Every finding on record at St John's Lutheran Home

Based on observation, interview, and record review, the facility failed to maintain sanitary conditions for food storage by failing to ensure food items stored in cottage refrigerators, freezers, and dry storage areas were consistently labeled with the contents and dated; failed to ensure staff involved in food preparation and service wore hair and beard covers; and failed to ensure refrigerator and freezer temperatures were consistently monitored and documented. The deficient practices increased the risk for food contamination and foodborne illness for residents residing in the cottages. Findings include:1. During the initial tour of the [NAME] Cottage kitchen on 7/29/26 at 7:41 a.m., the following food items were observed without labels and/or without dates: Refrigerator: - Plastic bag containing shredded mixed vegetables. Freezer: - Clear plastic bag containing frozen meat patties. - Large plastic bag containing frozen diced ham. - Plastic bag containing frozen sausage. - Clear plastic freezer bag containing frozen waffles. During the initial tour of [NAME] Cottage kitchen on 7/29/26 at 8:06 a.m., the following food items were observed without complete labeling or dating: Refrigerator: - Plastic bag containing a wedge of cabbage. Freezer: - Clear plastic bag containing frozen waffles. - Plastic bag containing frozen carrots. - Plastic bag containing frozen hashbrowns. - Plastic bag containing diced ham. - Plastic bag containing cauliflower. - Opened bag of French fries. During the initial tour of the [NAME] Cottage kitchen on 7/29/26 at 8:25 a.m., the following food storage concerns were observed: - Two clear plastic bags of rice in the dry storage area without labels or dates. Refrigerator: - Plastic bag containing sliced red onions dated 6/26 with visible specks of what appeared to be mold. Freezer: - Opened plastic freezer bag containing sweet potato fries without a date. - Plastic bag labeled fish without a date. - [NAME] paper bag containing French fries was without a label or date. - Clear plastic bag labeled ravioli without a date. During the initial tour of the [NAME] Cottage kitchen on 7/29/26 at 8:37 a.m., multiple food items were observed stored without complete identification or dating: - Tray containing miniature tart shells, covered with clear plastic wrap without a label or date, was in the dry storage area. Refrigerator: - Plate containing a sandwich and a vegetable salad covered with plastic wrap. - Sliced yellow cheese wrapped in plastic wrap. - Clear plastic container containing white sauce. - Plastic bag dated 7/20 containing crumbled white cheese without identification of what it was or date. - Plastic bag containing thawed chicken breasts. - Plastic bag containing raw meat. - Opened bag of shredded white cheese wrapped in plastic. Freezer: - Plastic bag containing frozen meat patties. - Plastic freezer bag containing frozen egg rolls. - Plastic bag of breaded meat patties with a hole in the package. - Opened bag of frozen corn. - Plastic bag containing unidentified breaded food items. - Opened bag of frozen peas wrapped in plastic. - Plastic bag containing frozen chicken breasts that was not properly sealed, labeled, or dated. During an interview on 7/29/26 at 8:02 a.m., staff member D stated food delivered from the main pantry frequently was not labeled or dated despite the employee responsible having been instructed multiple times to do so. During an interview on 7/29/26 at 8:55 a.m., staff member E stated the food had been delivered from the main kitchen storage already packaged in plastic bags. Staff member E stated he did not know when the food had been repackaged and could identify many frozen items only by appearance because the packages lacked labels and dates. During an interview on 7/29/26 at 10:33 a.m., staff member I stated bulk food items were portioned into plastic storage bags in the main kitchen storage and distributed daily to the cottages. Staff member I stated the employee responsible had been instructed to label and date the bags; however, the practice continued despite the education. During an interview on 7/30/26 at 9:07 a.m., staff member J stated foods distributed to the cottages were expected to be labeled and dated. Staff member J said the audits of the kitchen focused primarily on refrigerator contents and not foods stored in the freezers. During an interview on 7/30/26 at 10:37 a.m., staff member F stated refrigerated foods were required to be labeled and dated but was unaware the same expectation applied to foods stored in cottage freezers. Review of the facility's policy titled, Food Storage, last reviewed 1/2/23 showed, Policy: Food items will be stored, thawed and prepared in accordance with good sanitary practice. Procedure: All products shall be dated upon receipt or when they are prepared. Use Date shall be marked on all food containers according to the timetable in the Dry, Refrigerated and Freezer Storage Chart found in this section. [sic] 2. During the initial tour of the [NAME] Cottage kitchen on 7/29/26 at 8:37 a.m., staff members were observed in the kitchen during breakfast service with no hairnets. Staff member E was observed assembling breakfast plates while having exposed facial hair and was not wearing a beard covering. Staff member E stated he did not know the facility's expectations regarding beard coverings because he had not received training on the use of hair or beard nets. During an observation and interview on 7/29/26 at 8:58 a.m., staff member H was observed preparing a bowl of cereal and retrieving milk from the refrigerator without wearing a hair net. Staff member H stated certified nursing aides routinely entered the kitchen to prepare and serve food and had not received training regarding hairnet use. During an interview on 7/30/26 at 9:07 a.m., staff member J stated she was unsure of the facility's expectations regarding hair or beard coverings for staff, particularly nursing aides who entered the kitchen to prepare, serve, or distribute food. Review of the facility's policy titled, Personal Hygiene, issued 5/1/19, showed: Policy: These are the guidelines for personal hygiene to promote a safe and sanitary department. Procedure: . 3. Head covering worn: -If hair is long and not covered properly with a cap, a hairnet must be worn. - Beards or any body hair that may be exposed (i.e., arms) must be covered. [sic] 3. During an interview on 7/30/26 at 10:37 a.m., staff member F said refrigerator and freezer temperatures were to be logged daily in the cottages. Review of the [NAME] Cottage refrigerator and freezer temperature logs showed: - January 2026: Refrigerator temperatures were not logged for 31 days; freezer temperatures were not logged for 11 of 31 days. - March 2026: Refrigerator temperatures were not logged for 15 of 31 days; freezer temperatures were not logged for 31 days. - April 2026: Refrigerator temperatures were not logged for 12 of 30 days, freezer temperatures were not logged for 12 of 30 days. - May 2026: Refrigerator temperatures were not logged for 23 of 31 days; freezer temperatures were not logged for 16 of 31 days. Review of the facility's policy titled, Record Refrigeration Temperatures, issued 5/1/19 showed, Policy: A daily temperature record is to be kept of refrigerated items. Procedure: The Dietary Manager is to assign an employee to daily record all refrigerator and freezer temperatures on 'Record of Refrigeration Temperature.' . [sic]

Based on observation, interview, and record review, the facility failed to ensure staff members did not provide medications for residents to self-administer, for residents who had been assessed by staff and did not qualify for self-administration of medications for 2 (#s 45 and 55) of 31 sampled residents. Findings include: 1. During an interview on 7/28/26 at 10:51 a.m., resident #45 stated she had complained about an issue with a nurse (NF1) having trouble with getting her medications prepared and her insulin ready. Resident #45 stated the nurse no longer worked at the facility. Resident #45 stated she had been uncomfortable with the nurse leaving her insulin pens for her to take on her own on different occasions. Resident #45 stated she was legally blind in her left eye and could not see well, but did not wear glasses because they would not help with her eye conditions. During an interview on 7/29/26 at 3:24 p.m., staff member B stated NF1 had resigned from her position after having been observed by a pharmacy staff member for a medication pass audit. Staff member B stated NF1 had been observed leaving medications including insulin pens for resident #45 to give to herself. Staff member B stated resident #45 had vision issues but could take medications on her own. Staff member B stated assessments of resident self-administration of medications were completed annually.Review of a facility document titled, Self-Administration of Medication, dated 2/25/25, showed resident #45 was not approved for self-administration of medications.Review of a facility document titled, Medication Pass Evaluation, dated 6/26/26, showed NF1 was observed on [NAME] Cottage for a medication pass by a pharmacy staff member. The general administration notes showed that NF1 did not ensure medications were administered for resident #45, with a comment of, [Resident #45] given meds to take on her own. A comment for resident #45 showed, [Resident #45] - tells nurse her sugars & carbs & how much insulin. Nurse gives pt insulin pens & oral meds & pt administers themself. I noticed pt is hard of sight. Nurse did not dial for them, just gave pen & needles & then left pt alone. [sic]2. During an observation on 7/28/26 at 10:03 a.m., resident #55 was in her room in her bathroom. There were two clear medication cups holding pills sitting on resident #55's bedside table. There were no staff members present in resident #55's bathroom or room.During an interview on 7/30/26 at 7:53 a.m., resident #55 stated she would take her own medications, since staff would leave her pills for her to take on her own.During an interview on 7/30/26 at 8:22 a.m., staff member G stated she thought resident #55 was okay to take her pills on her own. Staff member G stated she thought resident #55 was okay with pills being left to take since there had never been an issue with resident #55 taking her pills.Review of a facility document titled, Self-Administration of Medication, dated 9/3/25, showed resident #55 was not approved for self-administration of medications.Review of a facility document titled, Medication Pass Evaluation, dated 6/26/26, showed NF1 was observed on [NAME] Cottage for a medication pass by a pharmacy staff member. The general administration notes showed that NF1 did not ensure medications were administered, with a comment of, For multiple residents, left medication in room without watching if it was taken. A comment for resident #55 showed, Nurse left meds bedside. pt was sleeping. Nurse said that pt would request the meds to be left bedside if they were awake anyway. Nurse did not want to wake pt, did not watch pt take meds. [sic] Review of a facility policy titled, Medication Pass Procedure - Skilled Cottages, revised 4/26, showed: . Do not leave medications at bedside or on a table with meals. You must observe residents swallow the medication without exception. [sic]

Based on interview and record review, the facility failed to revise a resident's care plan to reflect a resident's current pressure wounds and care needs for 1 (#2) of 31 sampled residents. The failure placed the resident at a greater risk for delayed wound healing. Findings include:During an interview on 7/30/26 at 7:58 a.m., resident #2 stated, I had a surgical wound after surgery and a pressure sore on my bottom. Resident #2 stated he had been in the facility approximately one year and had multiple wounds. Resident #2 reported his wounds were treated at a wound care clinic once a week on Wednesday.During an interview on 7/30/26 at 10:15 a.m., staff member B stated resident #2 was receiving wound management by an [Clinic Name] wound clinic, but facility staff had been completing dressing changes per the wound clinic's instructions. Staff member B stated the MDS nurse and team lead were the main staff responsible for care plan updates. When reviewing the care plan with the surveyor staff member B stated, I would think that we would have something more (on resident #2's wounds) because he had so much skin issues since admission [DATE]). [sic]Review of resident #2's provider note dated 7/16/26 showed a Stage III pressure wound with initial onset date of 4/20/26 on the resident's penis and a Stage II pressure wound with initial onset date of 2/19/26 on the right buttock. The provider orders instructed staff to apply Bacitracin or triple antibiotic ointment two times a day to the affected areas, including the glans penis and penile body, and the pressure ulcer on the right buttock was to be offloaded (pressure relief) by alternating the resident's air mattress and ROHO cushion.Review of resident #2's care plan on 7/30/26 showed resident #2 was at risk for skin breakdown due to impaired mobility and cerebral palsy. The care plan failed to show resident #2 had two pressure wounds and the treatment ordered by the provider to care for the resident and to ensure offloading occurred.

