Every finding on record at St Luke Community Nursing Home

Based on interview and record review, the facility failed to ensure all infection control policies, and the list of reportable communicable diseases, were updated or reviewed annually. This deficient practice had the potential to affect all residents in the facility related to infection control prevention. Findings include:1. Infection Control PoliciesDuring an interview on 5/7/26 at 8:10 a.m., staff member A stated, I think we updated them [infection control policies] in 2024, and I think we looked at them [infection control policies] last year, too. We try to update our infection control policies annually.During an interview on 5/7/26 at 9:40 a.m., staff member C stated the infection control program and policies were reviewed two years ago and had not been reviewed since.Review of the following facility policies showed:- INFLUENZA IMMUNIZATION. Revised 06/2017. The facility provided an updated policy, IMMUNIZATION INFLUENZA, updated 5/7/26, after the start of the survey.- PNEUMOCOCCAL IMMUNIZATION. Revised 06/2017. The facility provided an updated policy, IMMUNIZATION PNEUMOCOCCAL, updated 5/7/26, after the start of the survey.- Antibiotic Stewardship Program (ASP). Effective Date: July 21, 2017, no revision date documented. - INFECTION CONTROL - PREVENTION. Updated 4/20/24, two years prior to the survey start date.2. Reportable Communicable DiseasesDuring an interview on 5/7/26 at 9:44 a.m., staff member D stated they would tell staff member A or B if there was a communicable disease to report.During an interview and record review on 5/7/26 at 9:48 a.m., staff member A stated the facility was supposed to report communicable diseases to the local county health department. Staff member A pointed to the document, Reporting of Communicable Diseases in Montana, dated March 2017, and stated, This is the sheet the health department sent us. Staff member B viewed the document and stated, I did not even notice the date; it is just the one I found real quick this morning. I think this is the one on their website. Staff member A stated, We need to update this [list of reportable diseases].Review of the Lake County health department website showed the current list of reportable communicable diseases was revised in June 20241, almost five years after the facility's list of communicable diseases was provided to the surveyor.REFERENCE1DPHHS, Communicable Disease Reporting, June 2004, https://www.lakemt.gov/244/Communicable-Disease (May 7th, 2026).

Based on observations, interviews, and record review, the facility failed to ensure staff utilized safety straps for sit-to-stand lifts, resulting in a fall with major injury, for 1 (#11); and placing residents requiring the use of the sit-to-stand lift at risk of falls, for 3 (#s 9, 20, and 23) of 4 sampled residents; and failed to ensure a resident was sufficiently assessed on an ongoing basis and monitored for the use of a Broda chair related to her fall risk and prevention, which may have led to a further decline in mobility, for 1 (#10) of 19 sampled residents. Findings include: 1. During an interview on 3/25/25 at 4:04 p.m., staff member R stated resident #11 slid out of the sit-to-stand mechanical lift a few months ago. Review of resident #11's Post Fall Huddle Investigation, dated 11/25/25, reflected resident #11 fell from the sit-to-stand mechanical lift, landing on her knees, during a transfer. The report reflected, . [Resident #11] was on the Vera-Lift near the bathroom doorway so he thought that [name] must have toileted her. [Resident #11] kneeling on the lift leaning forward. [Left] arm was up and out of the sling - [Right] arm was against the bar. [sic] The Post-Fall Huddle reflected the form was not completed until the day after the fall occurred, because the CNAs involved did not report the incident to the nurse on duty. The form was incomplete and did not reflect a root cause analysis was completed to determine why the fall and misuse of the lift occurred. Review of resident #11's Communication Progress note, dated 11/26/24, reflected, . nurse had spoke with [Physician name] and she reported that the resident does have a fracture through her humeral neck. [sic] During an interview on 3/26/25 at 2:15 p.m., staff member D stated she believed the safety straps would have been beneficial in preventing resident #11 from sliding through the sit to stand lift lift. Staff member D stated a resident would not slide through the lift if they were strapped in with the chest and knee safety belts. During an interview on 3/27/25 at 3:40 p.m., staff member A stated the staff did not report the fall until the next day, so they did not have a post fall huddle, and no root cause was determined for the fall. The fall from the lift resulted in a substantial injury for the resident. 2. During an observation on 3/24/25 at 12:15 p.m., staff members I and M transferred resident #9 to the toilet using the sit-to-stand lift (Vera-Lift). Both staff members I and M assisted in placing the sling on the resident, then prepared resident #9 for the transfer to the toilet. Staff member M lifted resident #9 off the toilet, with assistance of staff member I, and returned her to her recliner. The knee safety straps, or safety strap around the sling, were not utilized during either transfer, so the transfer was completed without following safety precautions for the lift use. During an observation on 3/25/25 at 3:49 p.m., staff members Q and R transferred resident #9 to the toilet using the sit-to-stand lift (Vera-Lift). Both staff members Q and R assisted in placing the sling on the resident and prepared the resident for the transfer to the toilet. Staff member R lifted resident #9 off the toilet, with assistance of staff member Q, and returned the resident to her bed. The knee safety straps, or safety strap around the sling, were not utilized during either transfer. During an interview on 3/25/25 at 3:55 p.m., with staff member Q and R, staff member Q stated she, . only used the safety straps when we assess the need in the moment, like if they seem weaker than usual. Staff member R stated, The staff generally do not use the safety straps unless the patient seemed weaker or resistant to cares. 3. During an observation on 3/24/25 at 1:02 p.m., staff members H and T transferred resident #23 to the toilet using the sit-to-stand lift (Vera-Lift). Both staff members H and T assisted in placing the sling on the patient and prepared resident for transfer to the toilet. Staff member T lifted resident #23 off the toilet with the assistance of staff member H and returned her to her bed. The knee straps or safety strap around the sling were not utilized during either transfer. 4. During an observation on 3/25/25 at 10:01 a.m., staff members G and S transferred resident #20 to the toilet using the sit-to-stand lift (Vera-Lift). Both staff members G and S assisted in placing the sling on the resident and prepared resident #20 for the transfer to the toilet. Staff member G lifted resident #20 off the toilet, with the assistance of staff member S, and returned her to her bed. Neither the knee safety straps, nor safety strap around the sling, were utilized during either transfer. During an interview on 3/27/25 at 10:07 a.m., staff member Y stated she would expect staff to use safety straps on the lifts, unless the resident had wounds or pain in the area where the straps cross. Review of the facility's policy, Long-Term Facility Fall Prevention and Management, dated 2/26/25 reflected: - . In the event of a fall or near fall, the charge nurse will initiate the Fall Report and Fall Huddle. After each fall, a thorough review and investigation will take place. This includes: - a. Identifying contributing factors (e.g., environmental, staff actions, or resident conditions) - b. Reviewing whether fall prevention strategies were in place and effective. Review of the facility's policy, Transfer P&P For Vander-Lift/Vera-Lift, dated 5/6/20, reflected: - . Secure leg straps around resident's legs for safety. Review of the Vera-Lift II Operating Manual, provided by the facility, no date, reflected: - . Fasten the inner safety belt snuggly. On 3/16/23, a Recertification survey was completed. F689 - Accidents and Hazards, was cited related to fall prevention, to include staff not reporting fall(s). The severity and scope for the deficiency was cited at the level of J, Immediate Jeopardy to Health and Safety of the resident(s). The facility implemented a plan of correction, to include staff training on fall prevention, identifying root causes, and staff reporting falls. 5. During observations on 3/24/25 at 12:05 p.m., 3/24/25 at 4:02 p.m., 3/25/25 at 8:19 a.m., 3/26/25 at 9:56 a.m., and on 3/27/25 at 8:58 a.m., resident #10 was reclined in a Broda chair either at the nursing station or her room. During an interview on 3/25/25 at 10:00 a.m., NF2 stated she was concerned resident #10's mobility was being taken away from her since a fall in 2023, and now she was 100% wheelchair bound. During an interview on 3/25/25 at 3:00 p.m., NF2 stated staff members A and E told her the use of the Broda chair was required for several reasons, to include the Broda chair keeps her safe from falling; and the Broda chair was harder for her mother to climb out of. NF2 stated she was upset watching her mother decline physically and mentally since she was placed in the Broda chair to prevent falls two years ago. During an interview on 3/26/25 at 10:14 a.m., staff member A and E stated they did not have physician orders, consents, and quarterly assessments for the use of the resident #10's Broda chair as a possible restraint. During an interview on 3/27/25 at 8:59 a.m., staff member L stated there was a safety component with the use of resident #10's Broda chair because she used to fall a lot. Staff member L stated she could probably sit in a wheelchair but was not sure how she could be assessed for the manual wheelchair. Review of the facility's policy titled, Policy and Procedure Broda chair, updated 3/25/25, showed: .The goal is to support residents .improved quality of life. .An assessment by the IDT team, including input from the resident and their family, will determine the need for a Broda chair. The Broda chair assessment will be completed quarterly and annually by the care team. .A physician order and consent form will be obtained . On 3/25/25 at 4:30 p.m., a request for patient #10's Broda chair assessments, orders, and consents was requested from the facility. No additional documentation was provided by the end of the survey.

