood pressure). The nurse documented the resident was, drowsy, but responds well to penlight. Review of resident #22's hard copy fall care plan, printed on 7/1/22, did not show any fall prevention interventions related to her walking without a walker, vision impairments, or the potential impact on falls these had. A care plan intervention related to #22's blood pressure showed: - Remind me when I am changing positions that I do so slowly so my blood pressure adjusts slowly with the change, The intervention had not been revised since 3/18/19. The facility had not updated the plan to address the resident's advancement in dementia, and how the intervention may no longer be beneficial or affective due to her deteriorating cognition. b. Review of resident #22's nursing progress notes, dated 7/25/22, showed: - An unwitnessed fall occurred when she was walking near her door without her walker. - RN and OT assessed resident, and the nurse documented, .asking where it hurt, all resident said was 'owe, owe, owe.' When I touched her right hip she complained of an increase in pain. - Resident #22 was sent to the hospital where a urinary tract infection, and a closed right femur fracture were diagnosed . Review of the investigation file for resident #22's fall on 7/25/22, which was requested during the survey entrance conference on 2/28/23, showed no new interventions were added to her care plan after the fall with the significant fracture injury. During an interview on 3/1/23 at 2:17 p.m., staff members A and B stated resident #22 had been independently ambulatory, before the fall when she sustained the fracture, on 7/25/22. Resident #22 passed away on 8/21/22, which was approximately one month after the fall with the fracture. The resident had experienced a decline in health condition, leading to her death, after the fall with the fracture. 2. Review of resident #7's nursing progress notes, dated 10/30/22, showed, Resident has experienced moderate-severe confusion over past 48 hours. Visual hallucinations of seeing people and things that are not present. These hallucinations continued to be documented by the staff, per the review of the resident's electronic medical record. a. Review of resident #7's nursing progress notes, dated 10/30/22, showed: - Resident #7 had an unwitnessed fall in the doorway between her room and hallway. - She was found with her feet on the transitional strip (on floor), and her head was facing her recliner. Her right shoulder and elbow had hit the floor during the fall. - Resident #7 stated her walker had caught on the transitional strip as she was turning around. - Resident #7 was diagnosed with a right shoulder fracture, and the injury occurred during the fall. Review of resident #7's fall care plan, print date 2/28/23, showed the following intervention was added after resident #7's 10/30/22 fall: - 10/30/22: Remind me to walk out so that I am clear from the doorway before turning around, and Ghost alarm . because of increased confusion and hallucinations. The care plan failed to address the environmental contributing factors for the fall, or the resident's updated ADL and transfer status, once the resident's arm had been fractured and placed in a sling. b. Review of resident #7's nursing progress notes, dated 11/21/22 and 12/4/22, showed the resident had two falls while being assisted by the CNA, back from the bathroom. These included: - 11/21/22 the resident was lowered to the ground by the CNA with the gait belt. After this fall the intervention, ONLY USE WHEELCHAIR TO TAKE [RESIDENT #7] TO TOILET FROM NOW ON, was added to the care plan. - 12/4/22 the resident fell while being assisted from the bathroom by a CNA. The resident was lowered to the ground as she started to fall, receiving a skin tear from the walker, to her left forearm. Review of resident #7's care plan failed to show the previous intervention of bringing the resident to the bathroom with a wheelchair was discontinued. The care plan failed to show how many staff should be assisting the resident with ambulation when she had an arm in a sling, when going to the bathroom or using her walker. c. Review of resident #7's nursing progress notes, dated 12/10/22, showed: - Resident #7 fell in her room and was found, sitting on the floor, next to her bed. She stated she was moving from the recliner to her bed, and As I started to sit on the edge of the bed, I saw my sister on or near the other side of the bed. Review of resident #7's fall care plan, with a print date of 2/28/23, showed the following intervention was added after the 12/10/22 fall: - 12/10/22: Reminded [resident #7] she has to use call bell and have staff assist her to transfer. The IDT, or staff member adding interventions, failed to address how an intervention that reminded the resident may not be beneficial due to the resident's cognitive status or hallucinations. 