Based on interview and record review, the facility failed to ensure a staff member had the necessary competencies and skill set to provide safe medication administration practices for 2 (#s 24 and 45) of 31 sampled residents. The deficient practice negatively affected resident #45's sense of well-being due to concerns with a nurse's medication administration abilities. Findings include: During an interview on 7/28/26 at 10:51 a.m., resident #45 stated she had complained about an issue with a nurse (NF1) having trouble with her medications and insulin. Resident #45 stated the nurse no longer worked at the facility. Resident #45 stated the nurse had asked her on different occasions how much insulin she needed to give her. Resident #45 stated the nurse had asked her how to use her long-acting Toujeo insulin pen and stated she had never been shown how to use it. Resident #45 stated she had to count her potassium tablets because the nurse did not give her enough to take until she had said something. Resident #45 stated she was concerned that if she had not complained about the nurse, there would still be room for errors for her own medications or for other residents.During an interview on 7/29/26 at 3:27 p.m., staff member B stated NF1 had been hired to work as an as-needed resource nurse to help fill in needs during shifts, usually four hours at a time. Staff member B stated NF1 had a medical condition which caused her medication passes to go more slowly as she went through and passed medications to residents. Staff member B stated NF1 resigned from her position after being observed by a pharmacy staff member for a medication pass audit. Staff member B stated NF1 resigned on her own and had not been terminated. Staff member B stated the pharmacy staff member had intervened during NF1's observed medication passes because her administration practices could have harmed someone. During an interview on 7/30/26 at 11:59 a.m., staff member B stated staff were still looking to see if NF1's competencies from the employee's initial hire were available to turn in. Staff member B stated they had NF1's training schedule available but had not found competencies or skill checklists from her initial hiring.Review of resident #45's Annual Minimum Data Set assessment, dated 6/30/26, showed resident #45's BIMS (Brief Interview for Mental Status) summary score was 15. The score of 15 showed resident #45 had an intact cognitive response.Review of a facility document titled Medication Pass Evaluation, dated 6/26/26, showed NF1 was observed on [NAME] Cottage for a medication pass by a pharmacy staff member. A note was made for resident #24's observed medication pass which showed No gloves for lidocaine patches/eyedrops. Placed lidocaine patches w/out gloves, then immediately instilled eye drops (no handwashing). Had to inform nurse to wash hands before continuing med pass for other pts, but nurse did not wash thoroughly. [sic]Review of a facility document titled, Medication Pass Evaluation, dated 6/26/26, showed NF1 was observed on [NAME] Cottage for a medication pass by a pharmacy staff member. A comment was made for general medication administration, Pt [Resident #45] dosed own insulin based on carbs & told nurse how much she would give, nurse did not watch administration or dial pens for pt. A comment for resident #45 showed, [Resident #45] - tells nurse her sugars & carbs & how much insulin. Nurse gives pt insulin pens & oral meds & pt administers themself. I noticed pt is hard of sight. Nurse did not dial for them, just gave pen & needles & then left pt alone. [sic]A request to the facility was made on 7/30/26 at 7:28 a.m. for NF1's certifications, education, training, and competencies. No documentation for NF1's completed education, skills, or competencies was provided by the end of the survey.

Based on interview and record review, the facility nursing staff failed to meet professional standards of quality by not ensuring all controlled substance medications were accurately accounted for and documented in a resident's EHR, for 3 (#s 2, 6, and 9) of 3 sampled residents for controlled substance medications. This deficient practice affected the accuracy of medication administration records, had the potential to result in administration errors, and to allow unidentified controlled substance diversion to occur. Findings include:1. Review of resident #9's MAR and narcotic sign-out showed the following discrepancies:- MAR, 3/30/26, 0.5 ml at 9:33 a.m., narcotic sign out 3/30/26, 0.25 ml at 9:00 a.m.,- MAR, 4/1/26, none, narcotic sign out 4/1/26, 0.5 ml at 7:15 p.m. and at 9:00 p.m. 2. Review of resident #2's MAR and narcotic sign-out showed the following discrepancies:- [DATE]/11/26 0.25 ml at 5:00 p.m., narcotic sign out none,- [DATE]/17/26 0.25 ml at 8:00 a.m., narcotic sign out none 3. Review of resident #6's MAR and narcotic sign-out showed the following discrepancies: - MAR, 1/22/26 none, narcotic sign out 1/22/26 0.5 ml at 2:00 p.m. and 7:10 p.m.- [DATE]/23/26 sleeping at 9:00 a.m., not given, narcotic sign out 0.5 ml at 10:37 a.m., and- [DATE]/26/26 none, narcotic sign out 1/26/26 0.5 ml at 3:00 a.m. During an interview on 6/30/26 at 2:03 p.m., staff member J stated that the MAR documentation and the narcotic sign-out sheet should match. Staff member J stated that any discrepancies needed to be reported. Staff member J stated she had seen instances where the medication was signed out from the locked medication cart and not documented on the resident's MAR and instances where the medication was signed out on the MAR without a corresponding entry on the narcotic sign-out sheet. During an interview on 7/1/26 at 10:30 a.m., staff member B stated that the facility's expectation was that every dose of a narcotic (controlled substance) needed to be documented on both the narcotic sign-out sheet and the resident's MAR, and this was the standard of practice for medication administration.

Based on interview and record review, the facility failed to ensure a resident's right to a dignified existence for 1 (#8) of 3 sampled residents. The failure exposed the resident to feelings of embarrassment and shame associated with incontinence. Findings include:Review of a Facility-Reported Incident which occurred on 3/13/26 and was submitted to the State Survey Agency on 3/17/26, showed that while attending a group activity, resident #8 had an episode of incontinence and had to leave the activity so she could be cleaned up. The report showed NF1 had announced loudly, and in front of other residents and staff, that there was a big mess needing to be cleaned up, referencing the resident's situation. During an interview on 6/30/26 at 1:27 p.m., staff member D stated she had received a verbal report from staff member E alleging NF1 had been picking on resident #8, and the resident became so upset she was incontinent of stool during the activity and had to be removed from the activity to receive care for the incontinent episode. During an interview on 6/30/26 at 3:15 p.m., staff member C stated she usually handled incidents involving staff behavior and discipline. Staff member C reported she had spoken to staff member E, who had initially reported the incident, and to NF1, the staff member who had been accused of mistreating resident #8. Staff member C stated that after speaking with staff who witnessed the incident and reviewing the documentation for the incident, she determined there was no malicious intent on the part of NF1. Staff member C, in consultation with staff member B, determined the incident involved resident dignity and resident rights rather than actual resident abuse. Because NF1 had been an employee for many years and did not have any disciplinary write-ups in her personnel file, the decision was made to do a written disciplinary warning and additional education instead of termination for the staff member. Staff member C stated NF1 refused to sign the disciplinary write-up and resigned from her position. Staff member C stated that NF1 did admit to feeling frustrated when caring for resident #8, due to the resident's intellectual disability. During an interview on 7/1/26 at 10:30 a.m., staff member B stated he did not feel the incident rose to the level of abuse because the accused, NF1, was only trying to get the attention of someone to assist the resident and did not identify the resident by name. Staff member B also stated NF1 did not specify the type of mess needing to be cleaned up.

Based on interview and record review, the facility violated a resident's right to privacy during incontinence care when, during direct care and in the presence of the resident, a caregiver used her personal cell phone to discuss a resident's care with someone who was not a staff member of the facility for 1 (#7) of 3 residents sampled for abuse by facility staff. The failure involved allowing an unauthorized person, not employed by the facility, to be present via telephone during incontinence care. Findings include:Review of a Facility-Reported Incident which occurred on 8/3/25 and was submitted to the State Survey Agency on 8/4/25, showed NF2 was alleged to have used her personal cell phone to contact a CNA regarding how to handle resident #7's resistance to care. As part of the investigation of the incident, NF2 was found to have contacted her family member, who was a CNA but was not employed by the facility. The call was made while personal care was being provided to resident #7, who had an episode of bowel incontinence. NF2 was immediately suspended pending investigation of the allegation.During an interview on 6/29/26 at 9:47 a.m., staff member K stated resident #7 was independent with her ADLs except toileting. Staff member K stated if abuse was alleged, the DON was notified immediately.Review of NF4's written statement, dated 8/4/25, showed she observed NF2 on the phone with someone while performing incontinence care for resident #7. NF4's written statement showed it was a video call because she could see the camera was on. When NF2 was asked what she was doing by NF4, NF2 stated, It's ok, He is a CNA. NF4's statement also showed, [NF2] turned the camera towards [Resident #7's] bottom (buttocks area) and the mess all over the floor.Review of NF2's interview, dated 8/4/25, showed NF2 did call someone to ask for advice on how to care for someone resistant to care. The person on the phone was a CNA who was not employed by the facility. NF2 denied the call was a video call.