Based on observation, interview and record review, the facility failed to ensure staff changed gloves and performed hand hygiene when moving from a contaminated task to a clean task during the provision of ADL care for 2 (#s 9 and 11); failed to maintain a clean gait belt for 1 (#14) of 19 sampled residents; and failed to maintain a soiled/dirty area separate from the clean equipment and supplies; and failed to maintain cleanable surfaces in the laundry room. These deficient practices increased the risk of infection for all residents receiving services in the facility. Findings include: 1. Hand Hygiene and Glove Changes a. During an observation on 3/25/25 at 9:15 a.m., staff member G cleaned resident #11 of BM. With the same gloved hands used to wipe the resident of BM, staff member G opened a clean brief and laid it out to be placed on the resident. Staff member G then opened the package of wet wipes and grabbed out several more wipes and continued to cleanse the resident of BM. Staff member G did not change her gloves or cleanse her hands between completing the soiled care to when she placed the clean brief on resident #11. During an interview on 3/25/25 at 9:30 a.m., staff member G stated it was the expectation to change gloves and disinfect hands when transitioning between a contaminated task and a clean task. b. During an observation on 3/25/25 at 10:01 a.m., staff members G and S were preparing resident #9 to be toileted with the Vera-lift. Staff member G attached the lift belt to resident #9 and to the lift. Staff member S ran the lift, and both assisted resident #9 to the bathroom. Staff members G and S each assisted on opposite sides of resident #9, removing the dirty brief and guiding resident #9 to the toilet. Staff member G exited the bathroom and began scratching her face above her eye with the dirty glove on. Staff member S exited the bathroom and pulled out a brief and the wipes from the closet with her dirty gloves. Both staff members G and S re-entered the bathroom and put on a new brief and pantyliner in place with their soiled gloves on. Staff member S began to raise the Vera-lift and staff member G began to clean resident #9's peri-area. Staff member G and S did not change their gloves or cleanse their hands between completing the soiled care to when they placed the clean brief on resident #9 and touched face with soiled glove. c. During an observation and interview on 3/25/25 at 3:49 p.m., staff members Q and R prepared resident #9 for transfer to the toilet with the Vera-lift. They transferred resident #9 to the toilet, with one on each side of the resident and assisted each other in the removal of the soiled brief. Staff member Q exited the bathroom, with her dirty gloves still on, and removed a clean brief and wipes from the closet stock and returned to the bathroom. Staff member R grabbed new gloves from the box on the wall while wearing her contaminated gloves. Staff member Q raised resident #9 up from the toilet, using the Vera-Lift, while staff member R cleansed resident #9's peri-area. Staff member Q began to pull up the brief she and staff member R placed on resident #9. Staff member R took her gloves off, and took resident #9 to her recliner, using the Vera-Lift. Staff member R did not complete hand hygiene after degloving. Staff member R stated she forgot to complete hand hygiene and then was overthinking it because her hand sanitizer was in her pocket. Staff member Q and R did not change their gloves or cleanse their hands between completing the soiled care to when they placed the clean brief on resident #9. During an interview on 3/26/25 at 11:30 a.m., staff member A stated it was the expectation for staff to wash their hands and change gloves between clean and dirty care. On 3/26/25 at 5:00 p.m., a request for the facility's policy and procedure for hand hygiene was requested. The document was not provided by the end of the survey. During an interview on 3/27/25 at 8:33 a.m., staff member D stated there was not a policy specific to the hand washing, but the staff had the hand washing training with return demonstration. 48261 2. Gait Belt Disinfection During an observation and interview on 3/25/25 at 7:48 a.m., staff member G offered to assist resident #1 to walk from the dining room to her room for her exercise program. Resident #1 stood up from her wheelchair and staff member G removed the gait belt from around her own waist and placed the same gait belt around resident #1's waist. Staff member G walked resident #1 to her room, removed the gait belt from resident #1, and placed the gait belt back on her own waist. Staff member G stated the facility issued them a gait belt to be used on all residents throughout the day and then the CNAs each sanitize their own gait belts at the end of their shifts. On 3/26/25 at 5:00 p.m., a request for the facility's policy and procedure for gait belt disinfection was requested. The document was not provided by the end of the survey. During an interview on 3/27/25 at 11:03 a.m., staff member D stated the facility did not have a policy related to cleaning of the gate belts, but she would expect the staff to clean the gate belts after every use. 3. Dirty Linen and Laundry Room a. During an observation and interview on 3/26/25 at 12:35 p.m., of the shower room on unit 300, there were three bins inside the door for dirty linens and trash. Next to those bins was a clean shower bed, a tub, and clean Vera-lifts/Vander-Lifts. Upon immediate entrance of the room, across from the trash and dirty laundry bins, was two clean linen racks full of linens. The shower area had multiple cracks in the flooring, creating an uncleanable surface. Staff member W stated the facility was planning to do a remodel soon and create a separate space for the dirty linens and trash. During an observation and interview on 3/26/25 at 12:45 p.m., of the shower room on unit 200, there were three bins immediately upon entry of the shower room to the right for dirty linens and trash. Above the bins was wooden cabinets with clean linens and peri care supplies and briefs. In front of the dirty linen bins and trash bin was the clean Vera-lifts/Vander-Lifts, two tubs, and a dirty linen bin. Down the right wall along the floor was a crack through the tile running the length of the wall. To the left of the door was a clean linen cabinet with briefs blocking the access to the sink. Across from the cabinet, was a shower area. Between the shower area and the tub area was a half wall with broken tiles, with missing pieces, creating an uncleanable surface and an injury hazard. Staff member W stated the dirty linen bins were placed in the shower room for convenience for staff. Staff member W stated there was also a dirty utility room two doors down the hall. Staff member W stated the facility was aware of the shower room being used to store both clean and dirty linens and trash but thought the remodel would have been done sooner. Staff member W stated they recently had an Infection Control Assessment and Response (ICAR) evaluation completed which determined the shower room was inappropriately being used as a dirty and clean utility. During an observation and interview on 3/24/25 at 1:10 p.m., the shower room had a strong odor of bowel movements and trash. Staff member AA stated, I clean the shower room once a day. It usually smells pretty bad from the trash. The CNAs are supposed to take it out, but they don't. b. During an observation and interview on 3/26/25 at 12:50 p.m., in the dirty laundry area on the left side of the wall along the washing machines the paint on the wall was bubbling, had multiple holes and damage to the wall. The wall was not a cleanable surface. The Formica along the sorting countertop had chips and breaks creating an uncleanable surface. Inside the clean laundry area, there was chipped and broken Formica on the counter tops for the sink and the folding counter, creating an uncleanable surface. There was a missing tile on the left side of the dryer duct which was allowed dust and debris to enter the clean folding area. During an interview on 3/27/25 at 11:10 a.m., staff member B and O stated they had an opportunity to observe the laundry room and shower rooms. Staff member O stated, The laundry room was pretty bad.

Based on interview and record review, the facility failed to maintain documentation of its ongoing QAPI program efforts which demonstrated how the facility determined contributing causes of problems to determine the root-cause of identified issues; failed to establish corrective action plans which included interventions to correct the problem to establish measurable outcomes for established goals; and failed to establish measurable goals in order to determine a process on how to monitor projects to ensure expected results of the established goals. This deficient practice placed all residents receiving care at the facility at risk for missed opportunities to identify and implement improvements that could enhance patient care, increased safety risks, and operational efficiency; and the facility failed to establish a process to review and revise performance improvement projects to ensure goals would be met; and failed to determine the root-cause of a fall with major-injury which resulted in a fractured arm for 1 (#11) of 4 sampled residents for falls. This deficient practice placed residents at risk for increased falls and major injury. Findings include: 1. During an interview on 3/25/25 at 4:04 p.m., staff member R stated resident #11 slid out of the sit-to-stand lift a few months ago. During an interview on 3/26/25 at 1:30 p.m., staff member D stated the performance improvement plan was started on 3/24/24, for falls, and has been ongoing through, 2/19/25. Staff member D stated there had not been additional documents to attach to the performance improvement project form. There were no interventions in plan tasks to be done, until 2/26/25. Review of the facility's Performance Improvement Project (PIP) Guide, dated 3/24/24, listed the key area for improvement as, reduce the number of falls per month. The root-cause was listed as, continue 5-why's and fall huddles. The section titled, Brainstorm: interventions, ideas, staff input. The plan section reflected: data collection of falls for 2024, dated 2/26/25 and comparison of 2023 and 2024, dated 2/26/25. The section titled, Study and Act Benchmarks, reflected: the progress will be measured during quarterly QAPI meetings. With the following dates: 4/23/24 - Baseline, 8/29/24 - First Measurement, 11/11/24 - Second Measurement, 2/19/25 - Final Measurement. The facility's PIP failed to determine the root-cause of a fall with major-injury for patient #11 and failed to review and revise performance improvement interventions to ensure goals were met. Review of resident #11's Post Fall Huddle Investigation, dated 11/25/25, reflected resident #11 fell from the sit-to-stand lift landing on her knees during a transfer. The report reflected, . [Resident #11] was on the Vera-Lift near the bathroom doorway so he thought that [name] must have toileted her. [Resident #11] kneeling on the lift leaning forward. [Left] arm was up and out of the sling-[Right] arm was against the bar. [sic] The Post-Fall Huddle reflected the form was not completed until the day after the fall occurred because the CNAs involved did not report the incident to the nurse on duty. The form was incomplete and did not reflect a root cause was completed. Review of resident #11's Communication Progress note, dated 11/26/24, reflected, . nurse had spoke with [Physician name] and she reported that the resident does have a fracture through her humeral neck. [sic] During an interview on 3/27/25 at 3:40 p.m., staff member A stated the staff did not report the fall until the next day, so they did not have a huddle, and no root cause was determined. 2. During an interview on 3/27/25 at 11:00 a.m., staff member A stated she was unable to explain the process the QAPI team utilized to determine the root-cause of problem-prone areas, how the facility determined which interventions would be developed to correct the problem, how the facility implemented measurable time-line driven goals, and processes for monitoring projects to ensure expected outcomes were met. Staff member A stated these areas were not documented in the facility's QAPI program. A review of the facility's QAPI Plan and Program for, 2024 to 2025, failed to show documentation of processes for determining the root-cause of problem-prone areas, interventions to be utilized to improve identified problems, establishment of measurable time-line driven goals, and processes for monitoring projects to ensure outcomes were met. A review of the facility's policy and procedure titled, Quality Assurance Performance Improvement Plan, with a review of date of 11/22/24, showed: . An important aspect of our PIPs is a plan to determine the effectiveness of our performance improvement activities and whether the improvement is sustained. . The responsibilities for the PIP teams will be to determine what information is needed for the PIP and how to obtain the information . The team will develop an action plan using the organizations usual format. When determining and implementing interventions, [Plan-Do-Study-Act] cycles will be used . . Our facility uses a systematic approach to determine when in-depth analysis is needed to fully understand identified problems, causes of the problems, and implications of a change. To get at the underlining cause of issues, we bring teams together to identify the root cause and contributing factors. . To prevent future events and promote sustained improvement our organization develops actions to address the identified root cause and/or contributing factors of an issue/event that will affect change at the systems level. We use Plan-Do-Study-Act cycles to test actions and recognize and address unintended consequences of planned changes. . To ensure the planned changes/interventions are implemented and effective in making and sustaining improvements, our organization chooses to conduct ongoing periodic measures and review.

Based on observation, interview, and record review, the facility failed to ensure safe labeling of food storage in accordance with professional standards for food service safety, placing residents at risk for consumption of expired or contaminated food and risk for food-borne illness; and failed to develop and implement policy and procedures regarding food storage and labeling. These deficient practices affected all residents receiving food services from the facility. Findings include: During an observation on [DATE] at 11:40 a.m., the following had incomplete or missing labels, with dates, in the kitchen and dining areas: - Blueberries (opened) in refrigerator, dated ,d+[DATE], no year noted; - Pickled relish (opened) in refrigerator dated ,d+[DATE], no year noted; - Pepperoni (opened) in freezer dated ,d+[DATE], no year noted; - Ricotta cheese (opened) in refrigerator dated ,d+[DATE], no year noted; - Caesar dressing (opened) in refrigerator dated ,d+[DATE], no year noted; - Sour cream (opened) in refrigerator dated ,d+[DATE], no year noted; - Hashbrowns (opened) in freezer with no date; - Honey (opened) dated ,d+[DATE], no year noted; - Sugar free icing (opened) in refrigerator with no date; - Vinegar (opened) in dry storage dated, ,d+[DATE], no year noted; - Bag of dried elbow pasta (unopened) labeled as received on ,d+[DATE], no year noted; with an expiration date of [DATE]; - All opened spices in kitchen with missing/incomplete dates and/or expired included: Cream of Tartar dated [DATE], Old Bay expired [DATE]; - Thyme, whole bay leaves, chili powder, granulated garlic, and whole oregano leaves were opened with no dates; - Ground basil, with an expiration date of [DATE]; - Salt Free Dash (in dining room) dated [DATE] and expired [DATE]; - Red and green food dye, peppermint flavor, balsamic vinegar, and caramel sauce (all opened) with no dates; - Worcestershire sauce (opened) dated ,d+[DATE], no year noted. During observation on [DATE] at 11:40 a.m., staff member F stated he had not done much with the labels on spices because, Seasonings don't expire like tea and honey; we use open dates now. Staff member F stated he did not have use-by date charts in the kitchen area for staff to use because, Our policy is five days and ninety days for everything. Staff member F stated it was easier to use the same dates for everything because there were new cooks who still need to learn. Staff member F stated pasta should be labeled with a receive-by date then the expiration date was 12 months after. Staff member F stated pickled relish was technically good for ,d+[DATE] months, but he used 90 days. During an interview on [DATE] at 7:28 a.m., staff member J stated she had meetings every month educating the kitchen staff on food labeling policies and procedures. During an interview on [DATE] at 10:42 a.m., staff member K stated it was obvious when to throw out food if it did not look good. Staff member K stated food labeling depended on the food, Like Jello is about five days, but spices I don't know, I never really tried to keep on top of those. During an interview on [DATE] at 8:00 a.m., staff member F stated he did not think they had a policy on received-by, opened, and use-by dates. During an interview on [DATE] at 8:35 a.m., staff member F presented pages 55, 57, and 61 of a document titled, Food Preparation: Purchasing, Receiving and Storage of Food Products. This document reflected the following: Page 55: .Dry Pasta .Aim to use within 12 months, Maximum shelf life of 24 months .Other open foods in dry storage, refrigerator and freezer should be shut/wrapped tightly and labeled and/or dated . [sic] Page 61: .All refrigerated ready-to-eat potentially hazardous foods (TCS Foods) prepared in house or received from suppliers must be clearly marked with the date by which the product should consumed, sold or discarded (use by date) . should be held for a maximum of 5 days .Refrigerated, ready-to-eat, NON-TCS food should be held for a maximum of 30 days .Staff will check coolers daily, checking items for dates and spoilage, discarding expired and/or spoiled foods . [sic] On [DATE] at 4:30 p.m., a request was made for a complete policy and procedure on food storage. This document was not received by the end of the survey.