3. During an observation of resident #6's room, on 3/1/23 at 8:42 a.m., there was a large wardrobe by the doorway entrance. The bottom drawers were at floor level and would require someone to bend far forward to open the drawers. Review of resident #6's fall worksheets, dated 9/19/22 - 1/6/23, showed the resident had ten (10) falls in a four-month period. Four of the falls occurred while the resident was getting objects out of his closet and bottom dresser drawers. The worksheets showed: - 9/19/22, resident stated at time of fall he was, Getting clothes out of closet to go take a bath. - 9/30/22, resident was found sitting next to his closet. He stated he was trying to pick up a hanger he had dropped. - 1/2/23, resident had a fall near his closet, resulting in a contusion, to his left forehead. He stated he was getting socks out of his drawer and lost his balance. - 1/6/23, resident fell in his room, after tipping over on a stool, near his closet. He stated, I was sitting on that stool and trying to look in my drawers to find my checkbook. Review of resident #6's care plan, with an initiation date 1/2/23, showed a lack of interventions related to the trending of the resident's falls, such as the specific activity the resident was engaging in at the time (dressing/bending over/reaching), limitations the resident had and if they contributed to the falls, or the specific locations the falls occurred in the room, such as by or at the closet, showing the facility was proactive in preventing the falls vs being reactive and responding to the falls. Review of resident #6's fall worksheet, dated 11/25/22, showed: - Resident #6 had an unwitnessed fall in his room. He was moving pillows around, sat back on his walker, this caused the walker to tip, and the resident fell . The incident report for resident #6 showed the predisposing factors of furniture, crowding, and improper footwear. Review of resident #6's care plan, with the initiation date of 9/5/18, showed the updated intervention post fall: - Reminded not to sit on his walker. The facility failed to address the identified crowding in the resident's room, or the improper footwear, on the resident's care plan. During an interview on 3/1/23 at 10:32 a.m., staff member A and B stated reminding residents to call for help had become a go to intervention. They stated they were at a loss for interventions with the non-complaint resident (resident #6). Review of resident #6's care plan, with an initiation date of 1/2/23, showed all the interventions listed after a fall were ones in which the staff were to remind the resident of something. No new interventions were initiated based on the fall predisposing factors, a root cause analysis of the actual fall and details of the fall, or a means to prevent future falls from occurring related to the root causes and predisposing factors. 4. During an observation on 2/28/23 at 8:01 a.m., resident #19 was asleep in her room. A tab alarm was observed in her wheelchair nearby, and a motion alarm (ghost alarm) was on the floor, next to her bed. Review of resident #19's care plan, with an initiation date of 10/5/21, showed the resident had three falls occurring from April of 2022 - November of 2022. Staff were alerted to two of the three falls by the sound of the resident's chair or motion alarm going off. Review of resident #19's care plan, initiated 10/5/21, showed, I have motion sensor alarm to be put beside my bed when I am in it to alert staff when I try to get myself up. I also have a tabs alarm on my wheelchair. After each of resident #19's falls, her care plan interventions of, Continue with using tabs alarm and Continue with the ghost alarm, were the only new interventions. These interventions were reactive vs proactive to prevent future falls and were not based on predisposing factors, a root cause analysis of the actual fall or details of it, or a means to prevent future falls from occurring. 32997 5. During an observation on 3/1/23 at 3:23 p.m., resident #4 wheeled herself into the dining room. No other residents or staff were in the dining room at the time. Resident #4 had a coffee cup in her hand. She wheeled herself to the sink on the wall by the entrance to the kitchen. The resident stood up from her wheelchair. When she stood it was observed a fall alarm was attached to her wheelchair and to the back of her shirt. The alarm did not sound when the resident stood up. Resident #4 dumped the contents of her cup into the sink, rinsed it out, and sat back down in her wheelchair. When the resident sat down the alarm sounded. Resident #4 reached over her left shoulder and grabbed the alarm box. She pulled the box around in front of her, she shut the alarm off, and then tossed it back over her left shoulder. Resident #4 stated, I hate that thing! It's so noisy. Resident #4 refilled her coffee cup and left the dining room. Her alarm had sounded for about 20 seconds. No staff came to check on resident #4. Review of resident #4's electronic medical record showed the diagnoses including: - pathological fracture of the left femur, - displaced intertrochanteric fracture of the right femur, - right humerus fracture, - fractures of the right pubis, - impaired mobility, - chronic pain, and - arthritis. Review of resident #4's Annual MDS, with an ARD of 12/16/22, showed: - Resident #4 was moderately cognitively impaired. - Resident #4 needed the assistance of one staff member for transfers, walking in her room, walking in the hallway, getting dressed, using the toilet, for her personal hygiene, and her bathing. - Resident #4 had a ROM (range of motion) impairment to the upper and lower sections of both sides of her body. - Resident #4 was not steady when moving from a seated to standing position, when walking, and when