Based on interview and record review, the facility failed to protect the resident's right to be free from physical and verbal abuse by a staff member for 1 (#7) of 3 residents sampled for abuse by facility staff. During the survey, it was found the facility had previously identified, investigated, and corrected the non-compliance for abuse by a staff member. Findings include:Review of a Facility-Reported Incident, which occurred on 8/3/25 and was submitted to the State Survey Agency on 8/4/25, showed NF2 was alleged to have yelled at resident #7 because she had a bowel movement during an activity session. NF2 continued to complain about the resident's incontinent episode, in front of resident #7, about how far behind she was because of the mess resident #7 made.Review of the investigative file for the incident showed the facility gathered the following written statements associated with the incident: - Staff member G, dated 8/3/25, stated [NF2] was going off about how big of a mess it was and how gross it was in front of [Resident #7]. And . I heard [Resident #7] screaming. So I went to [Resident #7's] room . and seen [Resident #7] sitting in her wheel chair with no pants on and no brief. BM was all over the walls in the bathroom . [NF2] went off again about [Resident #7] . [sic]- NF2's written statement, dated 8/4/25, showed she found resident #7 falling out of her chair, and she used a Hoyer (mechanical) lift to get the resident into a shower chair to be cleaned up. The statement did not contain information showing anyone heard NF2's verbal statements during the activity session referencing how big and gross the mess was for resident #7. - NF2's written interview, dated 8/4/25, showed resident #7 was incontinent several times during the shift, and the resident became resistive to the care being offered. NF2 stated she did leave resident #7 in her room without a brief or pants. NF2 denied that her conversation with resident #7 was inappropriate. NF2 stated she called her family member, who was a CNA at another facility, to ask for advice on how to handle a resident who was resistant to care. NF2 denied the call was a video call. NF2 did state she was frustrated with the nurse, but not with resident #7.Review of resident #7's nursing progress note, dated 8/3/25, showed the resident was, . hanging off of her w/c and almost to the floor. Used hoyer lift to get up off the floor and into a shower chair. Elder (the resident) needed a shower due to having diarrhea. [sic]During an interview on 6/29/25 at 9:47 a.m., staff member K stated resident #7 was independent with her ADLs except for toileting. Staff member K stated she had received abuse reporting education after the incident, and if abuse was alleged, it was to be reported to the supervisor or the DON immediately.During an interview on 7/1/26 at 10:30 a.m., staff member B stated all of the residents in the cottage were asked about similar treatment by NF2. All of the residents, except resident #7, denied any mistreatment by NF2. NF2 was terminated at the conclusion of the investigation. Staff member B stated that abuse identification and reporting education was provided on 8/14/25 and the incident was discussed in the QAPI meeting on 8/29/25.Review of the facility's investigative file showed the facility immediately suspended the alleged staff member (NF2). Resident #7 was assessed and found to have no injuries. The other 11 residents in the cottage were interviewed and none had complaints about the care received from NF2. Resident #7's provider and representative were notified when the abuse was substantiated and NF2 was terminated. Staff education occurred on 8/14/25 and QAPI involvement occurred on 8/29/25.

Based on observation, interview, and record review, the facility failed to protect a resident from misappropriation of resident property in the form of missing medication for 1 (#9) of 3 sampled residents. The failure increased the risk of the resident not having enough medication to adequately manage her anxiety. Findings include:Review of a Facility-Reported Incident for an event that occurred on 4/3/26, which was submitted as misappropriation of property, was sent to the State Survey Agency on 4/6/26. The report showed that two unlabeled syringes were found in the medication cart located at [NAME] Cottage. A review of the video surveillance in the cottage showed NF3 had placed the two syringes in the medication cart on the morning of 4/2/26. One of the syringes contained 0.4 ml of a clear liquid determined to be oral lorazepam. The second syringe contained a trace amount of a red liquid determined to be oral morphine sulfate. The only open bottle of lorazepam belonged to resident #9; a resident residing at the [NAME] Cottage. The open bottle of lorazepam and the narcotic sign-out sheet were taken to the pharmacy. The measured amount in the bottle of lorazepam was 23.5 ml. The narcotic sign-out sheet showed there should have been 26 ml; a difference of two and a half ml. At the conclusion of the investigation, NF3 was terminated for the substantiated misappropriation of property, and the local law enforcement and the State Board of Nursing were notified of the missing narcotic medication and misappropriation by staff member NF3.During an observation and interview on 6/30/26 at 2:03 p.m., staff member J demonstrated the process for dispensing, administering, and documenting oral lorazepam to a resident. A 30 ml syringe containing 15 ml of oral lorazepam (2 mg per ml strength) was removed from the locked refrigerator. A one ml syringe with markings at each 0.02 ml was filled with 0.25 ml of lorazepam oral liquid. Staff member J then documented on the narcotic sign-out sheet the amount to be given to a resident (0.25 ml). The amount taken (0.25 ml) was subtracted from the total amount (15 ml), and the amount of the medication remaining on the narcotic sign-out sheet was documented as 14.75 ml.During an interview on 7/1/26 at 12:16 p.m., staff member B described the sequence of events involved in the medication diversion and misappropriation of the resident's property. Staff member M was passing medications in [NAME] Cottage. At approximately 12:30 p.m., staff member M found two unlabeled syringes in the medication cart. Staff member M immediately reported this to staff member B. The unlabeled medication in the syringes was determined by the pharmacy to be oral lorazepam and oral morphine sulfate. The only open bottle of oral lorazepam had been dispensed to resident #9. Surveillance videos in both [NAME] and [NAME] Cottages were reviewed, and NF3 was identified as the staff member who placed the syringes in the [NAME] Cottage medication cart. The misappropriation of resident medication (property) was substantiated, and NF3 was terminated from the position at the facility. Review of the facility's policy titled Controlled Substances Recordkeeping, dated November of 2022, showed the following: - [Facility Name] strives to provide that every dose of a controlled substance is securely stored and accounted for.- [Facility Name] Nursing. B. Records on Controlled Substance Reconciliation Count Sheet each time a Controlled Substance medication dose is administered.C. Verifies counts of each Controlled Substance medication at the end of each shift and signs the Controlled substance Tracking Form.1. Any discrepancy in the controlled substance count will be reported to the member of nursing administration before the off-going nurse is dismissed.

Based on interview and record review, the facility failed to report an allegation of resident abuse in a timely manner for 1 (#8) of 5 residents sampled for timeliness of reporting abuse allegations. Findings include:Review of a Facility-Reported Incident for an event that occurred on 3/13/26 was submitted to the State Survey Agency on 3/17/26 and showed that an allegation of resident abuse was made by staff member E.During an interview on 6/30/26 at 1:27 p.m., staff member D stated she received a verbal report of an abuse allegation involving resident #8 and NF1. Staff member D stated she was new to her position, so she was not aware of the need to report allegations of abuse within 24 hours of the incident. Staff member D stated she took notes while interviewing staff member H on 3/13/26. Staff member D also spoke with staff member E regarding what she witnessed. Staff member D stated she received an email from her supervisor on Monday, 3/16/26, regarding the reporting timeframes for reportable events. Staff member D stated she was now aware that a reportable event needed to be reported within 24 hours of the incident.During an interview on 7/1/26 at 10:30 a.m., staff member B stated he knew the abuse allegation was reported late.Review of the facility's policy titled Abuse, dated August of 2022, showed, Abuse is reported no later than 24 hours after the allegation is made ., to the Director of Nursing or designee of the facility and to other officials (including to the State Survey Agency .

Based on interview and record review, the facility failed to develop and implement a system that accurately recorded, monitored, and reconciled the accuracy of dispensing lorazepam oral liquid for 1 (#9) of 3 sampled residents for use of controlled substance medications. The deficient practice resulted in a discrepancy between the number of doses removed from secure storage and the number of doses administered to a resident. Findings include:Review of a Facility-Reported Incident for an event that occurred on 4/3/26 was submitted to the State Survey Agency on 4/6/26. The document showed that two unlabeled syringes were found in the medication cart in [NAME] Cottage. One of the syringes contained 0.4 ml of a clear liquid determined to be oral lorazepam. The second syringe contained a trace amount of a red liquid determined to be oral morphine sulfate. The open bottle of lorazepam and the narcotic sign-out sheet were taken to the pharmacy. The measured amount in the bottle of lorazepam was 23.5 ml. The narcotic sign-out sheet showed there should have been 26 ml, a difference of two and a half ml. Refer to F602 - Misappropriation of Property, related to the diversion of a controlled substance medication.During an interview on 7/1/26 at 12:16 p.m., staff member B described the usual process for dispensing, storing, and destroying lorazepam oral liquid. The lorazepam liquid was dispensed in a 30 ml bottle. Each time a dose was removed and administered to a resident, the amount removed was subtracted from the amount on hand, and the amount remaining was documented. The amount remaining was transferred to the next line and documented in the amount on hand column. This process was done for each dose of medication. When the resident is no longer receiving the medication, the amount in the bottle is measured and should match the amount remaining. Staff member B stated that the process for dispensing controlled substance medications was changed when the medication diversion was identified in April of 2026. Staff member B stated the lorazepam oral liquid was no longer dispensed in a brown multidose bottle. It was being dispensed as 15 ml in a 30 ml syringe. Review of a pharmacy audit, dated 3/31/26, showed there were several discrepancies with controlled substances, including two bottles of lorazepam oral liquid.Review of a pharmacy audit, dated 5/21/26, failed to identify discrepancies in the dispensing and administration of lorazepam oral liquid. One of the audits monitored each of the four long-term care cottages, identifying discrepancies in the accurate completion of the controlled substance sign-out sheets. Although the accuracy of some controlled substances was monitored, there was nothing regarding the accuracy of lorazepam oral liquid.Review of the facility's policy titled, Controlled Substances Recordkeeping, dated November of 2022, showed the following: - [Facility Name] strives to provide that every dose of a controlled substance is securely stored and accounted for.- [Facility Name] Nursing.B. Records on Controlled substance Reconciliation Count Sheet each time a Controlled Substance medication dose is administered.C. Verifies counts of each Controlled Substance medication at the end of each shift and signs the Controlled substance Tracking Form.1. Any discrepancy in the controlled substance count will be reported to the member of nursing administration before the off-going nurse is dismissed.