Based on observations, interviews, and record review, the facility failed to ensure medication error rates were under 5% for 2 (#s 17 and 24) of 9 sampled residents for medication errors. The medication errors placed residents at risk for overdose side effects of the medications, and the errors were not identified as a concern and continued over a period of time, per staff. The calculated medication error rate was 10%. Findings include: 1. During an observation on 3/25/25 at 11:47 a.m., staff member U prepared three medications to be crushed and administered for resident #17. Staff member U placed one acetaminophen tablet, two carbidopa-levodopa tablets, and opened one capsule of gabapentin, putting all the medications in a clear bag. Staff member U then crushed them into a powder. Staff member U poured the powder in pudding and administered the pudding to resident #17. The bottle for the gabapentin reflected: DO NOT CRUSH OR CHEW, TAKE WHOLE. During an observation on 3/26/25 at 11:56 a.m., staff member L prepared three medications, which were crushed and administered for resident #17. Staff member L placed two acetaminophen tablets, two carbidopa-levodopa tablets, and opened one capsule of gabapentin, putting all the medications in a clear bag, and then crushed them into a powder. Staff member L poured the powder in pudding and administered the pudding to resident #17. The bottle for the gabapentin reflected: DO NOT CRUSH OR CHEW, TAKE WHOLE. 2. During an observation on 3/25/25 at 7:37 a.m., staff member U prepared three medications to be administered crushed for resident #24. Staff member U placed two acetaminophen tablets, two Senna-S tablets and opened a Tamsulosin 0.4 mg capsule, putting all of them in a clear bag, and crushed the medications into a powder. Staff member U then poured the powder into a cup of chocolate pudding and administered the chocolate pudding to resident #24. The card for the capsule of Tamsulosin reflected: DO NOT CRUSH, SWALLOW WHOLE. During an interview on 3/26/25 at 11:58 a.m., staff member L stated, It's just one of those things, I'm sure the pharmacy and doctor are aware. We all have been doing it this way for a long time. When asked, staff member L stated she was not sure if there was an order for crushing medications for the residents and she assumed there would be. Staff member L deferred to staff member D to check on those orders. During an interview on 3/26/25 at 12:10 p.m., staff member D stated the facility did not obtain crushed medication orders for residents in the facility. Staff member D stated she was unaware gabapentin and tamsulosin packaging showed to not crush or chew the medication. Staff member D stated medications should not be crushed if the packaging showed to not crush. Staff member D stated the nurse should contact the pharmacy and doctor for other options. Review of the facility's policy, Medication Administration, no date, reflected: - . 11. Read the label of the medication and the route of administration and check with the medication record, being sure they are the same. - . 21. Give the drug by the method ordered. Check to be sure the drug is in the form for the method used. Check the label on the container . A total of 30 medication administrations were observed, with three errors, for a total of a 10% medication error rate.

Based on observation, interview, and record review, the facility failed to ensure personal privacy resulting in a resident feeling uncomfortable and imprisoned, for 1 (#4) of 19 sampled residents, and the resident requested the camera, placed by the facility, to be removed from her room, but the facility stated if it was removed, her door would need to remain open, so her privacy was not respected. Findings include: During an observation and interview on 3/24/25 at 3:27 p.m., a video camera was noted on resident #4's desk, facing her, as she was sitting on her bed. Resident #4 stated she did not like the video camera because sometimes she would forget it was there, Like when I am dressing. During an interview on 3/24/25 at 3:51 p.m., resident #4 stated she wanted to be alone because of anxiety. Resident #4 stated she used to have a private room because of her PTSD and social phobia, but that was no longer an option for her. During an interview on 3/25/25 at 9:02 a.m., staff member M stated the video camera was in resident #4's room for safety, Because she (resident #4) will do unsafe stuff and fall. Staff member M stated resident #4 did not have dementia and was able to call for help independently. During an interview on 3/25/25 at 11:34 a.m., staff member A stated the video camera was removed once, but resident #4 asked for it to be turned back on. During an interview on 3/25/25 at 11:43 a.m., resident #4 stated she did not want the camera, but it was her only choice. Resident #4 stated she was given the option to remove the video camera, but then she would have to always leave her door open. Resident #4 stated she wanted her door closed because it was very noisy, and it made her anxiety worse, It was the lesser of two evils. During an interview on 3/26/25 at 12:19 p.m., NF1 stated she was frustrated that the facility would not remove the video camera (in resident #4's room) even after repeatedly asking for it to be removed, per resident #4's request, and attending two care plan meetings with resident #4, to discuss the concern with the camera. NF1 stated she was told by the facility if they remove the camera then her door must always be open. NF1 stated she was frustrated the facility was, Not listening to me or the resident. During an interview on 3/26/25 at 1:46 p.m., resident #4 stated she felt like she must follow the rules, or she would be treated like a child. Resident #4 stated, I hate how it (the video camera) makes me feel, like I am in a prison, like I am being controlled. NF1 stated they had been working on getting rid of the video camera for months. Review of the facility's policy titled, Policy and Procedure Non-Recording Video Monitoring Fall Prevention for Long-Term Care, updated 5/23/24, showed: .Respecting resident privacy: Video monitoring will be used in a way that does not violate residents' right to privacy .Residents will be assured that their personal privacy is respected .

Based on observation and resident interview, the facility failed to provide an emergency call light system for 2 (#s 10 & 27) of 2 residents sampled for call light concerns. Findings include: During an interview on 3/12/24 at 5:22 p.m., resident #27 stated his call light did not work for quite a while when another piece of equipment had been used to allow for more than two call lights to be plugged into the wall. Resident #27 also stated, People would not really believe me (when I said) that it did not work. He also said that he now pays close attention to the call light system as there have been instances where a staff member has clipped the call light to the overhead light, clipped it to the curtain, or accidentally pulled the cord out of the wall when moving the curtain. Resident #27 mentioned these instances were all by accident, but still made it difficult for him to access the call light or get help when he needed it. During an observation on 3/12/24 at 5:22 p.m., the call light splitter did not work in the resident's room; therefore, the call light was not working for resident #27. During an interview on 3/13/24 at 1:36 p.m., a chair alarm had been going off in resident #10's room for several minutes. Resident #10 had self-transferred from her wheelchair to her chair. Resident #10 stated the call light system had not been working for about two to three days. She also stated, It is the worst at night so sometimes I just yell. Resident #10 did say they (staff) were putting in a work order for the call light (to be repaired) at this time. During an observation on 3/13/24 at 1:36 p.m., neither the bed or chair call lights worked in resident #10's room. Observation showed two different call light cords. One call light was clipped to resident #10's bed while the other call light was clipped to the chair. Record review of the facility's policy and procedure on Call Lights, dated 6/2/20, showed, If call light is defective, report immediately to office so that they can have Maintenance repair it. Check room frequently until light is repaired.

Based on observation, interview, and record review, the facility failed to protect a resident's right to privacy of their body for 1 (#8); and failed to have a process for evaluation and re-evaluation , or a policy, for video cameras and the continued use and impacts on personal privacy for 1 (#84) of 4 residents sampled for continuous video monitoring. Findings include: 1. During an observation on 3/12/24 at 9:19 a.m., there were four video monitors at the front nurses' desk. The monitors were positioned so nursing staff could see them while at the computers, however the content on the screen could also be viewed by anyone standing at the periphery of the nurses' station. Resident #8 was observed on the camera by the surveyor to be placed in bed by two staff members and undressed from the waist down for incontinence care. The camera in the resident's room was not turned, and the entire care procedure could be viewed by anyone at the desk or on the periphery. During an interview on 3/12/24 at 9:25 a.m., staff member K stated they [nursing and aides] usually turn the camera in the resident's room for privacy and it had gotten missed. During an interview on 3/13/24 at 9:40 a.m.,staff member B stated the facility did not have a policy on the use of video monitoring for residents, but the expectation was cameras would be turned away during cares. Staff member B stated [staff member J] had said anything viewed behind the nurses' station was covered by HIPAA. 2. During an interview on 3/11/24 at 3:52 p.m., resident #84 stated she had a camera in her room and an alarm on her door because she had fallen several times. She stated if she could get stronger and stop falling she would be able to have the monitors removed. Review of resident #84's nursing progress notes dated 8/2023 - 3/2024, showed the resident continued to have eight falls while on the 24-hour video monitoring intervention. Review of resident #84's consents for 24-hour continuous video monitoring, dated, 8/11/23 and 12/29/23, signed by her representative, showed there would be a reevaluation of the monitor use in three months. There was no documentation of the reevaluation. Review of resident #84's Significant Change MDS, dated [DATE], showed the resident had a BIMS of 15; intact cognition. Review of resident #84's nursing progress notes, dated 8/11/23, showed the resident was unhappy about the video monitoring and felt like she was in prison. During an interview on 3/13/24 at 9:40 a.m., staff member B stated the facility did not have a policy on their use of video monitoring. There were no written protocols determining: - Criteria for the residents being placed on 24-hour monitoring, - Physician orders, - Re-evaluation of the 24 hour monitoring as an intervention, or - Privacy procedures for staff during care. During an interview on 3/13/24 at 1:55 p.m., staff member A stated the facility tried to use the video monitoring as a last resort for resident fall prevention.