moving on and off the toilet. She was only able to stabilize herself with human assistance. - Resident #4 used a walker and or a wheelchair for mobility. - Resident #4 had a fall with a major injury. Review of resident #4's fall care plan, printed on 2/28/23, showed: - Focus: I am unable to safely take care of myself because of history of falls at home that left me with broken hips that were repaired and falls here that resulted in fractured arm and pelvis but I often still having pain in my right hip and leg and may sit for prolonged periods of time. Revised on 8/29/2020 [sic], - Goal: I will my needs met through the next review date. I will have no injuries from falls through next review date. I will have pain less than daily by next review date . [sic] - Interventions for resident #4's two fall's, which occurred on 10/2/22 and 2/10/23, showed each fall date and time, and the facility listed details of the fall directly from the nursing progress notes, and the subsequent nursing assessment. The following were listed after the details of the fall: - 10/2/22: Encourage her to rest right arm and wear sling and remind to always call for help. Continue with alarms. - 2/10/23: Alarm use will continue and ghost alarm will be placed in areas not as easy for her to reach. She was reminded repeatedly that she has to call for staff to assist her with transfers and toileting. All the interventions listed after a falls were reminders for the resident. No new interventions were initiated based on predisposing factors, a root cause analysis of the actual fall details or contributing factors, or a means to prevent future falls from occurring for a practice approach for prevention. The facility had not addressed the resident's actions of removing or shutting off the alarms sufficiently, and making the determination if they were/were not beneficial for fall safety. During an interview on 3/2/23 at 1:26 p.m., staff member A said resident #4 shuts off her chair alarm. Staff member A said prior to resident #4's fall on 2/10/23, a ghost alarm had been placed on a shelf in her bathroom. On 2/10/23 when the resident fell in her bathroom, staff found the ghost alarm underneath the bathroom sink, and it had been turned off. Review of Resident #4's nursing note, dated 2/10/23, showed the resident told staff she was in the bathroom, the alarm was going off, she reached up and took it off the shelf, and when she was trying to turn the alarm off, she fell . 6. During an observation on 3/1/23 at 3:52 p.m., resident #17 was seated in a chair at the nursing station. A bedside table, on wheels, was placed in front of the resident. Several toys and pieces of paper were on the bedside table. Review of resident #17's electronic medical record showed diagnoses of an epileptic syndrome, a pathological fracture of the left femur, and fracture of the neck of the left femur. Review of resident #17's Quarterly MDS, with an ARD of 1/13/23, showed: - Resident #17 was not able to complete the cognitive status assessment. - Resident #17 needed the assistance of two staff for transfers. - Resident #17 needed extensive assistance of two staff for dressing - Resident #17 needed extensive assistance assistance of one staff for toileting and personal hygiene. - Resident #17 was totally dependent on one staff member for bathing. - Resident #17 was not steady when moving from a seated to standing position. - Resident #17 used a walker for mobility. Review of resident #17's fall care plan, printed on 2/28/23, showed: - Focus: I am unsteady and have a history of falls. Date initiated: 5/20/21 - Goal: I will have no new injuries from falls through next review date. - For the interventions, the three falls which occurred on 11/6/22, 11/24/22, and 2/11/23, showed after each the facility documented the date and time, the details of the fall, directly from the nurses progress notes, and the subsequent nursing assessment. The following were listed after the details of the fall: - 11/6/22: Aides will continue to stand close by and assist him as he will allow. - 11/24/22: No new interventions were identified for this fall. - 2/11/23: No new interventions were identified for this fall. No new interventions were initiated based on the resident's individual predisposing factors, a root cause analysis of the actual fall or environmental factors, or a means to prevent future falls from occurring in an attempt to be proactive vs reactive to the falls once they occurred. Resident #17's falls care plan, with a print date of 2/28/23, also showed: - Resident #17 had at least eleven falls, with injuries, due to seizures. - The fall care plan failed to show evidence the facility initiated any interventions after any of these eleven falls. - Resident #17 had a fall related to his use of a wheeled bedside table when sitting at the nurse's station. The table moved when the resident pushed a toy tractor across the top of it, causing resident #17 to fall. The falls care plan failed to show evidence the facility initiated any interventions after this fall related to his safety with the use of the table. - There were documented notes in resident #17's fall care plan related to concerns of the resident standing and placing his weight on the wheeled bedside table. The care plan failed to show evidence of how the facility addressed this safety concern. During an interview on 3/2/23 at 1:26 p.m., staff member A said resident #17 was very child-like and would throw tantrums when he did not want to do something. Staff member A said resident #17 had previously thrown himself on the floor when he did not want to do something. 