Based on observation, interview, and record review, the facility failed to dispose of expired foods; failed to ensure dietary staff prepared and served food in a sanitary manner; and failed to properly test dish sanitization water used to sanitize dishes in the kitchen. This deficient practice had the potential to affect all residents served food in the LTC Cottages by increasing the risk of foodborne illnesses. Findings include: 1. During an observation and interview on 7/16/25 at 7:58 a.m., several items were observed to have expired and were still in use. Staff member E stated all items should be dated with an open date, and any expired items used past their use-by date should be discarded. Staff member E stated, “We use the Montana use-by date for milk.” Items observed to be expired were: [NAME] Cottage: -salted caramel coffee creamer, expired June 2025. -sweetened original coffee creamer, expired June 2025. -sliced cheese, in a Ziploc storage bag, with a date of 6/18. -sliced ham, in a Ziploc storage bag, which was open and not dated. -one gallon of milk, half used, which had an expiration date of 7/9, but it did not have an open date. Powers Cottage: -salted caramel coffee creamer, expired January 2025 -sweetened original coffee creamer expired May 2025, and -individual prune juice cups expired November 2024. [NAME] Cottage: -sweetened original coffee creamer expired February 2025. [NAME] Cottage: -two bags of open chips, neither was labeled with an open date. -sweetened original coffee creamer, expired May 2025, with no open date. -salted caramel coffee creamer, expired January 2025, with no open date. -individually wrapped fig newtons, expired May 2025. Main storage room: -three gallons of milk, with an expiration date of 7/9. -a case of individual cups of grape juice, expired February 2025. During an interview on 7/16/25 at 8:54 a.m., staff member E stated, “I don’t have policies for food storage and handling, but I will work on creating some.” 2. During an observation and interview on 7/16/25 at 7:58 a.m., staff member E stated she did not have dietary policies; she only told her staff to follow Serve Safe guidance. The three dish sinks in the kitchen of [NAME] Cottage were observed to be full of dish water, rinse water, and sanitizer water. Staff member E stated, “Ecolab handles all sanitizer units. They (Ecolab) come and check them once a month. I was told when Ecolab took over and installed these units that we would not have to do testing on our sanitizer. We do not have test strips in any of the cottages, and we don’t test any of the water used for sanitizing dishes.” Review of a facility document titled “[Facility name]: Food Safety Policy” with an initiation date of 11/2016 and no revision date, showed: “Food Safety Requirements-Use and Storage of Food and Beverage Brought in for Residents, Food Procurement: Policy: It is the policy of [Facility name] to provide safe and sanitary storage, handling, and consumption of all foods including those brought to resident by family and other visitors. … Objective of Policy: The objective/intent of this requirement is to ensure that [Facility name]: … 2. Follows proper sanitation and food handling practices to prevent the outbreak of foodborne illness. Safe food handling for the prevention of foodborne illnesses begins when food is received from the vendor and continues throughout the facility’s food handling processes. … ii. … This education will include at a minimum: 1. Proper food handling to prevent foodborne illness. 2. Perishable food such as meat, poultry, fish, and dairy products must be frozen or refrigerated immediately after receipt. … 4. Proper labeling and dating of each item. 5. Leftover foods will be used within 3 days or discarded. …”

Based on observation, interview, and record review, the facility failed to ensure staff used appropriate hand hygiene after assisting residents; failed to ensure staff used appropriate hand hygiene while preparing ready-to-eat foods; and failed to ensure enhanced barrier precautions were followed for 1 (#4) of 25 sampled residents. This deficient practice increased the spread of bacteria and increased the risk of infections to residents in the facility. Findings include:1. During an observation on 7/15/25 at 11:04 a.m., staff member G brought a resident, via wheelchair, placed her at a dining table after rubbing her back when speaking to her, went to the kitchen and brought a cup of coffee to another resident seated at a separate table. Staff member G then went back to the kitchen and brought a cup of coffee to the first resident. This was done without performing hand hygiene between residents. During an observation on 7/16/25 at 8:30 a.m., staff member G washed her hands and then went to a dining table, seated herself between two residents, and began feeding both residents their meal. Staff member G would provide a bite of food for one resident and then provide a bite of food for the second resident. Staff member G assisted both residents throughout the meal without any hand hygiene being performed. During an observation on 7/16/25 at 8:40 a.m., staff member H, using her bare hands, rolled a sitting stool across the dining area and placed it at a table with three seated residents. Staff member H then seated herself on the stool and began assisting all three residents with their meal, rolling between residents. No hand hygiene was performed throughout the meal. During an interview on 7/16/25 at 9:55 a.m., Staff member D said the facility had a CNA, studying to be a nurse, assigned to complete hand hygiene audits. Staff member D said the facility's Resource Team was responsible for the audits on Enhanced Barrier Precautions (EBP). The facility was providing education on EBP and was working with education for staff, and the information was still a little murky for now. Staff member D said if an issue was noted by the individuals completing the audit, it was reported back to the Infection Preventionist (IP), and education would be provided. During an interview on 7/16/25 at 2:07 p.m., staff member G said she had been provided hand hygiene instruction sheets for education on hand hygiene. Staff member G said the resource team came through the cottage to observe the staff and check to see if the staff were washing their hands correctly. The staff were observed washing their hands with soap and water at the sink and monitored for the process and length of time the hands were washed. Staff member G said she was not provided specific education on when hand hygiene was to be performed when serving meals or when appropriate while wearing gloves. Review of a facility policy, Handwashing/hygiene Policy, with a revision date of 1/23, showed: .Hand hygiene is a general term that applies to handwashing, antiseptic hand wash and alcohol-based hand rub (ABHR). Process .5. Employees must wash their hands for at least twenty (20) seconds using antimicrobial or non-antimicrobial soap and water if hands are visibly soiled. .7. In most situations, the preferred method of hand hygiene is with an alcohol-based hand rub. If hands are not visibly soiled, use an alcohol-based hand rub containing 60-95% ethanol. 8. Hand hygiene is always the final step after removing and disposing of personal protective equipment. 9. The use of gloves does not replace handwashing/hand hygiene. 2. During an observation on 7/14/25 at 4:02 p.m., resident #4 was observed sitting in a wheelchair in her room. A wound dressing was observed on resident #4's left foot. During an observation on 7/15/25 at 8:43 a.m., staff member P was observed assisting resident #4 out of bed. Staff member P was not wearing an isolation gown as she transferred resident #4 to the chair and to the bathroom. During an interview on 7/15/25 at 9:25 a.m., staff member P stated there were currently no residents in [NAME] cottage who required PPE for their care. During an interview on 7/15/25 at 11:30 a.m., staff member N stated resident #4 was on hospice, but the facility nursing staff changed the wound dressings daily, or as needed. During an interview on 7/16/25 at 2:12 p.m., staff member N stated, The only person right now in the cottage that should have enhanced barrier precautions would be one (unnamed) resident with a urinary catheter. Review of the facility policy titled, Enhanced Barrier Precautions with a revision date of 3/24, showed: . The recommendations now include the use of EBP during high-contact care activities for residents with chronic wounds or indwelling medical devices, regardless of their MDRO status . High-Contact Resident Care Activities include: • Dressing• Bathing/showering• Transferring• Providing hygiene• Changing linens• Changing briefs or assisting with toileting . 3. During an observation on 7/16/25 at 7:51 a.m., staff member F was wearing a glove on the left hand and holding a pan handle, while cooking something that resembled eggs, on the stove. Staff member F used the gloved hand and reached into a container with shredded cheese. Staff member F took the cheese and sprinkled it over the food in the frying pan. Staff member F then touched the lid on the cheese and reached into the refrigerator, grabbing a package which was placed on the counter. Staff member F then grabbed a soiled bowl and rinsed it off in the sink. Staff member F then removed the soiled glove from her hand and threw it away. During an interview on 7/17/25 at 9:11 a.m., staff member E stated, “Staff should wash their hands and use gloves whenever they are preparing ready-to-eat food. If they touch something besides the food while serving, they should remove gloves and wash their hands . and It is not ok to wear a glove and then touch the handle of a pan and then use the same gloved hand to reach into shredded cheese . and would then be contaminated.” Review of a facility document titled Hand Washing and Glove Use, undated, showed: “Policy: Guidelines for hand washing and glove use to promote safe and sanitary conditions throughout department. [sic] Procedure: Hand Washing Procedure: 1. Hand washing is a priority for infection control. 2. Hands must be washed prior to . working with different food substances, i.e. raw chicken to fresh fruit, following contact with any unsanitary surface i.e . Procedure: Gloves: 1. Gloves may be used when working with food to avoid contact with hands. Gloves must be worn when touching any ready-to-eat food. 2. When gloves are used, hand washing must occur per above procedure prior to putting on gloves and whenever gloves are changed. Gloves must be changed as often as hands need to be washed, see above. Gloves may be used for one task only.