Based on observation, interview, and record review, the facility failed to evaluate and implement individualized and affective fall prevention care plan interventions, after a resident's fall with a major injury which resulted in blindness in one eye, and the resident to continued to fall, and had three more injuries, for 1 (#11); failed to assess, revise, and implement fall interventions, to prevent falls, for 2 (#s 14 and 25); and failed to ensure staff were trained in fall prevention and reporting, resulting in a major injury, for 1 (#39) of 8 sampled residents. Findings include: On 3/15/23 at 3:04 p.m., the St. Luke Community Nursing Home Director of Nursing, Assistant Director of Nursing, and Administrative Assistant, were notified of an Immediate Jeopardy situation for F689 - Accidents and Hazards, which included 1 (#1) resident. The Severity and Scope was identified to be at the level of J, and upon removal of immediacy, was lowered to G. The facility removed the immediate threat of harm on 3/16/23 at 11:00 a.m. 1. During an observation and interview on 3/13/23 at 12:49 p.m., resident #11 appeared lethargic, was falling asleep, and confused. Resident #11 was unable to complete the remainder of the interview. Resident #11 was observed to be on documented hourly checks, per the observation of a clipboard on the resident's door jamb. The hourly checks were incomplete. During an interview on 3/13/23 at 1:05 p.m., staff L stated, She (resident #11) waxes and wanes a lot throughout the day, some days she is clear but more often than not she is very lethargic and confused. Staff member L stated, [Resident #11] was scheduled to start physical therapy in a couple of weeks because she is having injections to control the pain in her back first. During an observation and interview on 3/13/23 at 1:15 p.m., staff member M stated, I help her (resident #11) get up and started for the day, dressing, brushing teeth and getting her to breakfast. Then I bring her back from breakfast, and she likes to stay in her room. I check and change her (brief) about three times a day, and that's about it. Resident #11 was in bed sleeping, with her bed in a high position, there was no fall pad by the bed on the floor, and there was a bed alarm under her. During an observation and interview on 3/14/23 at 11:05 a.m., resident #11 stated, I fall a lot, so they have me strapped up (referring to her bed alarm) because I seem to need to learn the hard way. Resident #11 was able to carry on the conversation with complete sentences, with some confusion noted. During an interview on 3/14/23 at 2:45 p.m., staff member C stated, (Resident #11's) Fall Investigation packets provided are all of the information we have, if the root cause and interventions are not there, then there were no new interventions added. Staff member B stated, We have applied for CMP monies to work on falls. Staff member C stated, We didn't have any more interventions than what is attached (to resident #11's fall investigations) . if there is nothing attached, then we didn't do anything else. During an interview on 3/15/23 at 7:30 a.m., staff member B stated, I've seen an uptick in falls in building since I started trying to work on fall issues. Staff member B stated she had requested [University name] to come in and do some fall education, but did not have a date for this training yet. Staff member B stated, It really doesn't look like the documentation is there (for the resident's falls), but I know we've really tried with her . You should call the [family member], she will tell you. Staff B stated the lack of fall care plan interventions, attached to the care plan, has been a problem. During an observation and interview on 3/15/23 at 9:30 a.m., resident #11's hourly checks, documented on the clipboard on the door jamb of her room, showed blank time slots during 3/13/23 - 3/15/23. Resident #11 stated she felt the facility could help her prevent falls by, Helping me with my balance, that's one thing, I'm sure there's more, but that's what I can think of now . I think a lot also has to do with this darn eye, my eye is on the floor or something, since I fell . During an interview on 3/15/23 at 10:00 a.m., staff member E stated resident #11's fall interventions did not consistently align with the causes of the falls. Staff member E stated, A lot of things just don't get charted as it really takes away from patient care . I'm sure we did things though. Staff E stated, She (resident #11) has permanent loss of sight in her right eye. During an interview on 3/15/23 at 2:00 p.m., NF2 stated resident #11, Is still distraught about the look and feel of the eye, and wants to hear from a doctor if any more can be done . [Resident #11] is very angry as more and more independence is taken from her. First it was the move here, then the electric wheel chair was taken away, then the loss of walking. Then her two-person transfer was lost, and now they stick a bedpan under her, how dignified is that? During an observation on 3/15/23 at 2:30 p.m., resident #11's hourly checks, documented on the clipboard, continued to have multiple gaps in documentation. During an interview on 3/16/23 at 11:27 a.m., staff member E stated, Well we just came from meetings and were discussing the fact that we do not have a formal fall assessment form (for resident #11), or process, so I wouldn't have any others except maybe the admission one from 2020 We do not appear to have a fall assessment from admission on her (resident #11). Review of resident #11's falls, from 1/26/22-2/3/23, showed 23 falls in 2022, and four falls in 2023. Review of a sample of resident #11's fall investigation reports, including four falls with injury (6/15/22, 8/12/22, 9/1/22, and 9/26/22), and three falls without injury (8/16/22, 9/17/22, and 10/27/22), showed the fall investigation reports were incomplete, with missing Unit Manager reports for 4 of 7 fall investigation reports received. The fall reports included the following information: - 6/15/22: rolled out of bed causing fall with major injury (permanent loss of sight in right eye). Cognition noted as clear. Interventions: tab alarm and hourly checks x 1 week. - 8/12/22: reaching for something on bookcase and fell out of electric wheelchair. Dementia checked yes. Intervention: reminder to call for help. - 9/1/22: resident lost balance while toileting. Cognition noted as clear. Intervention: none listed. - 9/17/22: spilled water and stood up to clean up herself, slippery footwear worn and fell . Cognition checked yes, as potentially having been a factor in this fall. Intervention: electric wheelchair taken away. - 9/26/22: fell asleep and fell out of recliner. Sustained head injury requiring ER visit. Nurse stated root cause was, Resident has increased weakness/cognitive changes past months. Interventions: no new interventions noted. - 10/23/22: resident standing to reach outlet across bed and legs became weak. Cognition checked yes, as potentially having been a factor in this fall. Nurse statement showed, Resident is declining, more confusion and increased weakness chronic backpain. Intervention: reminder to call for help and slippers provided. - 10/27/22: attempted to self-transfer from wheelchair to recliner, stating wheels were not working on wheelchair. Cognition checked yes, as potentially having been a factor in this fall, with the nurse documentation showing, resident not thinking clearly. Intervention: signs to remind to call for help. Review of resident #11's Care Plan, dated 2/21/22, for falls, did not contain any interventions for reachers, a floor mat, or placement of an anti-slide mat in the resident's chairs. The safety reminders were shown to be ineffective due to the ongoing falls, and the resident's waxing and waning impaired cognition. Review of resident #11's EMR and hard copy documentation showed no Fall Risk Assessment was completed since the resident's admission. 2. During an observation and interview on 3/15/23 at 1:20 p.m., resident #14 was in her room with the door closed. Upon entrance, resident #14 was sitting in her wheelchair. Resident #14 stated she was not aware of a plan for her to keep her door open. Resident #14 appeared to be alert and oriented. During an observation on 3/15/23 at 2:19 p.m., resident #14's door remained closed. During an observation and interview on 3/15/23 at 2:20 p.m., in front of resident #14's closed door, staff member O described the intervention she used during her shifts to prevent falls for resident #14 was, Always keeping the door open so we can watch her. Staff member O stated, She (resident #14) closes the door sometimes. Staff member O then returned to working with other residents on the hall, and the door remained closed. Review of resident #14's current fall care plan intervention showed, Remind [Resident #14] to keep her door opened (okay with [family]). During an observation on 3/15/23 at 5:21 p.m., resident #14's door remained closed. During an observation on 3/16/23 at 10:35 a.m., resident #14's door remained closed. 45447 3. During an interview on 3/14/23 at 10:18 a.m., staff member L stated resident #25 had a history of falls while trying to transfer herself. Staff member L stated resident #25 got confused, and thought she saw puppies in her room, and needed to take care of them, so she would fall. Staff member L stated the staff tried to ensure the call light was close by, toilet the resident every few hours, and kept the bed in a low position, to prevent falls. During an interview on 3/15/23 at 12:05 p.m., with staff member B and C, staff member B stated there had been no fall prevention training over the past year, due to COVID. Staff member C stated resident #25 did not have injuries with her falls over the past year, and falls were discussed in IDT care conferences. Staff member C stated the facility did not complete any fall investigations, root cause analysis, or implement new fall interventions for the resident's falls, because the resident did not have injuries with her falls. Staff member C stated staff member E oversaw the updating of the care plans, after the care conferences, and resident #25 should have had a fall risk assessment done upon admission to the facility. During an interview on 3/16/23 at 10:40 a.m., staff member P stated she was not sure when a fall risk assessment was done at the facility. During an interview on 3/16/23 at 10:43 a.m., staff member R stated she believed the fall risk assessments were completed for all residents, and she was, Pretty sure, the nurses had to complete one for the residents upon admission to the facility. During an interview on 3/16/23 at 12:08 p.m., staff member B and C stated when falls occurred, fall reporting sheets were to be filled out by the charge nurses. Staff member B and C stated falls were to be tracked and trended on fall logs, but there were a lot of informal meetings about patterns in falls with the IDT. These meetings were not documented. Staff member B stated the facility would be better at coming up with interventions moving forward, as what the facility was doing was, Not working. Staff member B stated she had not had training on how to complete PIPs, which was why the PIP she provided surveyors, regarding falls, was incomplete. Review of resident #25's EHR Nurse Note Narratives, dated 10/19/22 to 3/3/23, showed the resident had ten falls, with the following documented injuries: - 12/30/22: Resident hit back of head on the floor, small raised area on the right back side . - 2/1/23: . tailbone hurt and said it was from a fall before. The fall noted in the Nurse Note Narratives, on 2/20/23, did not include a progress note or any information explaining the details of the incident. Review of resident #25's Social Services Notes, dated 11/8/22 - 2/9/23, including the IDT care conference notes, showed there were no new fall interventions discussed. Review of resident #25's Quarterly MDS, with an ARD of 11/8/22, showed the resident had a BIMS of six; severely impaired cognition. The MDS showed the resident was frequently incontinent and needed a one-person physical assist with toileting and transferring. The MDS showed the resident had two or more falls since the prior annual assessment, on 8/8/22. Review of resident #25's Quarterly MDS, with an ARD of 2/8/23, showed the resident had a lower BIMS score of five; severely impaired cognition. The MDS showed the resident, again, had two or more falls since the prior assessment, on 11/8/22, and with one of the falls, there was a resident injury. The MDS also showed the resident still required a one-person physical assist with transfers and toileting. Review of resident #25's Care Plan, reviewed 2/9/23, reflected a lack of new or revised fall interventions after 8/11/22. The Care Plan included an intervention to, Keep call light within reach and encourage to use when needing assist. This intervention was not beneficial due to the resident's severely impaired cognition. The care plan did not include the bed being kept in a low position, or toileting the resident every few hours. On 3/16/23 at 11:18 a.m., surveyors requested resident #25's Fall Risk Assessment. The documentation was not provided by the end of the survey. 4. Review of a facility reported incident, dated 5/23/22, showed Resident #39 sustained right side facial bruising, eye swelling, and an abrasion to her right shoulder. The incident showed, [Staff member Q] .stated when he went to change her at 2am he rolled her towards him, and her skin was sweaty and slipped out of his grip. She started to fall forward, and he used his knees to catch her causing the mattress to shift towards the wall. This exposed the metal bed frame which resident bumped head and shoulder on. He caught resident with arms and knees and turned her, rolled her back over, and didn't see any injury at that time. He thought she was ok, so he never reported anything. [sic] During an interview on 3/16/23 at 11:57 a.m., staff member Q stated he recalled the incident with resident #39 in May 2022. Staff member Q stated resident #39 was sweaty when he went to change and move her, towards the end of his shift. Staff member Q stated she slipped, and he braced her with his knees. Staff member Q stated he received training after the incident on reporting, falls, and transferring. Staff member Q stated prior to the incident, he had training when he was in school, but it had been three years after he finished school before he started his job. Review of resident #39's Care Planning Worksheet, showed the resident was a, Fall Risk. Review of resident #39's Annual MDS, with an ARD of 6/12/22, showed the resident required a one-person physical assist with bed mobility. Review of the Root Cause Analysis, dated 5/28/22, showed the Root Cause of the fall was, Staff member (Q) in a hurry to get cares done. There was no further causation that showed why staff member Q was in a hurry, or if the transfer was safe, per the resident's identified transfer/turning positioning requirements. Review of staff member Q's personnel file, and educational records, showed a lack of fall prevention training for the past year, and the post incident education given to staff member Q. Review of the facility's annual training attendance and agenda, dated 11/22/22, reflected a lack of fall prevention training for all staff. Review of a facility document, Performance Improvement Project (PIP) Guide, dated 2/1/22, showed: Key Area for Improvement: Reduce # of falls per month + falls with injuries. The sections Goal, Root Cause, and Barriers, was incomplete. A review of the facility's policy, Falls, dated 5/20/20, showed, E. If a resident falls, the fall is documented in their chart . A report is completed to include circumstances of fall, vital signs at time of fall, any injury that may have occurred, etc. Fall reports are reviewed to identify any potential cause of fall and to help prevent further falls. Incidence of falls reports are logged and kept on file. The facility's fall policy reflected a lack of QAPI involvement, fall prevention education for staff, care plan updating and completion, and root cause analysis.

Based on interview and record review, the facility failed to include fall prevention and fall safety training on the Facility Assessment, as an assessed need, based on the resident population; and, failed to provide QAPI and Root Cause Analysis training to management. This deficient practice had the potential to affect all residents in the facility. Findings include: During an interview on 3/15/23 at 12:05 p.m., with staff member B and C, staff member B stated there had been no fall prevention training over the past year due to COVID. Staff member B stated she had identified falls as an issue at the facility. Staff member B stated she had not had training on root cause analysis or PIPs, as part of the QAPI process. During an interview on 3/15/23 at 2:25 p.m., staff member S stated he could not remember if he had training on fall prevention, and he had not had fall prevention training in the past year. Review of the facility's annual training attendance and agenda, dated 11/22/22, reflected a lack of fall prevention training. Review of the Facility Assessment, undated, showed: .2. Facility Resources: .Training: .Compliance, QAPI, . Resident Care and Services Correlating to Resident Population The facility provides care and services based upon the needs of our resident population.Including the following: . -Mobility and fall/fall with injury prevention: Transfers, ambulation . Staff Education, Training and Competencies . Every staff member has knowledge competency in: . -QAPI- training is completed upon hire and annually .

Based on interview and record review, the facility failed to develop and implement a Performance Improvement Project due to the high number of facility falls; and failed to monitor prophylactic antibiotic use for residents with UTIs. These deficient practices had the potential to affect all residents in the facility who had falls, was at risk for falls, or using prophylactic antibiotics. Findings include: During an interview on 3/16/23 at 12:05 p.m., staff member B and C stated the facility had a high number of falls, and had informal, undocumented meetings with the IDT about any patterns of falls in the facility. Staff member B stated there has not been monitoring and implementation of interventions, and the facility needed to be better as what they were currently doing was not working well. Staff member B stated she had not had QAPI training in the past, and it was something they needed to do. Staff member B stated she had not had training on how to complete PIPs, which was why the fall PIP from 2/1/22, provided to surveyors, was not completed. During an interview on 3/16/23 at 12:32 p.m., staff member C stated she had not formally kept track of residents on prophylactic antibiotics and their symptoms. Review of a facility document, Performance Improvement Project (PIP) Guide, dated 2/1/22, showed: Key Area for Improvement: Reduce # of falls per month + falls with injuries. The sections for the Goal, Root Cause, and Barriers, were not filled out. A review of the facility's QAPI Plan, reviewed 2/28/23, showed: The principles of QAPI will be taught to all staff on an ongoing basis . When the need is identified we will implement Performance Improvement Projects (PIPS) to improve processes, systems, outcomes and satisfaction . The Director of Nursing (DNS) has the responsibility and is accountable to the administrator for ensuring that QAPI is implemented throughout our organization . Our organization will use the following . data sources to monitor/analyze our ongoing performance: - .Fall Report - .Infections . To prevent future events and promote sustained improvement our organization develops actions to address the identified root cause and/or contributing factors of an issue/event that will affect change at the systems level.