7. During an observation on 2/28/23 at 11:20 a.m., resident #9 was sitting on the edge of his bed. A bedside table was pulled up in front of him. The left side of resident #9's bed was placed up against a wall. The bed placement would require the resident or staff to use the resident's right side of this body when getting up, out of, or off the bed. Review of resident #9 diagnoses included a Cerebral infarction, Hemiplegia, and hemiplegia following cerebral infarction affecting the right dominant side. Review of resident #9's Quarterly MDS, with an ARD of 2/4/23, showed: - Resident #9 was moderately cognitively impaired. - Resident #9 had a range of motion impairment to the upper and lower side of his body. - Resident #9 was not steady when moving from a seated to standing position. - Resident #9 used a walker. Review of resident #9's fall care plan, printed on 2/28/23, showed: - Focus: I am at risk for falls because the stroke left me unsteady with right sided weakness. Revised on 6/26/19 - Goal: I will have no major injuries from falls through next review date. - Interventions for the three falls occurring on 11/6/22, 1/13/23, and 1/20/23, showed after the fall the facility staff documented the date and time the fall occurred, listed details of the fall, taken directly from the nursing progress notes, and the subsequent nursing assessment. The following were listed after the details of the fall: - 11/6/22: No new interventions were identified for this fall. - 1/13/23: Reminded him (resident #9) to always wear slippers when up walking or wear non slip socks, although the resident was cognitively impaired. - 1/20/23: No new interventions were identified for this fall. - Interventions listed after these falls were either a reminder or new interventions were not initiated based on predisposing factors, a root cause analysis of the actual fall details or environmental factors, or proactive measures taken to prevent future falls. During an interview on 3/2/23 at 1:26 p.m., staff member A said resident #9 was very independent with his activities of daily living, and he did not want assistance from staff. During an interview on 3/1/23 at 10:13 a.m., staff member F said a verbal report was given before the start of every shift on which residents had fallen, and any new interventions that were put into place. Staff member F said there were pocket care plans (abbreviated version) back there somewhere (motioning to the nursing station), and they were used by travel staff. Staff member F said the direct care staff knew all the residents, what interventions to use, and did not need pocket care plans. Staff member F said it would be nice to have some type of communication book so when he came back from days off he would know what had happened. 41951 8. During an observation and interview on 3/1/23 at 8:39 a.m., resident #8 was lying in her recliner, and a front wheel walker was placed to the right of her chair. She stated when she had the multiple falls last year (2022), they just happened. Resident #8 stated they (staff) tried to remind her each time she fell , of ways to prevent falling again, but she lost balance easily and continued to fall. She stated each time she fell there was not a specific reason for falling, it would just happen. Resident #8 stated she had multiple falls at home before coming to the facility. Resident #8 stated she had neuropathy and at times did not feel her feet when she was walking. Review of resident #8's care plan, printed on 2/28/23, showed an admitted [DATE]. The care plan also showed the following information related to falls: - Focus: I [resident] have history of falls and have weakness and balance problems. - Goal: I [resident] will have no injuries from falls through next review date. Review of resident #8's care plan, printed on 2/28/23, showed under Interventions, the four falls which occurred on 9/27/22, 10/3/22, 10/11/22, and 10/31/22. After each fall date and time, the facility listed details of the fall, directly from the nurses progress notes, and the subsequent nursing assessment. The following interventions were listed after the details of the falls: - 9/27/22 - Staff asked resident to please allow staff to take care of spouse and to stay in bed unless she needed to go to the bathroom. - 10/3/22 - Resident reminded to make sure she is fully in front of chair and backed up before sitting. - 10/11/22 - Resident reminded to watch for anything in pathway of walker. - 10/31/22 - Reminded [resident #8's name] to be slow if walking backwards. All the interventions listed after a fall were reminders for the resident. No new interventions were initiated based on predisposing factors and anticipating the resident's needs, a root cause analysis of the actual fall or environment, or a means to prevent future falls from occurring. Review of resident #8's Annual MDS, with an ARD of 12/23/22, showed under Section C, a BIMS score of 10, moderately impaired cognition. Review of resident #8's diagnoses, as of 3/1/23, showed: - Pneumonia, unspecified