Based on observation, interview, and record review the facility failed to develop and implement a facility policy and procedure for written grievances to be submitted anonymously; failed to provide residents with readily available grievance forms; and failed to provide a resident with the option to submit written grievances anonymously for 1 (#83) of 25 sampled residents. This deficient practice could affect all residents residing in the [NAME] cottage. Findings include:During an observation on 7/14/25 at 3:30 p.m., a walk-through of the [NAME] cottage common areas was conducted. A resident information board was located on a wall across from the entrance to the cottage. No documentation was observed on how a resident could file a grievance. No grievance forms were found readily available to residents, and no secure receptacle was identified to submit a written anonymous grievance.During an interview on 7/14/25 at 3:36 p.m., staff member K stated that if a resident had a grievance, the resident would notify a staff member. Staff member K stated that the staff member would then notify her, and she would address the issue with the resident and provide a grievance form to the resident if it was needed. Staff member K stated the resident grievance forms were stored in her office. Staff member K stated that resident grievance forms were not available to residents in the common areas of the [NAME] cottage. Staff member K stated the [NAME] cottage did not have a secure receptacle for residents to submit a written grievance anonymously.During an interview on 7/15/25 at 10:30 a.m., resident #83 stated the resident council meets monthly in the dining room. Resident #83 stated she did not know where grievance forms were located in the ([NAME]) cottage, or whether a grievance could be filed anonymously. Resident #83 stated that if she had a problem, she would let staff know, and they would take care of the issue. Resident #83 stated she was not sure how to submit a written grievance anonymously if she needed to.Review of the facility's policy titled GRIEVANCE POLICY, dated November 2016, showed: . PROCEDURE . E. A grievance or concern can be expressed orally to the Grievance Official or [facility staff] or in writing using a grievance form, which will be located adjacent to the Resident of Rights posting located throughout [facility name].F. Grievances may be given to any staff member who will forward the grievance to the Grievance Office, or they may file the grievances anonymously to the Compliance Hotline at [Phone Number]. [sic]

Based on interview and record review, the facility failed to report their investigative findings of a facility reported incident to the State Survey Agency in a timely manner for 2 (#s 23 and 72); and failed to report allegations of resident abuse to the State Survey Agency within 24 hours of the incident for 2 (#s 24 and 95) of 25 sampled residents. This deficient practice increased the risk of unnecessary psychosocial harm to the residents involved in the incident due to the delay in reporting both the allegations of resident abuse and results of the facility investigation. Findings include: 1. Review of a facility-reported incident, dated 4/30/25, showed resident #23 and resident #72 were involved in an exchange at a cottage dining room. Resident #72 was witnessed by staff yelling at and insulting resident #23. Review of the facility reported incident findings, submitted 5/9/25, showed both residents (#23 and #72) were attended to and evaluated by staff members. Resident #72 was assessed by a provider to obtain behavioral health treatment following the incident. Staff members were educated to prevent and respond to verbal exchanges between residents. During an interview on 7/17/25 at 10:02 a.m., with staff members B and C, staff member B stated an IDT member enters incident investigation findings within five days to the State, “Usually me or [staff member C's name].” Staff member C stated, “That incident (reporting) might have been me, I might not have done it within the five days.” Staff member B stated that the staff member who was on-call covers the initial report submission. Staff member B stated the follow-up was not assigned to just one person, due to someone potentially being off or unavailable. Staff member B stated that the administrative staff rotate through scheduled on-call assignments. Staff member B stated that staff member C had not been assigned to report incident investigation findings for some of the times being looked at. The facility findings of the incident, dated 4/30/25, were due on 5/7/25. The results of the facility investigation findings were not submitted to the State Survey Agency until 5/9/25. 2. Review of a facility-reported incident, dated 11/23/24 at 12:15 p.m., showed resident #24 and resident #95 were involved in a physical altercation. Resident #24 grabbed resident #95’s left upper arm with her hand, leaving a nail imprint on resident #95. The allegation of resident-to-resident abuse was not reported to the State Survey Agency until 11/25/24, exceeding the required timeline for reporting events. During an interview on 7/17/25 at 9:37 a.m., staff member B stated he was not aware the facility failed to report allegations of resident-to-resident abuse to the State Survey Agency within 24 hours for the facility-reported incident dated 11/23/24. Staff member B stated he had a nursing administration team capable of reporting allegations to the State Survey Agency in his absence. Staff member B stated the incident, dated 11/23/24, occurred on a weekend, and it was possible he was unable to review the incident until the following Monday, 11/25/24. Review of the facility's policy titled, Abuse Policy, last revised in August 2022, showed: “ . PURPOSE To provide a mechanism by which supervisors will initiate an investigation while ensuring the safety of the resident. … 2. Notify Nursing Administration present at [Facility Name] or on call. Nursing Administration or designee will notify the [State Survey Agency] and any other necessary authorities within 24 hours of the incident. Documentation of the investigation will be provided within five business days.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive, person-centered care plan, for a resident who required oxygen therapy for 1 (#12) of 25 sampled residents. The facility's failure could jeopardize the resident's health resulting in a risk for low blood oxygen levels or oxygen services not being provided. Findings include:During an observation on 7/16/25 at 10:36 a.m., resident #12 was in her room sitting in a recliner with her legs elevated. Resident #12 appeared to be asleep with a nasal cannula applied to her nostrils. Resident #12's oxygen concentrator was running at 2 liters per minute. During an interview on 7/17/25 at 9:37 a.m., staff member B stated the MDS nurse and interdisciplinary team were responsible for updating a resident's care plan. Staff member B stated he was not sure why resident #12's oxygen therapy was not initiated in the resident's care plan. Staff member B stated, I don't know why it is not there. Review of resident #12's medical provider order, dated 2/20/25 at 9:30 a.m., showed, Oxygen at 2 liters/minute. Keep oxygen saturation above 90% Delivery method nasal cannula [sic]Review of resident #12's current care plan, with a revision date of 3/21/25, did not include a focus, goal, or interventions related to resident #12's oxygen therapy treatment.

Based on observation, interview, and record review, the facility failed to ensure a resident-centered care plan was updated to include specific activity preferences and current participation for 2 (#s 24 and 56); and include use of enhanced barrier precautions for 1 with an indwelling urinary catheter (#9) of 25 sampled residents. This deficient practice increased the risk of staff members not implementing resident-centered care plans in the specific areas of activities and infection control. Findings include: 1. During an observation and interview, on 7/14/25 at 3:45 p.m., resident #32 was sitting in her recliner with her feet elevated, watching television. When asked, resident #32 stated she did participate in activities, but she was unable to identify which activities she participated in. Resident #32 was able to answer yes or no questions regarding participation in reading activities and watching television. The resident was unable to recite or recall the names of any activities on her own. NF1 arrived at 3:50 p.m. and joined the conversation regarding resident #32's care. NF1 stated he came almost daily to visit resident #32, and she did not participate in many of the group activities in the cottage. During an interview on 7/16/25 at 9:01 a.m., staff member O stated resident #32 did not routinely participate in group activities in the cottage, except for church on Friday. Staff member O stated that resident #32's family visited daily. Staff member O stated she talked to each resident and representative quarterly. Staff member O stated that notes about changes in the resident's activity participation and preferences were documented in the care team meeting progress notes. When asked where she was documenting the specific types of preferred activities for each resident, she stated it should have been on the resident's care plan. Review of resident #32's Activity Care Plan, dated 1/21/25, showed the problem's focus was that the resident was dependent on staff and family for meeting her social needs, which was due to cognitive deficits and physical limitations. The care plan showed interventions identified by the facility included encouraging ongoing family involvement and inviting the resident's family to special events, activities, and meals. The care plan failed to show the importance of church services, the resident's preference for not attending most group activities, or the use of one-to-one visits. 2. During continuous observations on 7/14/25 from 2:00 p.m. to 3:45 p.m. and 4:10 p.m. to 4:30 p.m., resident #56 did not come out of her room. The door to the resident’s room was closed, and the resident was left undisturbed. During an observation on 7/15/25 at 11:15 a.m., resident #56 requested help with a jacket and was escorted from her room to the dining room in the common area. The resident was not wearing her hearing aids, and staff used a small whiteboard to communicate with the resident. During an interview on 7/16/25 at 11:22 a.m., staff member H stated resident #56 was very hard of hearing and often did not participate in any activities in the cottage. Staff member H stated the resident liked visiting with family and listening to music, if she was located close enough to hear the music. During an interview on 7/17/25 at 9:04 a.m., staff member O stated she had not completed the activity assessment for resident #56 because the resident resided in a different cottage. Resident #56 was moved to the [NAME] Cottage on 3/3/25, and the first care team meeting was not completed until the middle of June 2025. Staff member O was not able to explain why the care team notes for activities were not completed during the care conference, when asked. Review of resident #56’s care team meeting notes, dated 6/24/25, showed the activities section was blank. Review of resident #56’s Activity Care Plan, dated 3/31/25, showed the problem's focus was the resident was dependent on staff for meeting her social needs due to cognitive deficits. The care plan interventions were to converse with the resident during care, encourage family involvement, ensure activities were compatible with the resident’s physical and mental capabilities, and compatible with the resident’s known interests and preferences. The care plan failed to reflect the resident’s interests and preferences, or the use of one-to-one visits to meet the needs of resident #56. 3. During an observation on 7/14/25 at 8:23 a.m., resident #9 was lying in her bed, and the resident had a urinary catheter. Resident #9 had enhanced barrier precaution signage on the front of the door, visible to anyone entering the resident's room. Resident #9’s room did not have personal protective equipment supplies available inside or outside of the room for staff to access and ensure enhanced barrier precautions were followed when providing resident care. During an interview on 7/17/25 at 9:51 a.m., staff member C stated she and staff member B updated resident care plans with nursing-related needs. Staff member C stated she would update the care plans for health conditions requiring the use of precautions. Staff member C stated nursing staff providing direct care in cottages typically did not enter updates on the resident care plans. Staff member C stated CNAs and nursing staff were able to view resident care plans. Staff member C stated it would be a good idea to include enhanced barrier precautions on a resident’s care plan. Staff member C stated she did not add enhanced barrier precautions related to resident #9’s indwelling urinary catheter to the care plan. Staff member C stated she would check to see why personal protective equipment was not available outside of resident #9’s room. Review of resident #9’s care plan, showed two problems related to an indwelling urinary catheter, initiated 10/7/24: “… [Resident #9] has an ADL self-care performance deficit r/t Parkinson's disease, presence of Foley catheter, and mild cognitive impairment. … [Resident #9] has an indwelling Foley catheter r/t neurogenic bladder. She has pulled it out multiple times since admission.” The two care plan problems listed for the indwelling urinary catheter did not include goals or interventions to address the use of enhanced barrier precautions for resident #9 during care provided by staff. Review of a facility document titled, “Baseline Care Plans,” initiated 1/2019, showed: “… 3. Care Plans must be updated every three months… Look at the problem and assess if it is still appropriate, has goal been met. If goal not met, change interventions or change the goal. Review interventions to see if they need to be changed.” [sic] Review of a facility document titled, “Enhanced Barrier Precautions Policy,” revised 3/2024, showed: “… Enhanced Barrier Precautions is intended for nursing homes to prevent the spread of novel or targeted Multi-Drug-Resistant Organisms (MDROs) when residents have an infection or colonization with an MDRO or if the resident has a wound or indwelling medical device, regardless of MDRO infection or colonization. … Enhanced Barrier Precautions require gown and glove use for residents with a novel or targeted MDRO or any resident with a wound or indwelling medical device during specific high-contact resident care activities.”