Based on interview and record review, the facility failed to ensure the system used for fall prevention included the necessary measures to protect and address residents who were at risk for falls, and who had recurrent falls, to include a lack of staff education, resident monitoring, and failure to use a root cause analysis process for the identification of contributing factors to falls. This deficient practice had the potential to affect all the residents in the facility who were at risk for falls, as it was a system failure. Findings include: During an interview on 3/15/23 at 12:05 p.m., with staff members B and C, staff member B stated there had been no fall prevention training over the past year due to COVID. Staff member C stated the facility did not complete any fall investigations, root cause analysis for falls, or implement new fall interventions, if a resident did not have injuries during their falls. Staff member B stated she knew falls had been a problem at the facility. See F689 for information on deficiencies related to falls in the facility. During an interview on 3/16/23 at 12:08 p.m., staff members B and C stated when falls occurred, fall reporting sheets were to be filled out by the charge nurses. Staff members B and C stated falls were to be tracked and trended on the fall logs, and there were a lot of informal meetings about patterns with resident falls with the IDT. These meetings were not documented. Staff member B stated the facility would be better at coming up with interventions moving forward, as what the facility was doing was, Not working. Staff member B stated she had not had training on how to complete PIPs, which was why the PIP she provided surveyors, regarding falls, was incomplete. Staff member B stated she had not had training on QAPI, and saw it was something she needed to do. Review of a facility document, Performance Improvement Project (PIP) Guide, dated 2/1/22, showed: Key Area for Improvement: Reduce # of falls per month + falls with injuries. The sections titled Goal, Root Cause, and Barriers, were not filled out. Review of a facility document, Job Description Extended Care Facility Director of Nursing, dated June 2016, showed: Statement of Purpose Manages the overall operation of the Extended Care Facility .Ensures departments are in compliance with current federal, state and local standards governing long term care facilities and as directed by Administration to ensure the highest degree of quality care can be provided to the residents at all times. - Institute and maintain a quality assurance/quality improvement department in concert with the organization's QI/QA.

Based on interview and record review, the facility failed to ensure antibiotic stewardship was followed and monitored, including prescribing ongoing prophylactic antibiotics for chronic UTIs, for 3 (#s 6, 7, and 25) of 3 sampled residents. Findings Include: During an interview on 3/16/23 at 9:00 a.m., staff member B stated the facility used the McGreers criteria (criteria to determine appropriateness for antibiotic use) for UTIs. Staff member C stated there were three residents in the facility on prophylactic antibiotics. Neither staff member B or C could provide documentation the McGreers criteria was being utilized for resident #s 6, 7, or 25. Staff member C said she had not discussed with the providers why they were not adhering to the McGreers criteria. Staff member C stated she had met with the pharmacist on a weekly basis, and had talked with the medical director regarding antibiotic usage, but had not documented the discussions. Staff members B and C stated they had not had comprehensive meetings with leadership relating to an antibiotic stewardship program. Staff member C stated the facility had not conducted surveillance for the three residents on prophylactic antibiotics. A review of resident #6's EHR physician orders, showed an order for an antibiotic, Nitrofurantoin Macrocrystal Capsule 100 MG, 1 tablet daily, with an order date of 1/8/22, and an end date of indefinite. A review of resident #7's EHR physician orders, showed an order for an antibiotic, Methenamine Hippurate Tablet 1 GM, 2 tablets daily, with an order date of 11/29/22, and an end date of indefinite. A review of resident #25's EHR physician orders, showed an order for an antibiotic, Cephalexin Capsule 250 MG, 1 tablet daily, with an order date of 12/22/22, and an end date of indefinite. A review of a facility policy, Antibiotic Stewardship Program, dated 8/11/17, showed: POLICY/PURPOSE: To monitor and optimize the use of antimicrobials across the continuum to improve clinical outcomes while minimizing the unintentional side effects of antimicrobial use, including toxicity and emergence of resistant organisms. Focus areas include hospital acute care services, outpatient (including clinics) and long term care resulting in an approach that provides organization wide oversight. The ASP may include, but is not limited to the following activities/elements: - Antibiotic Stewardship Program (ASP) policy development and implementation oversight . - Surveillance monitoring of the organizations healthcare acquired infections, including Clinic(s), Rural Health Clinic, Long Term Care and Hospital wide . - Prospective antibiotic review and feedback to optimize and monitor use of antibiotics . Extended Care Facility (ECF) 1. Establish a subcommittee within the ECF to provide monitoring and oversight of the ASP needs within the respective setting to support the implementation of the organizational ASP purpose and objectives. 2. The ECF ASP Subcommittee will share their monitoring and surveillance reports with the overall ASP for inclusion in the organization wide antibiotic surveillance and monitoring .

Based on observation and record review, the facility staff assisting in the dining room failed to complete proper handwashing and or sanitation while aiding 5 residents. This failure may have allowed the spread of contaminants to other residents. Findings include: During observation on 3/14/23 at 7:31 a.m., staff members M, N, and O were in rolling chairs, assisting residents requiring assistance to eat. None of the staff members observed completed hand hygiene between residents. A review of the facility's policy, Infection Control-Handwashing, updated 1/26/23, did not show instructions for handwashing or sanitization throughout food service. A review of the facility's CNA Job description, undated, showed . appropriate and effective handwashing . was an expectation. A review of the facility's New Employee Orientation Checklist for CNAs and Nursing Assistants, dated 6/20/19, showed three scheduled training opportunities for handwashing technique. Per CDC guidelines, updated January 30, 2020, handwashing or use of an alcohol based hand sanitizer should be used, .After touching a patient or the patient's immediate environment . https://www.cdc.gov/handhygiene/providers/guideline.html

Based on observation, interview, and record review, the facility failed to revise and monitor the effectiveness of care plan interventions for fall safety, and or modify the care plan as necessary related to falls, in an attempt to prevent ongoing accidents for 3 (#s 11, 14, and 25) of 8 sampled residents. Findings include: 1. During an interview on 3/14/23 at 9:59 a.m., staff member K stated resident #25 was unable to ambulate, and the CNAs had to assist her with transfers. During an interview on 3/14/23 at 10:18 a.m., staff member L stated resident #25 had a history of falls, and staff were to ensure the resident's TABS alarm was on, the call light was in reach, the bed was kept in a low position, and staff were to try to toilet the resident every few hours. During an interview on 3/15/23 at 12:05 p.m., staff member C stated resident #25 had no injuries with her falls over the past year, so there were no fall investigations, root cause analyses, or new interventions put in place on the resident's care plan. During an interview on 3/16/23 at 10:43 a.m., staff member R stated she did not look at care plan interventions in resident #25's physical (hard copy) care plan binder, but the unit managers updated the care plans. Review of resident #25's EHR Nurse Note Narratives, dated 10/19/22 to 3/3/23, showed the resident had ten falls. Review of resident #25's Quarterly MDS, with an ARD of 11/8/22, showed the resident had a BIMS of 6; severely impaired cognition. The MDS showed the resident was frequently incontinent and needed a one-person physical assist with toileting and transferring. Review of resident #25's Care Plan, reviewed 2/9/23, reflected a lack of new or revised fall interventions after 8/11/22. The Care Plan included an intervention to, Keep call light within reach and encourage (the resident) to use when needing assist. This care plan intervention of encouraging the resident was shown to be ineffective as the resident's falls continued, and she had severely impaired cognition. The care plan did not include the bed being kept in a low position, or toileting the resident, every few hours. 48261 2. During an observation on 3/13/23 at 12:51 p.m., resident #11 was sleeping in a chair, with a chair alarm attached. Resident #11 was lethargic, falling asleep and confused, unable to complete the remainder of interview. Resident #11 was observed to be on hourly checks, per a clipboard on the door jamb of the resident's room. Documentation for the hourly checks was observed to be incomplete. During an interview on 3/13/23 at 1:05 p.m., staff member L stated, She (resident #11) waxes and wanes a lot throughout the day, some days she is clear, but more often than not she is very lethargic and confused. During an interview on 3/14/23 at 2:45 p.m., regarding resident #11's fall history, staff member C stated the, Fall Investigation packets provided (regarding resident #11's falls), are all of the information we have. If the root cause and interventions are not there, then there were no new interventions added . We don't have any more interventions then what is attached (to the fall investigations) . if there is nothing attached, then we didn't do anything else. During an interview on 3/15/23 at 7:30 a.m., staff member B stated, It really doesn't look like the documentation (for new fall interventions for resident #11) is there (on the care plan), but I know we've really tried with her . You should call the daughter, she will tell you. Staff member B stated the care plan interventions were not consistently attached to the care plans, and it had been a problem (identified by the facility). During an observation on 3/15/23 at 9:30 a.m., the hourly checks, documented on the clipboard observed on resident #11's door jamb, showed blank time slots, and the checks were not signed off by staff, from 3/13/23 through 3/15/23. During an interview on 3/15/23 at 10:00 a.m., staff member E stated resident #11's fall interventions did not align with the cause of the fall, because, A lot of things just don't get charted as it really takes away from patient care . I'm sure we did things though. During an observation on 3/15/23 at 2:30 p.m., resident #11's hourly checks, on the clipboard on her door jamb, continued to have multiple gaps in documentation for the resident's monitoring. Review of resident #11's falls, from 1/26/22 - 2/3/23, showed 23 falls in 2022, and four falls in 2023. Review of resident #11's Care Plan, dated 2/21/22, showed a lack of fall interventions for reachers, a floor mat, or an anti-slid mat in the resident's chairs. The safety reminders were not beneficial for resident #11's waxing and waning impaired cognition, as the resident had repeated, and continuing, falls. 3. During an observation and interview on 3/15/23 at 1:20 p.m., resident #14 was in her room with the door closed. Upon entering the resident's room, resident #14 was sitting in her wheelchair. Resident #14 stated she was not aware of a plan for her to keep her door open. Resident #14 appeared to be alert and oriented. During an observation on 3/15/23 at 2:19 p.m., resident #14's door remained closed. During an observation and interview on 3/15/23 at 2:20 p.m., in front of resident #14's closed door, staff member O described the intervention she used during her shifts to prevent falls for resident #14, which was, Always keeping the door open so we can watch her. Staff member O stated, She (resident #14) closes the door sometimes. Staff member O then returned to working with other residents on the hall, and the resident's door remained closed. Review of resident #14's current fall care plan intervention, showed, Remind [Resident #14] to keep her door opened (okay with [family]). The resident had a prior fall with injury, and was at a risk for falls. During an observation on 3/15/23 at 5:21 p.m., resident #14's door remained closed. During an observation on 3/16/23 at 10:35 a.m., resident #14's door remained closed. A review of the facility's policy, Guideline and Rules for Interdisciplinary Care Planning, updated 6/11/20, reflected: Purposes and Goals: . 2. To determine effective individualized approaches/interventions and to assign the discipline responsible for carrying them out. 3. To evaluate progress or lack of progress to earlier goals and to revise the problem, goal or approaches as indicated.

Based on interview and record review, the facility failed to submit quarterly staffing information, based on the facility's quarterly payroll data, to CMS for the PBJ report. Findings include: During an interview on 3/15/23 at 11:40 a.m., staff member D stated staff member J had attempted to submit the payroll based journal data for Fiscal Year 2023, Quarter 1, on 2/14/23, but there was an error, and the submission failed. During an interview on 3/15/23 at 11:50 a.m., staff member J stated the system would not let her submit the payroll based journal data on the usual computer, so she used a different computer. Staff member J stated she was busy, and unable to go back and verify the information submitted correctly. Review of the Payroll Based Journal report, dated 10/1/22 - 12/31/22, showed no licensed nursing hours were submitted to CMS for Fiscal Year 2023, Quarter 1.