organism, - Bilateral Primary Osteoarthritis of knee, - Repeated Falls, - Other Cerebral Infarction due to occlusion or stenosis of small artery, and - Polyneuropathy. - The diagnosis of Pneumonia was the only contributing factor identified in any of the four falls resident #8 sustained. During an observation on 3/2/23 at 9:58 a.m., resident #8 was lying on her bed. Resident #8's walker was positioned next to her recliner, approximately three feet away from her bed. No interventions were listed in resident #8's individualized care plan which showed to observe the placement of her walker for easy access to prevent falls. The walker availability, which was needed by the resident for safe ambulation, was never identified as an intervention which could prevent future falls. During an interview on 3/1/23 at 8:46 a.m., staff member D stated she occasionally worked on the unit as a CNA. Staff member D stated she was involved in the resident's care plan meetings, so she was aware of changes to their plan. She stated the CNAs received new resident information or updates during a shift change report. Staff member D stated the CNAs knew how to care for the residents by relying on a verbal report, not a written plan of care. During an interview on 3/1/23 at 8:52 a.m., staff member E stated she was at the facility all the time and knew when changes in care for the residents occurred. She stated she used a pocket care plan for reference but was unable to show the State Survey Agency she had the information on her person. Staff member E stated the pocket care plan was updated weekly. She stated verbal communication from the previous shift was used most frequently, not written information. Staff member E stated she had reported to work at 8:00 a.m. this morning (3/1/23). Staff member E would not have been involved in a shift report communication due to her arrival after shift change, which happened at 6:00 a.m. Staff member E did not specify if 8:00 a.m. was her typical starting time for a shift. During an interview on 3/1/23 at 10:39 a.m., staff member A stated nurses did not update a resident's care plan after a fall with new interventions. Staff member A stated her process for adding to the care plan after a fall was to copy and paste the nurses progress notes into the care plan, and then add the intervention after the note. Staff member A stated CNAs did not have access to the full care plan on their computer access. She stated she usually had a printed copy available for them, but they had not had access to them for a while, due to recent updates. During an interview on 3/1/23 at 10:43 a.m., staff member A stated new resident fall interventions were determined by looking to see if the falls continued and if the interventions had been effective. Staff member A stated it could be difficult to make the interventions measurable to see if they were effective, especially when the residents did not do the interventions. Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, last revised March 2022, showed: - Policy Statement - A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. - 9. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. - 10. When possible, interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers. - 12. The interdisciplinary team reviews and updates the care plan: - a. when there has been a significant change in the resident's condition; - b. when the desired outcome is not met.

Based on record review and staff interview, the facility failed to ensure orientation of staff to the transfer needs of residents which resulted in the improper transfer of a resident and the resident fracturing both femurs (legs) for 1 (#10) of 10 sampled residents. Findings include: Resident #1 was originally admitted to the facility on [DATE] and then readmitted on [DATE]. The resident's [DIAGNOSES REDACTED]. Review of the Care Plan with the origin date of 5/3/11 indicated "she is lifted by hoyer only. She is unable to wheel/scoot self. CNA staff will assist (resident #1) with shower or tub bath; (resident #1) requires assist with bed mobility & transfers." During a review of incidents and events reported to the State Agency from 8/7/12 through 10/23/12, on 6/13/13 at 5 p.m., the surveyor identified an event that was reported to the State Agency on 10/23/12. The report indicated the date of the event was 9/20/12, a 33 day period which exceeded the 24 hour time frame of reporting. Review of the "Intake Information" indicated the name of the resident was (resident #1) with the injury being bilateral fracture femur. The 5 day investigation results report was sent to the State Agency on 10/23/12. Review of the "Intake Information" included the "Outcome of your investigation: 9/20/12 approximately 5 pm, resident was lowered to knees in bath area during transfer with 2 CNA's (sic) and walker when legs gave out from resident. Resident assessed by nurse and showed no visible signs of injury. 9/24/12 at 12:00 pm resident was sent to (name of hospital) ER due to low blood pressure and complaining of knee pain to bilateral knees. Resident returned to facility from ER at 1645 (4:45 p.m.) with [DIAGNOSES REDACTED]. 