Based on observation, interview, and record review, the facility failed to ensure the medication error rate was less than five percent, for 2 (#s 35 and 77) of 25 sampled residents. The medication error rate was calculated as 5.41 percent, and the medication errors placed the residents at increased risk of negative outcomes. Findings include:During a medication administration observation and interview on 7/15/25, between 8:28 a.m. and 8:45 a.m., staff member N stated, “I got busy in the other cottage, and [resident #77] was already wheeled out to the dining room, so I will just wait until she finishes her breakfast and returns to her room to give her insulin. Staff member N administered resident #77's insulin dose at 8:42 a.m., after resident #77 completed her breakfast and returned to her room. Review of resident #77's physician order, dated 7/4/25, showed, “Humalog 100 unit/ml Kwikpen before meals and at bedtime .” During an observation and interview on 7/16/25 at 8:04 a.m., staff member J gave two 500 mg tablets of acetaminophen to resident #35, who had been eating breakfast. In the MAR, staff member J charted the acetaminophen as given under the medication pantoprazole (40 mg), closed the computer, and walked away from the computer. The medication, pantoprazole, was in red on the MAR, and it was scheduled to be given at 7:00 a.m. Staff member J stated they would administer the pantoprazole at that time, when asked about the incorrect documentation, and stated they would have found the error when the rest of the medications in resident #35's bin were given around 8:30 a.m. or 9:00 a.m. Staff member J stated the pantoprazole should have been given before resident #35 had eaten. Review of resident #35’s EHR showed a physician’s order: “pantoprazole … take 1 tablet by mouth every day at 0700 (indications for use: GERD).”

Based on observation, record review, and interview, the facility failed to ensure residents were served meals to meet their nutritional needs, and staff serving meals failed to use the menu's and serve the planned meal, or offer an appropriate substitute, for the residents in the [NAME] Cottage. Findings include. During observations on 8/13/24 from 8:39 to 8:58 a.m., in the [NAME] cottage, staff member N did not review the residents diet orders or the menu prior to meal service. Staff member N did not use the required scoop size when serving the protein. Staff member N did not use a scoop when serving the bacon. Staff member N used her hand to scoop bacon out of the robo coupe. Five residents had orders for minced and moist diet. Staff member N scooped a serving of bacon out of the robo coupe with her hands for all five residents. The menu stated banana french toast was to be served for breakfast. The residents were served regular toast or pancakes. The residents were not asked their preferences prior to being served their meal. During an observation on 8/14/24 at 9:00 a.m., staff member P did not review the resident diet orders or the menu which showed the required portion size for the diets. Staff member P scooped the sausage out of the container with her hands and did not follow the recommended serving portion of protein. The menu planned for breakfast was confetti eggs, cereal, hashbrowns and toast. The cook told a CNA she ran out of hashbrowns and only had six hashbrown for the meal service. The census of [NAME] cottage was 13. Staff member P did not follow the menu and served plain scrambled eggs. Staff member N was observed to serve a non-measured scoop of scrambled eggs on the resident plates. No substitute was offered in place of the hashbrowns. During observation and interview on 8/15/24 at 8:53 a.m., in the [NAME] Cottage, staff member R said she only had six pancakes. Census in the cottage was 13. Staff member R told a CNA she did not know what to serve to the residents who did not get pancakes. Staff member R did not mince the sausage which was planned for breakfast. Staff member R said she did not have time to put the sausage in a blender. Staff member R failed to provide a minced meat substitute for breakfast. Staff member R stated she would just provide double portions of meat at lunch time. Eggs sterling was on the menu for breakfast. Plain scrambled eggs were observed in the cooking dish. There were not enough eggs to put on all the plates for the meal, so staff member R took eggs from the plates which had been dished and placed some of each serving of eggs onto two other empty plates.

Based on observation, interview and record review, the facility failed to update the comprehensive care plan for a resident who was dealing with grief, for 1 (#41); failed to update the care plan of a resident with frequent falls for 1 (#47); and failed to update the care plan of a resident who no longer had adjustment issues for a room change which occurred more than 12 months prior for 1 (#3) of 26 sampled residents. Findings include: 1. During an interview on [DATE] at 3:07 p.m., resident #41 said he was having problems dealing with some confusion and issues in his life. Resident #41 said his wife died in October of last year, and he still missed her. Resident #41 said his family visited, but he still missed his wife and expected to see her in her room at the cottage where they lived. He said someone from the facility may have talked to him at one time. Review of resident #41's current care plan failed to show a focus area related to grief due to the death of the resident's wife. No interventions were in place for helping the resident deal with grief, coping, or loneliness. During an interview on [DATE] at 10:40 a.m., staff member G said the care plan for resident #41 should have been updated. Staff member G said everyone here knew about his wife's death. Staff member G stated, I don't know if I have updated the care plan. I have to admit I'm not the best at updating care plans and would not be surprised if no update was made on the care plan. 41652 2. During an observation and interview on [DATE] at 9:50 a.m., resident #47 stated he did not like asking for help and had issues with his balance. Resident #47 stated he had a series of falls a while ago and injured his back. The resident stated he still had back pain. During an interview on [DATE] at 8:36 a.m., staff member F stated the fall prevention interventions for resident #47 included frequent checks, and the use of a camera, when he was in his room. Review of resident #47's care plan, dated [DATE], failed to show the use of a camera when the resident was in his room for fall prevention. During an interview on [DATE] at 10:05 a.m., staff member I stated it was everyone's responsibility to ensure care plans were updated timely. 3. During an interview on [DATE] at 8:50 a.m., staff member C stated resident #3 often refused showers and assistance with incontinence care. Staff member C stated she may be resistant because she was new to this cottage. Review of resident #3's care plan, dated [DATE], showed a problem with adjustment, which was for the move from a unit in the main building, to [NAME] Cottage. This move occurred in March of 2023. This problem should have been resolved or revised to identify a more recent move from [NAME] Cottage to [NAME] Cottage which occurred in June of 2024.