Based on observation, interview, and record review, the facility failed to ensure the kitchen staff were wearing facial hair coverings in the kitchen and when serving food to residents. This had the potential to affect residents consuming food made or served by the facility. Findings include: During an observation and interview on 3/15/23 at 8:20 a.m., staff members I and G stated they were required to wear a beard coverings when serving to the residents. Staff member I was not wearing a beard covering in the kitchen. During an interview on 3/15/23 at 8:40 a.m., staff member H stated he had to make constant reminders and provide continual training, to the kitchen staff, regarding facial hair covering. A review of the facility policy, [Facility Name] - Personal Appearance and Dress Code Policy, dated 3/24/14, showed, Employees with excess facial hair will be required to keep it covered at all times when on duty with a beard guard.

Based on interview and record review, the facility failed to provide the resident, and the resident's representative, with written bed hold information, prior to an emergent transfer to the ER, for 1 (#22) of 2 sampled residents. Findings include: During an interview on 3/14/23 at 3:50 p.m., staff member B stated, We only told (Resident #22's) POA that her bed would be held. The bed hold and transfer notice was given verbally to resident #22's POA. A review of resident #22's EHR progress notes, showed the resident was taken to the hospital at 7:30 a.m., on 12/27/22, and returned to the facility, on 12/28/22 at 2:04 p.m. A review of a facility policy, titled, Bed-Hold, updated 5/7/20, showed: POLICY: It is the policy of this facility to inform residents upon admission and prior to a transfer for hospitalization or therapeutic leave of our bed-hold policy. a. Before a resident is transferred for hospitalization or for therapeutic leave, a representative of the nursing home office will provide the resident with written information concerning our bed-hold policy. b. In cases of emergency transfer, notice 'at the time of transfer' means that the family, surrogate, or representative are provided with written notification within 24 hours of the transfer. The requirement is met if the resident's copy of the notice is sent with other papers accompanying the resident to the hospital.

Based on observation, interview, and record review, the facility failed to prevent and protect 3 (#s 4, 16, and 92) of 4 sampled residents, and put other residents at risk, from repeated physical and potential psychosocial abuse by a resident (#31) over an extended period of time. Findings Include: During an observation and interview, on [DATE] at 2:42 p.m., resident #31 was observed sitting in a recliner. Resident #31 did not respond to questions when asked. Review of resident #31's current care plan, initiated on [DATE], showed he had a BIMS score of 99 (severe cognitive impairment), and he could not verbally communicate. During an interview on [DATE] at 3:38 p.m., staff member E stated, there were initial reservations about admitting resident #31 because of the behaviors noted from his previous facility and the hospital. Staff member E stated the facility care planned his behaviors and tried to have a one-on-one staff member when needed. This was while the facility attempted to get resident #31 into a secure locked unit or behavioral unit. This was so he would not elope or hit other residents and staff. Resident #31 had been ambulatory on admission and he would hit other residents. During an interview on [DATE] at 9:03 a.m., staff member A stated, the facility had concerns about taking resident #31, but were pressured to, and he had worse behaviors than were documented prior to admission. Resident #31 had severe dementia with behavioral disturbance and would be physically abusive to residents and staff, targeting a select few, regularly. Staff member A stated the facility tried to get things under control by adding and adjusting medications, and 1-on-1 staffing when possible, but the resident was constantly ambulating, attempting to elope, and hitting other residents which was unprovoked. Resident #31's Nursing Progress Notes, related to behaviors, from [DATE] to [DATE], showed repeated physical abuse and aggression towards other residents, most notable: -[DATE]: Walked past a female resident and pushed her head causing her to lean over in her chair. -[DATE]: Resident #31 was rude and angry holding fists up, cursing, and frightening other residents. He targeted a specific female resident, followed her and said inappropriate things to her. -[DATE]: Resident #31 targeted a female resident in a wheelchair, grabbed it (chair), and shoved it down the hallway. -[DATE]: Resident #31 targeted a female resident and stole her drink from her hands. He had pushed her head down from the back and struck her across the face in a slapping motion with a handful of straws. The female resident was startled by the incident. He also smacked the resident on top of the head later in the shift. -[DATE]: Day of discharge to Behavioral Health Unit: Resident #31 walked up to a resident in a wheelchair and punched the resident in the head. When passing other residents he stated, You're next. -[DATE]: Day of readmission, after after return from the Behavioral Health Unit: Resident #31 went into several other resident rooms and got in their faces. He tried to throw a [CONDITION(S)] machine and gallon of water. He approached and pushed a female resident's face with a closed fist and forcefully pushed her in her wheelchair and then let go. He went behind another female resident and hit her in the back of the neck in a karate chop motion. -[DATE]: Resident #31 tried to hit several female residents in the hall and common areas and tried to get in other resident rooms. He took a banana from the dining room and stuck it into the mouth of a sleeping female resident in her wheelchair. He pushed several residents in wheelchairs down the hall. He pushed a female resident with a FWW and almost caused her to fall over. [DATE]: Resident #31 went into resident rooms to turn on the faucets and then left them running. He was also confrontational with other residents. [DATE]: Resident #31 punched a female resident in the arm in the hallway. He then went up to another female resident and flicked her hair bangs to wake her. Then he jokingly put up his fists in her face in a fighting motion. [DATE]: Resident #31 went into several female resident rooms. He traced the outline of one female's bed. He hit another resident in the hallway, on the arm, twice. He pinched a third female and pulled her nose hard. [DATE]-[DATE]: Resident #31 wandered into several resident rooms and rummaged through their belongings. Resident #31 had several falls with head injuries and was sent to the emergency room for the falls. [DATE]: Resident #31 returned to the facility with a nasal fracture and using a Broda wheelchair. Review of facility reported incidents regarding resident #31's resident to resident altercations, from [DATE] to [DATE], showed: -[DATE]: Resident #31 pushed the resident's head in a wheelchair so hard that resident #4 leaned over. -[DATE]: Resident #31 hit a female resident in the head, stole her drink out of her hand, and pushed the resident, who was sitting in her wheelchair, into a doorway. The report showed the Victim for the event was resident #4. -[DATE]: Resident #31 used his closed fist and hit resident #16, and then resident #31 had a fall. -[DATE]: Resident #31 used a closed fist and pushed the face of a resident, and then pushed a resident, who was sitting in a wheelchair, down the hall (then let go). Resident #31 karate chopped the neck of another female resident. One victim listed on the report was resident #4, the other resident name was not listed. -[DATE]: Resident #31 hit resident #92, pulled the nose of resident #4, then threatened another female resident stating, I'm going to kill you. Resident #92 was deceased prior to the survey and unavailable for interview. Review of resident #16's MDS assessment, dated [DATE] showed she had a BIMS of 99 (severe cognitive impairment) and could not be interviewed. During an observation, interview, and record review on [DATE] at 2:17 p.m., resident #4 was in her room, in bed, and did not respond when asked questions. Resident #4's care plan, dated [DATE], showed the had a BIMS of 99 and was severely cognitively impaired. Review of resident #4's care plan, updated on [DATE], did not show any interventions to keep the resident safe from other residents, even after several reported incidents of resident #4 being pushed or punched by another resident. Review of resident #4's progress note, dated [DATE] at 5:31 p.m., showed, Staff reported that yesterday a male resident passed by [resident #4] and pulled on her nose. Review of resident #4's progress note, dated [DATE] at 7:40 a.m., showed, Resident was punched in the left upper arm by another resident in the hallway at approx (6:20a.m.). Review of a Facility Reported Incident, dated [DATE] at 7:00 p.m., showed, Resident [#31] was in the hallway and placed his closed hand against a residents face and pushed her face with his fist, he then proceeded to grab her wheelchair handles and forcefully push the resident forward in the chair and let go. He also walked up to another resident who was eating dinner in the dining room and hit her in the neck with a straight sideways (similar to a karate chop). He has also hit a few staff members while they are trying to redirect and help him with cares. Resident #4's name was listed on the Facility Reported Incident as being one of the residents affected. Review of resident #4's progress note, dated [DATE] at 1:32 p.m., showed, On [DATE] at approximately 1630 (4:30 p.m.), [resident #4] was self-propelling in hall when a male resident walked by and pushed her head, causing her to lean over in her w/c (wheelchair).