9/27/12 resident continued to complain of knee pain and had bruising visible to bilateral knees, DON accompanied resident to (name of Clinic) for x-rays to bilateral legs resulting in the [DIAGNOSES REDACTED]. Resident was transported to (name of hospital) on 9/28/12 where she was seen by Ortho doctor, placed in bilateral leg immobilizers and returned to facility on 10/1/12 under the care of (Medical Director, staff member D). Resident seen by Medical Director on 10/5/12. On 10/22/12, family of (resident #1), (ombudsman), (Administrator), (Director of Nursing) met for meeting concerning residents (sic) incident, plan of care, and interventions to prevent further incidents. Family was shown the new bariatric shower bed which will result in reducing transfers in the shower area, resident will transfer to shower bed in personal room and be taken on shower bed to bath area instead of transferring from wheelchair to bath chair in bath area." Review of the "5 Day Investigation Results Report" did not include evidence of: -the CNAs who were transferring the resident had been trained prior to working with resident #1 in regards to her need for the mechanical lift, and -that the resident required a mechanical lift for safe transfers, During a review on 6/19/13 at 9 a.m., of the investigation packet regarding resident #1 being improperly transferred in the bathing room by the 2 CNAs was a hand written note signed by staff member B, an RN. The hand written note indicated, "Was called to bath area as CNA came and said resident was on floor. Resident was found lying on floor on her back with her left leg slightly bent back. Assessment was done and resident's left leg straightened. Resident had no apparent injuries but did say her legs hurt when moved. Resident was assisted back into w/c using the lift. When I asked CNA's (sic) what had happened they stated that when they had resident stand using her walker her knees buckled and she went down on her knees. CNA's then assisted her to lay down on the floor. When I informed CNA's (sic) that resident did not stand that they were to be using the lift they replied that another CNA had told them to use the walker & stand her." This evidence was not part of the Results of the 5 Day Investigation nor was there evidence of the CNA, the 2 CNAs had indicated had told them they should use her walker and stand her, had not been interviewed as part of the investigation. Review of the 9/27/12 referral order indicated the reason for the referral was due to a "9/20 fall-bruising & pain - bilateral legs." This order indicated the resident's weight was 212.5 pounds. The physician's report in this order indicated "x-ray: bilat (bilateral) distal femur fx. Physician Orders: Transport to (name of hospital) 9/28/12 ER, for admission. Review of the 10/2/12 Discharge Summary from the 9/28/12 hospital admission indicated "Patient (resident #1) was given blood transfusion at admission from acute on (sic) chronic anemia likely from bleeding from fracture." Review of the 9/28/12 transfer report included the "History of Present Illness: The patient is an 86- year-old female who sustained bilateral femur fractures 8 days ago while residing within the (name of nursing home)...Prior to this the patient was a nonambulator. She has not walked for 2-1/2 years, has severe hip arthritis...She does not have power of attorney provided to anyone particular, although the family does make decisions for her, according to her daughter, (name of daughter)..." During an interview on 6/19/13 at 10:15 a.m., the DON, staff member E, stated, "They (the 2 CNAs in the bathing room) had her (resident #1) stand from a shower chair. In the bathing room its a whirlpool tub. She (resident #1) was in the tub. They brought her out the back of the bathtub in the shower chair. They were attempting to stand her up to walker. They were on either side of her using a gait belt. They had the walker in front of her. They were going to stand her up to walker then move her wheelchair behind her. They were not using the hoyer lift. They were travel CNAs. They were not familiar enough with (resident #1). At that time didn't have orientation for travel CNAs. Since that time (Administrator) has put in place use of whirlpool tub policy for travelers. Normally, use travelers who have been here and familiar with residents. Rarely get travelers that are new. We have now done policy. Everyone that comes here that is new is oriented to the shower bed and whirlpool tub. I don't know how they got her into the tub." When questioned as to whether anyone interviewed the resident. The DON responded, "We did ask her (resident #1) what happened but we did not document it. She (resident #1) said she went down on the floor." When questioned as to whether it was possible her legs were broken before or during the bath the DON indicated it was but no one asked what had occurred prior to the 2 CNAs lowering her to the floor. Review of the "Training of new CNA's in bathing area..." and "Use of shower bed" did not include evidence of how the facility would orient new, existing (in that it could not be assured the CNA referenced as the CNA who oriented the 2 travelers to transfer resident #1 by using her walker was new, traveler or existing) and travelers to the transfer needs of residents outside the bathing area. During an interview on 6/19/13 at 3:52 p.m., the DON stated, "The 2 CNAs reported to the nurse on duty they had lowered her to the floor. They continued to work that evening and transfer other residents. I was not aware until the next day. After being told they then had training." During an interview on 6/19/13 at 4:05 p.m., the DON stated, "We had to go through something like this to find out we needed a procedure on what to train the travelers on."