Based on interview and record review, the facility failed to protect residents from staff abuse resulting in a bruise for 1 (#71) and emotional distress for 4 (#s 9, 28, 69, and 71) of 4 sampled residents. Findings include: 1. Review of the Facility Reported incident on 5/8/22 at 5:15 p.m., showed, Staff was notified that [staff member N] was kicking [resident #71]. [Staff member N] was asked not to return to the facility as she was a per diem agency [staff member N job title]. Police notified and investigation opened into the event. Findings . It was noted that [resident #71] did have a bruise to his left medial calf. [staff member L] did witness [staff member N] kicking [resident #71] foot pedals and legs under the dining room table. [Staff member L] told [staff member N] to stop, she did not. [Resident #71] was then removed from the dining area by [staff member M]. Review of a facility staff interview via email, dated 5/16/22, with staff member O showed, [Staff member L] reported that at dinner in the dining room she heard [resident #71] yelling saying, stop that and being very upset. [Staff member L] asked [resident #71] what was wrong, and he stated that [staff member N] was kicking him and sure enough she was kicking him under the table . [staff member L] told them to stop, that it is wrong .even after [staff member L] said something to them, they continued to mess with [resident #71]. Review of a facility staff interview via email, dated 5/16/22, with staff member L showed, . I (staff member L) had gone into the dining room and [resident #71] was yelling '[unknown person initials] stop it' I asked [resident #71] what was wrong and he she [staff member N] was kicking him. I then witnessed [staff member N] kicking [resident #71's] foot pedals and feet . [staff member N] continued to kick at [resident #71] and [staff member M] came in at that time and took [resident #71] out of the dining room. [sic] Review of an email from staff member P, dated 5/9/22, showed, [Resident #71] has approx. A 2.5 cm purple bruise to his left shin with a red area present. During an interview on 7/20/22 at 10:42 a.m., staff member B stated abuse was substantiated involving staff member N kicking resident #71. Staff member N was not allowed back to the facility, and she was not working during the investigation. Staff member B stated abuse training is completed upon hire and yearly with all staff members. 2. Review of a incident reported to the State Survey Agency, dated 3/7/22, showed, [Resident #9] was visible upset and crying to one of [facility name] CNA's stating that [NF3] asked him to go to dinner on March 7. He [resident #9] stated he was not going to eat that night . [NF3] stated 'oh yes you are .' and started to push his wheelchair out of the room. His foot hit something on the way out because he did not wish to pick up his feet and go-she then impolitely stated to him to 'move your feet.' He told the [facility name] CNA that he felt as though his rights were disregarded. Also reported that on the same that day 2 other C.NA's were changing another resident [resident#28], as she was very wet. [NF3] had disregarded answering her lights and when she went into [resident #28's] room and saw the other CNA's cleaning her up, [NF3] stated .to [resident #28], 'Did you really just go and soak your bed again?' [sic] Under the Findings submitted heading, showed the results of the investigation were relayed to the State Survey Agency on 3/10/22: This writer contacted [staffing company] owner immediately upon receiving this information and [NF3] was removed immediately from [facility name] and is no longer allowed on this Campus. Families and physicians of residents involved were informed. [staffing company] C.NA's are be to given further abuse education and will review [facility] policies in depth before coming to work here. [sic] During an interview on 7/20/22 at 11:00 a.m., resident #28 stated on night shift, back in March 2022, [NF3] said 'Did you really just go and soak your bed again?' I (resident #28) waited an hour or more for another CNA to come change me. It made me feel really bad, I don't have any control over my bladder. [sic] A review of a staff interview via email, dated 3/9/22, with staff member V showed, . I (staff member V) was in with [staff member X] helping change [resident #28] because she had soaked her bed. [NF3] went walking the floor looking for me because she couldn't find me to answer my own call lights. When I came out of [resident #28's] room she was standing in the hall. I told her why I was there and she became irritated stating she just changed her not long ago. She [NF3] then proceeded to go into [resident #28's] room again saying did you really just go and soak your bed again? We just changed you. [sic] A review of a staff interview via email, dated 3/8/22, with staff member W showed, . [Resident #9] has mentioned to me that on of the CNA's from [state name] told him that he can put himself into bed. Which he can not and I explained to him that the Physical Therapy has to evaluate him for that. [sic] A review of a staff interview via email, dated 3/9/22, with staff member U showed, . Yesterday during dinner I (staff member U) had a conversation with [resident #9] where he was visibly upset and crying throughout the entire talk. He informed me that [NF3] came into his room to ask him to go to dinner and he said he was not going to eat. This is a normal occurrence for [resident #9] He then said [NF3] told him he was going anyway and started to push his wheelchair out of the room. His foot hit something while she was pushing him because he was not wanting to go so his feet were not picked up and she then impolitely told him to move his feet. He told me this was not the first problem he has had with her that day but he did not go into detail on the other occurrences. He was very angry and upset that his rights as a person were disregarded. 3. A review of an incident reported to the State Survey Agency incident reporting system, dated 3/21/22, showed, Reported to this nurse this early morning 3-22-22: On 3-21-22-(staff member U) reports to the charge nurse that she put [resident #69] (elder) to bed around 7:05 pm/ Close to 5 minutes later she rang to use the bathroom--which is a normal occurrence for [resident #69]. (Another C.NA) put her on the toilet and left her to have some privacy. When [resident #69] rang from the bathroom after completing her toileting, [NF5] (Contract C.NA from [staffing company]) went in to help her. [NF5] reported to [staff member U] the following, which was also confirmed by the elder, [resident #69]: [resident #69] asked [NF5] to put her back in bed. [NF5] told her she was not going to put her back to bed, despite her wishes, as she was going to keep asking to go to the bathroom and she had already been twice which was enough for the night. [NF5] told [resident #69] that she would put her to bed no earlier than 9:30 because she was not going to deal with her bathroom needs. [Staff member U] went to [resident #69's] room less than 5 minutes after this incident and she was very upset and was left without her call light. [Staff member U] did put [resident #69] back to bed at this time, as requested. Family and providers made aware. Investigation will continue. [sic] Under the Findings submitted heading, showed the results of the investigation were relayed to the State Survey Agency reporting portal on 3/24/22: Verbal abuse and neglect did occur. The CNA, [NF5] (Contract C,.NA) through [staffing company] was terminated after the investigation showed that abuse did occur. Elder was spoken to and was physically unharmed but pleased to hear that matters were taken care of. [sic] A review of a staff interview via email, dated 3/21/22, with staff member U showed, Tonight there has been an instance of elder abuse I cannot leave untold. this is how the incident was recounted to me by [NF5]. I later talked to [resident #69] and she confirmed. [NF5] told me that [resident #69] asked to be put back in bed, to which [NF5] replied with something along the lines of she was not going to put her in bed despite her wishes because she was going to keep asking to go to the bathroom and she had already been twice which was enough for the night. [NF5] told [resident #69] she would put her to bed no earlier than 9:30 because she was not going to deal with her bathroom need. I [staff member U] went in to [resident #69's] room less than 5 minutes after this incident and she was very upset and left her without her call light. [sic] During an interview on 7/20/22 at 12:51 p.m., NF4 stated after the incidents of abuse involving residents #s 9, 28, and 69, I interviewed the residents involved. I did not interview any other residents. There was no nursing staff abuse education following the abuse incidents. New staff gets abuse training within the first week of being employed. A review of a facility policy titled, Abuse Policy, with an initiation date of 11/16, showed, . It is the policy [Facility name] that each resident will be free from 'Abuse'. Abuse can include verbal, mental, sexual, or physical abuse, corporal punishment or involuntary seclusion. Additionally, residents will be protected from abuse, neglect, and harm while residing at [facility name]. No abuse or harm will be tolerated, and residents and staff will be monitored for Protection. The facility will strive to educate staff and other applicable individuals in techniques to protect all parties. [sic] A review of the facility QAPI meeting minutes, dated 4/22/22, failed to show any discussion related to the 3/7/22 and the 3/21/22 incidents of abuse.

Based on observation, interview, and record review, the facility staff failed to prevent the development of pressure injuries resulting in pain for 1 (#48) and transfer to a higher level of care due to infection for 1 (#27); and failed to evaluate and document consistently the wound stage and characteristics for 1 (#48) of 2 sampled residents. These deficient practices had the potential to effect other residents who were at risk for altered skin integrity. Findings include: 1. During an interview on 7/20/22 at 2:16 p.m., with staff members I and J, staff member I stated resident #27 had a pressure wound located on her tailbone area. Staff member I stated she was not sure when the wound first occurred. Staff member I stated the resident went to the wound clinic once a week but she has not seen any improvement and the resident cannot feel the wound because it is necrotic. Staff member J stated the resident was using a sling for transportation and it caused shearing, which led to the pressure ulcer. During an interview on 7/20/22 at 3:22 p.m., staff member T stated she completed wound care at the facility. Staff member T stated a nurse observed a boil on resident #27 right above the resident's anus on 1/23/22. A few days later she went in to observe the wound and determined it was a Stage II pressure ulcer caused from shearing using a sling for transfers. Staff member T stated resident #27 had a sacral fracture and the wound was having a hard time healing due to its location. Resident #27's pressure ulcer was facility acquired caused by sling sheering. Review of resident #27's skin/wound progress note, dated 1/23/22, showed, Right buttocks has a boil, it is not open, it is red and irritated. Irritation is 4x4 in size. Area was cleaned and Mepilex border was applied. Review of resident #27's skin/wound progress note, dated 1/25/22, showed, stage II shearing R medial gluteal fold 2x2.80.1cm 50% epithelial tissue 50% nongranulating tissue, min exudate Caused - likely sling shearing skin. Signed by staff member T. Review of resident #27's skin/wound progress note, dated 2/8/22, showed, R medial pressure injury from shear: 2.5x3.3x0.3cm 75% adipose tissue stage III, 5% slough eschar 20% epithelial tissue, mod exudate purulent and serous, periwound pink and inflamed. Signed by staff member T. Review of resident #27's Communication with physician, dated 2/18/22, showed, [Staff member T] mentioned she would get a referral for wound care/I called provider and she accepted the request and an order was sent to wound care. Review of resident #27's Health Status note, dated 7/19/22, showed, This nurse spoke with [name of wound clinic] about the transfer of [resident #27] from wound clinic to ED. Wound clinic inform me that when [resident #27] first arrived at the clinic they removed dressing that was placed this morning and placed a new one. During actual appointment when the nurse practitioner took new dressing off, large amount of brown liquid drainage came out of wound. Upon assessment NP noted new tunneling forming. NP worried about possible fistula or abscess within wound. Sent [resident #27] to ED for imaging. [sic] Review of resident #27's Communication with family progress note, dated 7/19/22, showed, This nurse spoke with [resident #27's] daughter . ED currently giving [resident #27] IV antibiotics and pain meds. No word on plans of discharge. [sic] 41951 2. During an observation and interview on 7/20/22 at 2:14 p.m., resident #48's dressing was partially rolled back off of the wound which was located on his coccyx and both buttocks. The wound was dime sized open areas, through the top layer of skin, on both buttocks. Resident #48 stated the wounds were painful and caused him pain all the time. During an interview on 7/20/22 at 2:44 p.m., staff member Y stated resident #48's wound was an abrasion and the provider was aware of the wound. Staff member Y stated PT was who took care of the wound. When asked about the dressing being dated 7/15/22, with an order to change the dressing every three days, staff member T stated the dressing was changed when his last bath was done and left on if intact. During an interview on 7/20/22 at 3:21 p.m., staff member T stated she was not wound care certified and had been trained by a previous Director of Therapy. Staff member T stated she had seen resident #48 in the past but was not currently changing his dressings. During an interview on 7/21/22 at 8:53 a.m., staff member B stated he was aware there were areas in need of improvement with wound care. Staff member B stated the facility was working on education, documentation, and developing a consistent program for wound and skin care which prevented harm to their elder population. Review of resident #48's Wound/Skin progress notes, dated between 10/18/21 and 7/13/22, failed to show documentation of the size of the wounds on the resident's buttocks and coccyx. The notes also failed to show the progress in wound healing.