Based on record review, interview, and observation, the facility failed to adequately assess and monitor for adverse affects of multiple medication changes, which did not promote the quality of life, for 1 (#3) resident, who had cognitive and communication deficits, out of 11 sampled residents. Findings include: Review of a Pharmacy Recommendation for resident #3, dated 4/21/16, showed RN's and I talked about her crying etc. They think she is worse. Could be decrease of [MEDICATION NAME] or [MEDICATION NAME] needs increased. Could go back up with [MEDICATION NAME] and get [MEDICATION NAME] to therapeutic dose. Review of the physician's reply, which was in the medical record, showed Increase [MEDICATION NAME] to 150 mg daily, and no change in [MEDICATION NAME]. Review of the resident's Physician order [REDACTED]. [MEDICATION NAME] was increased in dose to .5 mg, 4 times a day, for anxiety and comfort. Review of the resident's Focus Charting notes showed [MEDICATION NAME] was discontinued on 5/9/16. The reason was not provided. Review of the resident's Hospice not on 5/19/16 showed the resident was agitated and trying to climb out of her chair. The resident cried through the visit and talked about home. She was given [MEDICATION NAME] and [MEDICATION NAME] for back pain. Review of the resident's Focus Charting notes on 5/20/16 showed Dr. here new order to DC [MEDICATION NAME] and consider taper of narcotics. Review of the resident's Hospice note on 5/23/16 showed staff reported the patient seemed to have an increase in agitation with use of [MEDICATION NAME], and the last week was the worst. No signs and symptoms of pain, and the MD decreased [MEDICATION NAME] to three times a day, and the [MEDICATION NAME], from 10 mg four times a day to 5 mg three times a day. Review of the resident's Physician Orders, dated 5/26/16, showed to discontinue [MEDICATION NAME] and start [MEDICATION NAME] for the resident's depression. Review of the resident's May Medication Administration showed ([MEDICATION NAME]) dated 4/18/16, 100 mg PO at HS. The administration record was blank, and said see page 3. Page 3 showed ([MEDICATION NAME]) 150 mg po daily. The administration record was blank. Review of the resident's Focus Charting on 5/28/16 showed the resident had a fall in her room. She was taken to the dining room for closer observation. She was given an extra [MEDICATION NAME] with her scheduled one at 1400. A reason was not provided. Pain was not addressed for the resident. Review of the resident's medical record did not show the monitoring for affects from the reduction in pain and anti anxiety medication, and discontinued use of the [MEDICATION NAME] on 5/23/15. Review of the resident's Focus Charting noted on 6/2/16 showed the resident had a rash, and the [MEDICATION NAME] was on hold. The documentation showed, Resident restless, crying, today at lunch. Pain was not addressed, although the resident had exhibited pain symptoms. Review of the resident's Focus Charting note on 6/2/16 showed the resident was restless and moaning. A PRN [MEDICATION NAME] and [MEDICATION NAME] was given, showing a positive outcome. Although the medication was beneficial to treat the restless and moaning, the facility did not consistently utilize this information when the resident exhibited future pain symptoms, but rather her pain symptoms were treated with behavior altering medications. Review of the resident's Focus Charting on 6/9/16 showed Clinical Pharm (sic) called about acute [MEDICAL CONDITION]/agitation. The recommendation given was for [MEDICATION NAME] 2 - 5 mg every hour as needed. Staff report the resident needs 1 to 1 care due to falling out of bed, agitation, and not sleeping for 48 hours. The resident's medical record lacked an assessment for possible pain and medication withdrawal as a potential cause for the [MEDICAL CONDITION]. Review of the resident's Focus Charting note, dated 6/9/16, showed a new order to increase the [MEDICATION NAME] to 10 mg, three times a day. Review of the resident's Focus Charting note on 6/10/16 showed the resident was crying and stating she was in pain. She was given 3 mg of [MEDICATION NAME], and 10 mg of [MEDICATION NAME] with a positive effect. Again, this showed the benefits of treating the resident's pain, rather than her behavior symptoms. Review of the resident's Focus Charting note on 6/11/16 showed the resident was awake most of shift and prn [MEDICATION NAME] and [MEDICATION NAME] was given. The nurse documented, Needing one on one care to keep her from climbing out of bed or off her chair. Review of the resident's Focus Charting note on 6/12/16 showed Became restless given [MEDICATION NAME], .5 mg and [MEDICATION NAME] 3 mg and [MEDICATION NAME] 10 mg. Wedge cushion used on mattress. At 1400, restlessness continue at time. Resident presents with tremor/shakes - possible side effect from [MEDICATION NAME]. Review of the Focus Charting notes dated 6/13/16 showed a fall out of bed; and, call placed to hospice - concerns of noted tremors and shakes. Review of the resident's Care Plan shows the resident's bed was placed against the wall, with a scoop mattress, and a 10 wedge on the outside of the mattress was in place to keep the resident from getting out of bed. Review of the resident's Focus Charting note on 6/16/16 showed the resident was extremely restless. The Hospice nurse advised to give 2 mg [MEDICATION NAME] and titrate up to 5 mg, if needed. At 2300, [MEDICATION NAME] 10 mg was given for pain. Gave her an increase 2 mg of [MEDICATION NAME] at 2255 - then increased dose to 3 mg, at 2355 now - much quieter now but awake. This note indicated the resident was given 6 mg of [MEDICATION NAME]. Review of the resident's Focus Charting Note on 6/17/16 showed a new order for [MEDICATION NAME] 50 mg, may titrate to 100 mg in 1 week, and [MEDICATION NAME] 1 mg every 2 hours as needed for comfort. The resident exhibited verbal complaints of pain, and 10 mgs of [MEDICATION NAME] was given. Review of the resident's Focus Charting Note on 6/18/16 showed the resident crying and complaining of pain. PRN [MEDICATION NAME] given. The documentation in the medical record lacked evidence for how the facility attempted to alter the resident's pain prior to her exhibiting the crying, or complaining of pain in an attempt to anticipate her needs due to her impaired cognition. Review of the resident's Hospice note on 6/20/16 showed Staff reported patient is a bit calmer since [MEDICATION NAME] and [MEDICATION NAME] med (sic) dose changes. Pt (sic) will get her first dose of [MEDICATION NAME] tonight. (ordered 6/17/16) Review of a Hospice note dated 6/28/16 showed Staff report patient typically becomes agitated when transferred to bed, appears fearful and trying to pull herself up out of bed. (Hospice) did note a pattern throughout nurses notes of increased agitation at night and calm during day when up in Broda chair. Review of the resident's medical record lacked evidence the facility assessed the resident's increase in pain when in bed, or the physical restriction placed on the resident while in bed, as possible contributing factors for the resident's increased agitation. Review of the resident's Focus Charting on 6/30/16 showed a new order for an increase in [MEDICATION NAME] from 1 mg to 2 mg, three times a day, for agitation. Review of the Significant Change MDS, with the ARD of 7/13/16, showed resident #3 had signs and symptoms of pain 3 to 4 days out of the 7 day look back period. This showed the facility had identified the pain concerns, but had not adequately assessed, or addressed the pain contributors. Review of the resident's Pharmacy Review and Recommendation, dated 7/7/16, showed She is doing well on the increase in [MEDICATION NAME], can we decrease [MEDICATION NAME] to 1 mg every 6 hours while awake, and keep the prn dose 1mg, four times a day. The physician agreed, and the order was changed on 7/15/16. Review of the resident's July MAR, 2016, showed the [MEDICATION NAME] was decreased on 7/29/16, back to 1 mg, three times a day, related to an increase in lethargy, and having to wake the resident up for meals. Review of the resident's Focus Charting on 8/29/16 showed the resident continued to be lethargic frequently, and often slept though meals and medications. During an interview on 10/5/16 at 8:20 a.m., staff member N stated that it was difficult to keep the resident comfortable, but functional. Staff member N stated, She is more sleepy and talking less. She can get really emotional. During observations on 10/3/16, resident #3 was sleeping at the nurses station in her Broda chair at 1:40 p.m., 2:40 p.m., 3:00 p.m., with no position change. At 4:30 p.m., staff member O took the resident to her room, and changed her incontinent brief as resident #3 was lying in the Broda chair. Staff member O stated She's calmed down a lot. At 5:30 p.m., resident #3 was sleeping soundly, while snoring, in the day room. During observations on 10/4/16, resident #3 was by the nurses station at 6:60 a.m., asleep. At 7:45 a.m. she was still sleeping. At 8:20 a.m., she was sleeping by the dining room. At 8:55 a.m. resident #3 was sitting at the table for breakfast, dozing, as her eyes opened and closed occasionally. During an observation on 10/4/16 at 9:05 a.m., resident #3 was sleeping while the staff member attempted to feed her. Staff member N stated She's really sleepy, maybe we shouldn't feed her. During an observation at 10:20 a.m., resident #3 was in bed sleeping, and remained in bed sleeping at 11:20 a.m., and 12:00 p.m. Resident #3 was up in dining room for lunch at 12:50 p.m. During an interview on 10/4/16 at 3:40 p.m., resident #3's sister stated She sleeps a lot. What causes that? During an observation on 10/4/16 at 4:00 p.m., resident #3 was sleeping at the nurses station, after the visit from the sister. During an observation on 10/5/16 at 8:40 a.m., 9:33 a.m., and at 10:20 a.m., resident #3 was sleeping in a dark room. During an observation on 10/5/16 at 11:20 a.m., resident #3 was in the beauty shop, getting a hair cut, with her head back and eyes closed, sleeping. During all observations, resident #3 was asked simple yes/no questions, and was not able to verbalize a response. Review of the resident's Activity Record for September 2016 showed resident #3 slept through 30 activities, and attended 16. During an interview on 10/6/16 at 9:40 a.m., staff members B and D stated the goal was to discontinue the [MEDICATION NAME] and continue to taper the [MEDICATION NAME] for resident #3. Staff member D stated the resident was inconsolable, and the facility did not know what else to do for her. Review of the resident's medical record showed resident #3 experienced 15 medications changes from 4/21/16 through 7/29/16. Review of the resident's July and August 2016 MARS showed her pain level and effectiveness of pain medications were not monitored.

Based on observation, interviews, and record reviews, the facility failed to recognize the loss of 8% total body weight over a period of nine days coupled with the loss of 9.4% body weight over four months, which was significant, as a problem requiring resident reevaluation, update of care interventions, and failed to adequately address the resident's ill fitting dentures, and diet concerns relating to choking and swallowing for 1 (#12) out of 14 sample and supplemental residents. Findings include: Resident #12 was admitted with [DIAGNOSES REDACTED]. Weight During an observation on 10/5/16, at 08:40 a.m., resident #12 refused the oatmeal she had ordered, requested, and received, dry toast. Jelly was spread on the toast by an assisting staff member. The resident was observed to experience coughing and difficulty swallowing with each bite of toast taken. She was observed to take four bites of the toast before she licked the jam off the toast and then stopped eating the meal. A review of Focus Charting for resident #12, dated 9/17/16, showed VS: 98/58, 16, 97.7, 52, 97% wt. 132.2 and stable. A review of Focus Charting for resident #12, dated 9/26/16, showed VS: 111/69. 98.1, 62, 22, 90%, wt: 121. This was a loss of 11.2 lbs or 8% of total body weight, over a period of nine days. A review of the 2016 CNA Weekly Weight Records for resident #12 showed the resident to have lost 5 lbs. in June, gained 5 lbs. in July, lost 2 lbs. in August, and lost 10.6 lbs in September. This was a loss of 9.4% of total body weight over a period of four months. A review of the Focus Charting nursing notes for resident #12, from 9/17/16 through 9/27/16, showed there was a lack of evidence that resident #12's physician, dietician, or family members had been notified of the resident's weight loss. There was no charting showing the nursing staff considered the resident's weight loss a significant problem. The charting did not show whether the DON or care team members had been made aware of the resident's weight loss. Refer to F157 Notification of Changes. During an interview on 10/4/16 at 11:10 a.m., staff member E said she was not notified by any of the nurses regarding resident #12's weight loss as determined on 9/26/16. She said that she was usually notified regarding resident weight loss with a call from the resident's nurse or by one of the care team managers. She also stated that resident #12 was due to have an updated diet assessment completed as of the date of the interview, 10/4/16. A review of resident #12's medical records, showed that the resident's last nutritional assessment was completed on 7/12/16, and the resident's food intake had decreased over the previous three months. It showed a greater number of lab values indicating a decline in general resident nutritional status were found abnormal during the same three months. A record review of an Estimation of Nutritional Needs, dated 4/12/16, showed resident #12 had gained weight over the past year, which was desirable. A record review of an Estimation of Nutritional Needs, dated 7/12/16, showed resident #12 had returned from a hospitalization for low blood pressure, and had experienced a 4.4% decrease in weight over the prior month. The record showed the plan was to monitor intakes and weight trends, and make further nutritional recommendations as appropriate. It also showed Nutrition POC (plan of care) updated. A review of the care plan for resident #12, showed that the resident had a potential for aspiration and weight loss related to wearing only upper dentures and the plan provided a list of interventions documented for aspiration and weight loss concerns on 4/17/15. Resident weights were documented on the plan but no other alterations or additions to the care plan had been made since 4/17/15, showing the weight changes had not been addressed on the plan. The resident's care plan was reviewed again on 10/6/16, after staff member E had been made aware of resident #12's weight loss on 10/4/16, but no changes had been made to the care plan. During an interview on 10/6/16 at 11:10 a.m., staff member C said We (the nursing staff) knew about the weight loss. The weight loss was thought to have occurred because resident #12 was receiving diuretics and leg wrapping treatments for her lower extremity [MEDICAL CONDITION]. She said it was the facility's policy that if a resident's weight loss was greater than three pounds, the nurse was to notify the resident's care team, which had not occurred. A review of the Medical Administration records showed that resident #12 received [MEDICATION NAME] and Spirolactone for lower extremity [MEDICAL CONDITION], prior to and during June and July of 2016. Both medications had been discontinued on 7/12/16. [MEDICATION NAME] was restarted on 7/15/16, and Spirolactone was restarted on 8/16/16. Both medications were continued and given to resident #12 during September 2016. No dose changes were ordered for either medication during September 2016, when resident #12 experienced a 10.6 lb weight loss over a nine day period. A record review of resident #12's 60 day visit appointment with her physician, dated 9/8/16, showed that the resident's weight at the time of the appointment was 131.6 lbs. Under the heading of chronic diastolic (congestive) heart failure the physician notes show: increased dieresis appears to have stabilized pt (patient) nicely. The record does not list weight loss as a problem. No other records were found to indicate that the resident's physician had been notified of the resident's weight loss determined on 9/26/16. A review of the facility's policy entitled Weight Loss or Gain, showed All resident weights will be monitored at least on a weekly basis and excessive weight loss or gain will be evaluated on an individual basis, and necessary steps will ensue. The procedure included in the policy lists the following: 1. Weekly weights will be taken and recorded both in the weight book and on the individual resident record on the CNA. flow sheet. 2. Staff nurses will evaluate and act upon weight gain or loss on their weekly summary, documenting the weight and indicating if there is a problem. 3. Each individual resident demonstrating weight loss or gain of more than three pounds per week will be re-weighed. 4. If a weight problem is identified, the staff nurse will notify the DON 5. The interdisciplinary care planning team will be notified of the problem by the DON and will meet to investigate the problem and identify possible solutions. The supervisor will notify the physician if weight gain or loss continues and will convey the recommendation of the interdisciplinary team. 6. In compliance with the physician's plan of care, the plan will be placed in the resident's care plan. 7. Weight problems will be monitored and evaluated weekly by the staff nurse until the problem is solved. The resident's weight concerns were not addressed using the procedures, or policies established by the facility to address the resident's weight loss, which was significant. Swallowing/Choking, and Dentures During an observation on 10/04/2016 at 08:05 a.m., resident #12 was eating breakfast in her room. The resident had coughed each time after taking a bite of pancake. The resident stated she usually coughed after she took bites of food. It was observed that the diet card had pureed foods circled for the resident, and the food being served to the resident was not a pureed diet. During an interview on 10/04/2016 at 08:05 a.m., staff member F stated the resident usually ate a mechanical soft diet, not pureed. At this time the resident stated her dentures do not fit right in her mouth, so she eats without the dentures. During an interview on 10/4/16 at 11:10 a.m., staff member E stated the resident should be on a pureed diet but she could pick a mechanical soft diet if she chose to. A review of the resident's Physician Orders, showed on 5/2/15 the diet was changed to reflect a pureed diet, but the resident could choose a mechanical soft diet. Because of this, the resident should have been served a pureed diet initially, and then given the option to choose a mechanical soft diet if she preferred. During an observation on 10/05/2016 at 08:40 a.m., the resident was eating breakfast in her room. The resident had taken four bites of toast and had coughed each time she took a bite. The resident stated she did not have any teeth, and it was hard for her to eat. The diet card had pureed food circled for the resident, but the food being served was not pureed. A review of the residents Care Plan interventions, dated 4/17/15 to 07/12/16, showed chewing problems, referral to speech therapy if indicated, potential for aspiration and weight loss related to wearing only upper dentures. The care plan showed staff were to monitor for coughing with meals. The plan lacked evidence to show what staff should do if she is coughing, or that it had been identified as an issue from the time the plan was initiated. A review of the residents Nutritional Assessment, dated 09/25/13, showed chewing difficulties and dentures. A review of the resident's CAA Analysis Report, under dental care report, and dated 04/14/2016, showed resident #12 triggered for not using her dentures, dentures loose, and currently on pureed diet with occasional mechanical soft every now and then. A review of the resident's dietitian notes, dated 07/12/16, showed dentition filled in as own-good and the Plan of Care updated. A review of the resident's Quarterly MDS, section K0100, with an ARD of 07/09/16, showed that the resident had no problems with chewing difficulty, or problems with her dentures. The medical record lacked documentation for how the diet and choking was addressed, as it was actively occurring, and failed to address the resident's ill fitting dentures, which hindered her eating.