Based on record review and staff interview, the facility failed to develop and implement policies and procedures prohibiting neglect. The facility did not have an effective system in place to ensure new, existing and traveling CNAs were aware of the transfer needs of residents. This resulted in one (#1) of 10 sampled residents experiencing neglect. Two CNAs assisted resident #1 to a standing position, when the resident was documented as being unable to stand; a mechanical lift was care planned as being necessary to transfer the resident. The resident's knees buckled, she fell to the floor and was subsequently diagnosed with [REDACTED]. Furthermore, the resident was not thoroughly assessed for injuries in a timely manner following the fall. The resident did not get x-rays or medical treatment for [REDACTED]. Findings include: Resident #1 was originally admitted to the facility on [DATE] and then readmitted on [DATE]. The resident's [DIAGNOSES REDACTED]. Review of the Care Plan with the origin date of 5/3/11 indicated "she is lifted by hoyer only. She is unable to wheel/scoot self. CNA staff will assist (resident #1) with shower or tub bath; (resident #1) requires assist with bed mobility & transfers." During a review of incidents and events reported to the State Agency from 8/7/12 through 10/23/12, on 6/13/13 at 5 p.m., the surveyor identified an event that was reported to the State Agency on 10/23/12. The report indicated the date of the event was 9/20/12. Review of the "Intake Information" indicated the name of the resident was (resident #1) with the injury being bilateral fracture femur (sic). The 5 day investigation results report was sent to the State Agency on 10/23/12. Review of the "Intake Information" included the "Outcome of your investigation: 9/20/12 approximately 5 pm, resident was lowered to knees in bath area during transfer with 2 CNA's (sic) and walker when legs gave out from resident. Resident assessed by nurse and showed no visible signs of injury. 9/24/12 at 12:00 pm resident was sent to (name of hospital) ER due to low blood pressure and complaining of knee pain to bilateral knees. Resident returned to facility from ER at 1645 (4:45 p.m.) with [DIAGNOSES REDACTED]. 9/27/12 resident continued to complain of knee pain and had bruising visible to bilateral knees, DON accompanied resident to (name of Clinic) for x-rays to bilateral legs resulting in the [DIAGNOSES REDACTED]. Resident was transported to (name of hospital) on 9/28/12 where she was seen by Ortho doctor, placed in bilateral leg immobilizers and returned to facility on 10/1/12 under the care of (Medical Director, staff member D). Resident seen by Medical Director on 10/5/12. On 10/22/12, family of (resident #1), (ombudsman), (Administrator), (Director of Nursing) met for meeting concerning residents (sic) incident, plan of care, and interventions to prevent further incidents. Family was shown the new bariatric shower bed which will result in reducing transfers in the shower area, resident will transfer to shower bed in personal room and be taken on shower bed to bath area instead of transferring from wheelchair to bath chair in bath area." Review of the "5 Day Investigation Results Report" did not include evidence of: -measures the facility put into place to prevent further neglect, -the CNAs who were transferring the resident had been trained prior to working with resident #1 in regards to her need for the mechanical lift, -that the resident required a mechanical lift for safe transfers, -staff conducting an interview with the resident. During a review on 6/19/13 at 9 a.m., of the investigation packet regarding resident #1 being improperly transferred in the bathing room by the 2 CNAs, was a hand written note signed by staff member B, an RN, a 10/2/12 Discharge Summary from the hospital resident #1 was admitted to following the discovery of her bilateral femur fractures, a 9/27/12 (name of nursing home) referral order and a 9/28/12 transfer report from the hospital resident #1 was taken to for the bilateral femur fractures. The hand written note indicated, "Was called to bath area as CNA came and said resident was on floor. Resident was found lying on floor on her back with her left leg slightly bent back. Assessment was done and resident's left leg straightened. Resident had no apparent injuries but did say her legs hurt when moved. Resident was assisted back into w/c using the lift. When I asked CNA's (sic) what had happened they stated that when they had resident stand using her walker her knees buckled and she went down on her knees. CNA's then assisted her to lay down on the floor. When I informed CNA's that resident did not stand that they were to be using the lift they replied that another CNA had told them to use the walker & stand her." This evidence was not part of the Results of the 5 Day Investigation nor was there evidence of the CNA, the 2 CNAs had indicated had told them they should use her walker and stand her, having been interviewed as part of the