Based on interview and record review, the nurse failed to notify a physician for a change of condition that resulted in a hospitalization for 1 (#238) of 38 sampled and supplemental residents. Findings include: During an interview on 8/21/19 at 1:54 p.m., staff member J stated changes of condition such as swelling and desaturation, would be documented in notebooks used by physicians that round in the facility, and then the nurse would call a provider depending on the seriousness of the resident's condition. During an interview on 8/22/19 at 11:16 a.m., staff member B stated a resident that was exhibiting swelling and desaturation, would receive oxygen right away, because it is in the facility's standing orders. The staff are always to let the physician know when a resident exhibited new signs and symptoms by filling out the SBAR form in the folder that the physcians use when rounding in the facility. The nurse should then monitor and use good nursing judgement, in accordance with what the physician recommends, and orders for the resident. Review of resident #238's Respiratory Measurements showed the following: -On 6/20/19 resident #238 had a non-productive spontaneous cough, lungs were clear, and oxygen saturation was measured at 97% on room air. -On 6/26/19 resident #238's cough was described as, Able to clear secretions, Dry, Harsh, Non-productive, Sponateous, Strong. (sic) -On 6/27/19 resident #238's lungs were noted to be clear and diminished at the bases, and was noted to have had, difficulty breathing with activity, Difficulty breathing at rest, Shortness of breath. (sic) Resident #238's oxygen saturation was measured at 89% on room air. -On 6/28/19 resident #238's cough was occasional, productive, spontaneous, strong, and able to clear secretions. Resident #238's oxygen saturation was measured at 88% and 84% on room air. -On 6/29/19 resident #238's lungs were noted to be clear and diminished at bases. Resident #238's oxygen saturation was measured at 88% on room air. -On 6/30/19 resident #238's lungs were noted to have had crackles at the bases of both her lungs. Resident #238's oxygen saturation was measured at 88% on room air. -On 7/1/19 resident #238's cough was described as barking, productive, spontaneous, strong, and able to clear secretions. Resident #238's left lung was noted to have an expiratory wheeze. Review of resident #238's Physical Therapy Long Term Care Progress Notes, showed the following: - On 6/27/19, Pt (patient) desaturation to 87 after ambulation . - On 6/29/19, Pt (patient) continues to be on 1L of oxygen with activity. Review of resident #238's Care Management Progress Note, dated 7/2/19, showed resident #238 was sent to the emergency room related to, .increased [MEDICAL CONDITION] today and needing more supplemental oxygen, and persistant cough. She was admitted to (hospital) for acute [MEDICAL CONDITION] secondary to heart failure exacerbation. A request on 8/22/19 at 12:15 p.m., for physician communication and visit documentation of resident #238 was not provided by the facility.

Based on record review and interview, the facility failed to utilize the residents fall history, to determine risk factors, and utilize root cause analysis to identify individualized interventions for fall prevention, and implement interventions which were reviewed and modified to determine if they were successful for future fall prevention; specifically, for a resident who had repeated falls, to include with head injuries, and who had a [DIAGNOSES REDACTED].#8); and for residents' who had a [DIAGNOSES REDACTED].#s 10 and 18) out of 26 sampled residents. Findings include: 1. Resident #8 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. Review of the Post Fall Evaluation LTC Forms, and the Immediate Post Fall Assessment forms showed the resident had falls which occurred on the following dates: 10/31/15, 11/7/15, 11/13/15, 11/15/15, 11/17/15, 11/26/15, 12/1/15; and 1/21/16, 1/25/16, 2/21/16, 3/4/16, 3/22/16 (lowered to floor), 3/24/16, 4/23/16, 5/7/16, 5/9/16, 5/15/16, 5/17/16, 6/27/16, and 7/31/16. The documentation showed: - The resident had three head injuries, to include lacerations. - Four of the falls involved the resident attempting to go to the bathroom, and/or she was incontinent. - Seven of the falls occurred between 3:30 a.m., and 7:00 a.m., which was almost half of the falls. - Nine of the evaluations lacked evidence for any new or modified interventions based on the resident's fall events at the time of the fall, to prevent future falls. - The residents cognitive status varied from confused to alert and oriented. - Several of the evaluations showed the resident needed increased monitoring and assistance, but the facility was unable to provide evidence of the increased assistance, or that the interventions were evaluated as being successful for the prevention of falls. - Several of the falls occurred when the resident was attempting to get a drink or personal item that was out of reach, which had not been maintained at her side. - Inappropriate footwear was identified on 11/7/15, but the resident continued to have repeat falls related to inappropriate footwear, or state of dress. During an interview on 8/30/16 at 4:00 p.m., staff member O stated the staff checked on the resident frequently. The facility was unable to provide documentation showing the resident was checked frequently. Staff member O stated, She keeps her door shut. He stated the resident will say, I'm [AGE] years old, and I'll do what I want. Get the hell out of my room. Review of the resident's Comprehensive Fall Assessment team meeting note, which was undated, showed: Does ADLs unassisted; fail in attempts to have her call for help; convince her to call for help when needing to walk in her room. Although the facility identified these concerns, the medical record lacked evidence relating to increased monitoring, or how the facility would directly address the resident's ability to call for assistance. During an interview on 8/30/16 at 4:15 p.m., staff member Q stated the resident tended to exhibit sun downing behavior 3:00 p.m. and 8:00 p.m. She said the resident required more time and attention during these hours to keep her safe. The concern was not identified on the care plan as a potential fall risk due to the change in behavior, and the care plan lacked evidence for any interventions staff would utilize for fall prevention relating to the sun downing behavior. During an interview and observation on 8/30/16 at 1:30 p.m., resident #8 said she would fall because the floor was too slick. A rug would help. She also stated she was blind in one eye, and that she now leaves her shoes on until bedtime so she does not fall. Resident #8 had her four wheeled walker in front of her while she sat in her recliner. Review of the Care Plan, dated 7/27/15, showed falls occurred in 2015 on 10/31, 11/7, 11/17(two), 11/26, 12/1/15; and in 2016 on 1/21, 2/21, 4/23, 5/7, 5/9, 5/15, 5/17, 6/22, 7/31, and 8/1/16. The intervention for each fall included continue same. Current Care Plan interventions dated 7/27/15 showed: Offer me verbal cueing as necessary for transfers, mobility, and safety. Assist me with ambulation - when I am restless assist me with a walk - maybe even Q 1 hour. Monitor me for any acute medical problems that may alter my mobility or cognition. I use an assistive devices for mobility. Assess my footwear for proper fit - monitor my feet for edema - monitor for bunions . Give me positive feedback for appropriate behavior. Please bring me out to the day area/living room for closer monitoring - do not leave me unattended in my w/c - either assist me to my recliner or assist me to bed. Low bed with mat on the floor - my bed should be in the low position when I am in bed. The care plan lacked evidence relating to how the plan was modified for the fall risk factors, interventions to address the root cause of falls, or if the current plan at the time of the fall continued to meet the resident's needs relating to falls. One new intervention dated 11/17/15 showed, splitter with dual pancake light; and an entry dated 8/1/16, showed Elder continues to decline to use call light stating The lord is ready to take me. 2. Resident #10 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. Review of the Post Fall Evaluation LTC Forms for resident #10 showed the resident had 18 falls from 12/2015 to 8/2016. Review of the Comprehensive Fall Assessment interdisciplinary notes (undated), showed falls occurred on the following dates in 2016: 2/4, 2/10, 2/24, 3/4, 4/4, 4/8, 4/20, 4/30, 5/3, and 5/21/16. Documentation showed, Most falls from recliner transfers, in room, time is usually late afternoon and early evening. No interventions were documented by the interdisciplinary team to help reduce the number of falls based on the history and circumstances of the repeated falls. Review of a second Comprehensive Fall Assessment interdisciplinary note (undated), showed falls occurred in 2016 on: 4/4, 4/8, 4/20, 5/3, and 5/21/16. The documentation showed, Falls in room without FWW use, and doesn't use call light. The recommendation was call light use reinforcement even though the team identified and documented that the resident did not always use the call light and the resident had a [DIAGNOSES REDACTED]. Review of the resident's Post Fall Evaluation Forms showed the following: - 2/10/16 - Interventions to Prevent Future Falls: remind to use call light, Other: Resident with advanced dementia, does not remember to use call light, even when reminded often. Call light in reach at all times. - Review of 10 alternate Post Fall Evaluation Forms for the resident's falls, which occurred in 2016, showed Remind to use call light although the facility had identified the resident's dementia was a factor with her recalling to use the call light, and the interventions remained the same for the 10 fall evaluations. The evaluations lacked evidence for individualized interventions based on the event details, root causes, and outcomes, for each fall. - Review of 3 additional Post Fall Evaluation Forms showed a lack of documentation for interventions to prevent future falls, although the resident continued to have falls, and was at risk for future falls. During an interview on 8/30/16 at 2:20 p.m., staff member K stated the resident required total assist for care, and was unable to use the call light because of cognitive impairment. Review of the care plan, dated 5/19/16, showed falls for resident #10 on 5/20, 6/8, 6/11, 6/16, 6/24, 7/1, 7/6 and 7/8/16. For each fall, the care plan showed No New Interventions. Review of the Care Plan interventions, with a start date of 6/1/15, showed interventions neither addressed the root causes of the repeated falls, nor were individualized to the resident based on her fall history, dementia and fall risk factors, and included: Offer me verbal cueing as necessary for transfers, mobility, and safety. Assist me with ambulation. Monitor me for any acute medical problems that may alter my mobility or cognition. Assess my footwear for proper fit. Give me positive feedback for appropriate behavior. If I am in my room please provide with frequent checks for safety. Continue toileting plan - be sure to toilet/change me prior to assisting me to my chair or bed. One new intervention was added to the care plan on 5/19/16 which showed, I use an assistive devices for mobility- FWW - wheelchair for long distances. During an interview on 8/31/16 at 8:00 a.m., staff member P stated she would fix the care plan for resident #10. She stated most of the falls were caused by the resident trying to get to the bathroom. Per the urologist, the resident had a blood clot in her bladder, which may have caused her to feel the need to use the bathroom frequently. This possible cause for falls was not addressed on the care plan with effective interventions to reduce falls. 3. Resident #18 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the Post Fall Evaluation Forms for resident #18 showed 13 falls from 10/26/16 to 7/29/16. Review of the Immediate Post Fall Assessments for the resident's falls showed the following: - The facility identified the fall may have occurred due to inappropriate foot wear two times. - The facility identified the falls may have occurred due to needing more assistance six times. - The facility identified the falls may have occurred due to the resident having incontinence with bowel and bladder two times. - The care plan did not address the potential causes for falls, noted above. Review of the resident's care plan, dated 1/6/15, showed falls occurred in 2015 on 10/26, 11/8, 11/9 (two times), 12/25, 12/3/15; and in 2016 on 1/16, 1/25, 4/3, 4/13, 5/23, 6/6, and 7/25/16. The care plan showed Continue same interventions which was written for each fall. The care plan for resident #18 contained the same interventions as residents #10 and #8 for the repeated falls, except for one new intervention, dated 1/16/16, which was for a pancake light outside of bed near hip. During an interview on 8/31/16 at 10:00 a.m., staff member N stated the facility looked at all falls each quarter in the quality assurance meeting. The resident falls were graphed for the numbers and injuries, which were for each living area in the facility.