Based on record review, interview, and observation, the facility utilized multiple [MEDICAL CONDITION] medications for one resident to treat behaviors which were identified as pain related for staff convenience for 1 resident (#3) out of 11 sampled residents; the effect resulted in significant lethargy for the resident who had cognitive and communication deficits. Findings include: Review of a Pharmacy Recommendation for resident #3, dated 4/21/16, showed RN's and I talked about her crying etc. They think she is worse. Could be decrease of [MEDICATION NAME] or [MEDICATION NAME] needs increased. Could go back up with [MEDICATION NAME] and get [MEDICATION NAME] to therapeutic dose. Review of the physician's reply, which was in the medical record, showed Increase [MEDICATION NAME] to 150 mg daily, and no change in [MEDICATION NAME]. Review of the resident's Physician order [REDACTED]. [MEDICATION NAME] was increased in dose to .5 mg, 4 times a day, for anxiety and comfort. Review of the resident's Focus Charting notes showed [MEDICATION NAME] was discontinued on 5/9/16. The reason was not provided. Review of the resident's Hospice not on 5/19/16 showed the resident was agitated and trying to climb out of her chair. The resident cried through the visit and talked about home. She was given [MEDICATION NAME] and [MEDICATION NAME] for back pain. Review of the resident's Focus Charting notes on 5/20/16 showed Dr. here new order to DC [MEDICATION NAME] and consider taper of narcotics. Review of the resident's Hospice note on 5/23/16 showed staff reported the patient seemed to have an increase in agitation with use of [MEDICATION NAME], and the last week was the worst. No signs and symptoms of pain, and the MD decreased [MEDICATION NAME] to three times a day, and the [MEDICATION NAME], from 10 mg four times a day to 5 mg three times a day. Review of the resident's Physician Orders, dated 5/26/16, showed to discontinue [MEDICATION NAME] and start [MEDICATION NAME] for the resident's depression. Review of the resident's May Medication Administration showed ([MEDICATION NAME]) dated 4/18/16, 100 mg PO at HS. The administration record was blank, and said see page 3. Page 3 showed ([MEDICATION NAME]) 150 mg po daily. The administration record was blank. Review of the resident's Focus Charting on 5/28/16 showed the resident had a fall in her room. She was taken to the dining room for closer observation. She was given an extra [MEDICATION NAME] with her scheduled one at 1400. A reason was not provided. Pain was not addressed for the resident. Review of the resident's medical record did not show the monitoring for affects from the reduction in pain and anti anxiety medication, and discontinued use of the [MEDICATION NAME] on 5/23/15. Review of the resident's Focus Charting noted on 6/2/16 showed the resident had a rash, and the [MEDICATION NAME] was on hold. The documentation showed, Resident restless, crying, today at lunch. Pain was not addressed, although the resident had exhibited pain symptoms. Review of the resident's Focus Charting note on 6/2/16 showed the resident was restless and moaning. A PRN [MEDICATION NAME] and [MEDICATION NAME] was given, showing a positive outcome. Although the medication was beneficial to treat the restless and moaning, the facility did not consistently utilize this information when the resident exhibited future pain symptoms, but rather her pain symptoms were treated with behavior altering medications. Review of the resident's Focus Charting on 6/9/16 showed Clinical Pharm (sic) called about acute [MEDICAL CONDITION]/agitation. The recommendation given was for [MEDICATION NAME] 2 - 5 mg every hour as needed. Staff report the resident needs 1 to 1 care due to falling out of bed, agitation, and not sleeping for 48 hours. The resident's medical record lacked an assessment for possible pain and medication withdrawal as a potential cause for the [MEDICAL CONDITION]. Review of the resident's Focus Charting note, dated 6/9/16, showed a new order to increase the [MEDICATION NAME] to 10 mg, three times a day. Review of the resident's Focus Charting note on 6/10/16 showed the resident was crying and stating she was in pain. She was given 3 mg of [MEDICATION NAME], and 10 mg of [MEDICATION NAME] with a positive effect. Again, this showed the benefits of treating the resident's pain, rather than her behavior symptoms. Review of the resident's Focus Charting note on 6/11/16 showed the resident was awake most of shift and prn [MEDICATION NAME] and [MEDICATION NAME] was given. The nurse documented, Needing one on one care to keep her from climbing out of bed or off her chair. Review of the resident's Focus Charting note on 6/12/16 showed Became restless given [MEDICATION NAME], .5 mg and [MEDICATION NAME] 3 mg and [MEDICATION NAME] 10 mg. Wedge cushion used on mattress. At 1400, restlessness continue at time. Resident presents with tremor/shakes - possible side effect from [MEDICATION NAME]. Review of the Focus Charting notes dated 6/13/16 showed a fall out of bed; and, call placed to hospice - concerns of noted tremors and shakes. Review of the resident's Care Plan shows the resident's bed was placed against the wall, with a scoop mattress, and a 10 wedge on the outside of the mattress was in place to keep the resident from getting out of bed. Review of the resident's Focus Charting note on 6/16/16 showed the resident was extremely restless. The Hospice nurse advised to give 2 mg [MEDICATION NAME] and titrate up to 5 mg, if needed. At 2300, [MEDICATION NAME] 10 mg was given for pain. Gave her an increase 2 mg of [MEDICATION NAME] at 2255 - then increased dose to 3 mg, at 2355 now - much quieter now but awake. This note indicated the resident was given 6 mg of [MEDICATION NAME]. Review of the resident's Focus Charting Note on 6/17/16 showed a new order for [MEDICATION NAME] 50 mg, may titrate to 100 mg in 1 week, and [MEDICATION NAME] 1 mg every 2 hours as needed for comfort. The resident exhibited verbal complaints of pain, and 10 mgs of [MEDICATION NAME] was given. Review of the resident's Focus Charting Note on 6/18/16 showed the resident crying and complaining of pain. PRN [MEDICATION NAME] given. The documentation in the medical record lacked evidence for how the facility attempted to alter the resident's pain prior to her exhibiting the crying, or complaining of pain in an attempt to anticipate her needs due to her impaired cognition. Review of the resident's Hospice note on 6/20/16 showed Staff reported patient is a bit calmer since [MEDICATION NAME] and [MEDICATION NAME] med (sic) dose changes. Pt (sic) will get her first dose of [MEDICATION NAME] tonight. (ordered 6/17/16) Review of a Hospice note dated 6/28/16 showed Staff report patient typically becomes agitated when transferred to bed, appears fearful and trying to pull herself up out of bed. (Hospice) did note a pattern throughout nurses notes of increased agitation at night and calm during day when up in Broda chair. Review of the resident's medical record lacked evidence the facility assessed the resident's increase in pain when in bed, or the physical restriction placed on the resident while in bed, as possible contributing factors for the resident's increased agitation. Review of the resident's Focus Charting on 6/30/16 showed a new order for an increase in [MEDICATION NAME] from 1 mg to 2 mg, three times a day, for agitation. Review of the Significant Change MDS, with the ARD of 7/13/16, showed resident #3 had signs and symptoms of pain 3 to 4 days out of the 7 day look back period. This showed the facility had identified the pain concerns, but had not adequately assessed, or addressed the pain contributors. Review of the resident's Pharmacy Review and Recommendation, dated 7/7/16, showed She is doing well on the increase in [MEDICATION NAME], can we decrease [MEDICATION NAME] to 1 mg every 6 hours while awake, and keep the prn dose 1mg, four times a day. The physician agreed, and the order was changed on 7/15/16. Review of the resident's July MAR, 2016, showed the [MEDICATION NAME] was decreased on 7/29/16, back to 1 mg, three times a day, related to an increase in lethargy, and having to wake the resident up for meals. Review of the resident's Focus Charting on 8/29/16 showed the resident continued to be lethargic frequently, and often slept though meals and medications. During an interview on 10/5/16 at 8:20 a.m., staff member N stated that it was difficult to keep the resident comfortable, but functional. Staff member N stated, She is more sleepy and talking less. She can get really emotional. During observations on 10/3/16, resident #3 was sleeping at the nurses station in her Broda chair at 1:40 p.m., 2:40 p.m., 3:00 p.m., with no position change. At 4:30 p.m., staff member O took the resident to her room, and changed her incontinent brief as resident #3 was lying in the Broda chair. Staff member O stated She's calmed down a lot. At 5:30 p.m., resident #3 was sleeping soundly, while snoring, in the day room. During observations on 10/4/16, resident #3 was by the nurses station at 6:60 a.m., asleep. At 7:45 a.m. she was still sleeping. At 8:20 a.m., she was sleeping by the dining room. At 8:55 a.m. resident #3 was sitting at the table for breakfast, dozing, as her eyes opened and closed occasionally. During an observation on 10/4/16 at 9:05 a.m., resident #3 was sleeping while the staff member attempted to feed her. Staff member N stated She's really sleepy, maybe we shouldn't feed her. During an observation at 10:20 a.m., resident #3 was in bed sleeping, and remained in bed sleeping at 11:20 a.m., and 12:00 p.m. Resident #3 was up in dining room for lunch at 12:50 p.m. During an interview on 10/4/16 at 3:40 p.m., resident #3's sister stated She sleeps a lot. What causes that? During an observation on 10/4/16 at 4:00 p.m., resident #3 was sleeping at the nurses station, after the visit from the sister. During an observation on 10/5/16 at 8:40 a.m., 9:33 a.m., and at 10:20 a.m., resident #3 was sleeping in a dark room. During an observation on 10/5/16 at 11:20 a.m., resident #3 was in the beauty shop, getting a hair cut, with her head back and eyes closed, sleeping. During all observations, resident #3 was asked simple yes/no questions, and was not able to verbalize a response. Review of the resident's Activity Record for September 2016 showed resident #3 slept through 30 activities, and attended 16. During an interview on 10/6/16 at 9:40 a.m., staff members B and D stated the goal was to discontinue the [MEDICATION NAME] and continue to taper the [MEDICATION NAME] for resident #3. Staff member D stated the resident was inconsolable, and the facility did not know what else to do for her. Review of the resident's medical record showed resident #3 experienced 15 medications changes from 4/21/16 through 7/29/16. Review of the resident's July and August 2016 MARS showed her pain level and effectiveness of pain medications were not monitored.