investigation. Review of the 9/27/12 referral order indicated the reason for the referral was due to a "9/20 fall-bruising & pain - bilateral legs." This order indicated the resident's weight was 212.5 pounds. The physician's report in this order indicated "x-ray: bilat (bilateral) distal femur fx. Physician Orders: Transport to (name of hospital) 9/28/12 ER, for admission. Review of the 10/2/12 Discharge Summary from the 9/28/12 hospital admission indicated "Patient (resident #1) was given blood transfusion at admission from acute on (sic) chronic [MEDICAL CONDITION]ly from bleeding from fracture." Review of the 9/28/12 transfer report (to the hospital) included the "History of Present Illness: The patient is an [AGE] year-old female who sustained bilateral femur fractures 8 days ago while residing within the (name of nursing home)...Prior to this the patient was a nonambulator. She has not walked for 2-1/2 years, has severe hip arthritis...She does not have power of attorney provided to anyone particular, although the family does make decisions for her, according to her daughter, (name of daughter)..." During an interview on 6/18/13 at 10:30 a.m. CNA, staff member O, stated, "(resident #1) will tell us if her ( name of roommate) is coughing. She can tell us her basic needs." During an interview on 6/19/13 at 10:15 a.m., the DON, staff member E, stated, "They (the 2 CNAs in the bathing room) they had her (resident #1) stand from a shower chair. In the bathing room its a whirlpool tub. She (resident #1) was in the tub. They brought her out the back of the bathtub in the shower chair. They were attempting to stand her up to the walker. They were on either side of her using a gait belt. They had the walker in front of her. They were going to stand her up to walker then move her wheelchair behind her. They were not using the hoyer lift. They were travel CNAs. They were not familiar enough with (resident #1). At that time didn't have orientation for travel CNAs. Since that time (Administrator) has put in place use of whirlpool tub policy for [MEDICATION NAME]. Normally, use [MEDICATION NAME] who have been here and familiar with residents. Rarely get [MEDICATION NAME] that are new. We have now done policy. Everyone that comes here that is new is oriented to the shower bed and whirlpool tub. I don't know how they got her into the tub." When questioned as to whether anyone interviewed the resident. The DON responded, "We did ask her (resident #1) what happened but we did not document it. She (resident #1) said she went down on the floor." When questioned as to whether it was possible her legs were broken before or during the bath the DON indicated it was but no one asked what had occurred prior to the 2 CNAs lowering her to the floor. Review at the time of this interview of the policy's referenced in this interview with the DON indicated a policy dated 11/15/12 "Subject: Use of shower bed Purpose: Instructions on use of the shower bed" and a policy dated 11/1/12 "Subject: Use of new CNA's (new or [MEDICATION NAME]) in bathing area to ensure resident safety." Review of the policies "Training of new CNA's in bathing area..." and "Use of shower bed" did not include evidence of how the facility would orient new, existing (in that there was not evidence the CNA referenced as the CNA who oriented the 2 [MEDICATION NAME] to transfer resident #1 by using her walker was new, [MEDICATION NAME] or existing) and [MEDICATION NAME] to the transfer needs of residents outside the bathing area. During an interview on 6/19/13 at 4:05 p.m., the DON stated, "We had to go through something like this to find out we needed a procedure on what to train the [MEDICATION NAME] on."

Based on clinical record review and staff interview the facility failed to monitor blood coagulation for one (#6) of 10 sampled residents on [MEDICATION NAME]. Findings included: Resident #6 was admitted to the facility on [DATE]; [DIAGNOSES REDACTED]. The resident was prescribed [MEDICATION NAME] for mitral valve insufficiency. On 7/20/11, the physician ordered a monthly blood sample for [MEDICATION NAME] time (PT) and international normalized ratio (INR) to measure the resident's anti-coagulation level. In December 2011, the resident received [MEDICATION NAME] 4 mg on Monday and Friday, and 6 mg on Saturday, Sunday, Tuesday, Wednesday, and Thursday. A PT/INR value for December was not in the clinical record. On 7/18/12 at 2:20 p.m., the DON stated the reference lab was contacted and the facility laboratory book was double checked, a PT/INR was not completed in December 2011. Based on Nurse's Notes dated 12/30/11, the resident complained of right knee pain and had a large bruise "at the back of that joint." Based on clinical notes, the resident waxed and waned with knee pain and progressive bruising on the right lower extremity. On 1/11/12, the resident was admitted to an acute care hospital for "significant ecchymosis in his right lower extremity . . . " The acute care facility assessed laboratory values. The resident's INR was 10. Based on a Mayo Clinic web site, an INR range of 2.0 to 3.0 is considered standard for people taking [MEDICATION NAME]. ? ? Retrieved 7/23/12, from the Mayo Clinic web site, on the World Wide Web: http://www.mayoclinic.com/health/[MEDICATION NAME]-time/my /dsection=results