Every finding on record at Tobacco Root Mountains Care Center

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 all residents at risk for consumption of expired or contaminated food and for food-borne illness. This deficient practice increased the risk of negative outcomes for all residents receiving food services from the facility. Findings include:During an observation on 5/18/26 at 1:59 p.m., of the walk-in coolers, the following items were not labeled:- Two sandwich bags with fruit,- One gallon jug of salad dressing,- An opened bag of grapes with no opened-on date.During an interview on 5/20/26 at 2:34 p.m., staff member E stated the procedure of labeling opened containers and repackaged containers included marking containers with the name of what is in the container and the date to be used by.A review of the facility's policy titled, Food Receiving and Storage, with an origination date of 6/11/20, showed, 8. All foods stored in the refrigerator or freezer will be covered, labeled and dated ('use by' date) .

Based on interview and record review, the facility failed to indicate a specific duration for the extended use of an as needed psychotropic medication past 14 days for 1 (#15) of 11 sampled residents. This deficient practice increased the risk of negative outcomes for residents on as needed psychotropic medications. Findings include:Review of resident #15's MAR, for May 2026, showed, lorazepam oral concentrate 2 MG/ML, give 0.25 ml by mouth every 2 hours as needed for prophylaxis related to unspecified psychosis not due to a substance or known psychological condition with a start date of 10/3/25. The order did not indicate the duration for the as needed order.Review of resident #15's GDR for lorazepam, dated 2/18/26, showed, [Status Post] major [cardiovascular accident]. [Previous] on hospice. Now palliative plan in place, decline potentially at any time. [sic]Review of resident of #15's GDR for lorazepam, dated 3/19/26, showed, Palliative care plan in place. Expected decline. Need to maintain available. [sic]Review of resident of #15's GDR for lorazepam, dated 4/16/26, showed, Needs available [as needed]. Reduction not indicated. [sic]Review of resident #15's GDRs from 10/22/25 to 4/16/26, failed to indicate a specific duration for as needed lorazepam.During an interview on 5/21/26 at 8:24 a.m., staff member B stated as needed psychotropic medications, such as lorazepam, that will be used beyond 14 days should have documentation in residents' records that would include the rationale for the extended use and indicate the duration. Staff member B stated resident #15's order for lorazepam did not indicate a duration.During an interview on 5/21/26 at 8:24 a.m., staff member D stated the facility completed a monthly medication review (MMR) on every resident with the input of the facility's IDT members, including staff member C. Staff member D stated they would review any as needed psychotropic medications, such as lorazepam, for extended use beyond 14-days every month. Staff member D stated they would not always indicate the duration of a mediation or assign a stop date to certain psychotropic medications so the medication would not be arbitrarily discontinued should the resident need it in an emergent situation. Staff member D stated resident #15 had transitioned from hospice to palliative care but still needed the lorazepam for anxiety related to the dying process. During an interview on 5/21/26 at 8:24 a.m., staff member C stated resident #15 had transitioned off hospice and started palliative care in October of 2025. Staff member C stated they had determined the as needed lorazepam for resident #15 was necessary related anxiety associated with his imminent decline and death. Staff member C stated they had not indicated a specific duration for resident #15's lorazepam as they had been reviewing the medication in the monthly MMR meetings. A review of the facility's policy and procedure titled, Psychotropic Medication Use, with an origination date of 8/20/25, showed:- 12. Psychotropic medications are not prescribed or given on a PRN basis unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record.- a. PRN orders for psychotropic medications are limited to 14 days.- 1. For psychotropic medications that are NOT antipsychotics: If the prescriber or attending physician believes it is appropriate to extend the PRN order beyond 14 days, he or she will document the rationale for extending the use and include the duration for the PRN order.

Based on observation, interview and record review, the facility staff failed to proactively identify and address the risks a heater posed to a dependent resident when the heater was next to the resident's bed, and the resident sustained second degree burns on her left calf, left toes, left heel, left foot, and the entire bottom of her left foot from the heater, for 1 (#1) of 10 sampled residents; and the facility failed to address a resident's complaints of pain over a period of time after the resident had the Heimlich maneuver provided, and it was later found the resident had lower right rib fractures, for 1 (#2) of 10 sampled residents. On 3/31/26 at 4:44 p.m., the facility Administrator and Director of Nursing were notified that an Immediate Jeopardy existed in the area of F689 - Accidents and Hazards, pertaining to resident #1. The severity and scope of the IJ were identified to be at the level of J. The facility submitted an acceptable plan to remove the immediacy on 4/1/26 at 1:22 p.m., which was accepted by the State Survey Agency on 4/1/2026 at 1:45 p.m. The facility alleged the immediacy would be removed as of 4/1/26 at 2:30 p.m. Surveyors were onsite and verified the removal of immediacy as of the alleged date and time, lowering the severity and scope to G. Findings include: 1 . Resident #1 - Heater Burn Review of a facility document, titled Self-Inflicted Injury, dated 2/20/26, showed resident #1's left leg was found hanging off the bed, and it was on the baseboard heater. Two staff members moved the resident's leg back onto the bed. The resident's leg was assessed, and the resident was found to have a second-degree burn to the left leg and foot, which was draining fluid and bleeding. The resident was not responsive to verbal or physical stimuli at the time and was not able to state whether she had pain or not from the injury. The nurse placed cold rags (cloths) on the resident's wounds. Review of two witness statements, dated 2/20/26, showed resident #1 was found lying in her bed at 5:30 a.m., with her left leg hanging off the side of the bed, and it was on top of the baseboard heater. Staff member E's witness statement showed the last time she was in the resident's room was at 3:00 a.m., and this was two and a half hours prior to the resident being found with the burn. Review of resident #1's Skin Observation Tool, which was dated with an effective date of 2/20/26, showed, Second-degree burn noted on left calf and left toes. Poor skin integrity as (the resident was) actively dying. Cause identified as baseboard radiant heat as resident placed leg over bed and onto heater. [sic] The document was signed on 3/3/26, eleven days after the event and burns occurred for resident #1. During an interview on 3/11/26 at 1:45 p.m., NF5 stated that when she arrived at the facility, she had the staff unwrap resident #1's left foot and leg. NF5 stated the hospice agency called her to report the burn on resident #1's foot and leg. NF5 stated the bandage on the burn appeared new, as if it had just been placed on the resident, although the burn occurred in the early morning. During an interview on 3/11/26 at 2:56 p.m., NF7 stated staff member B called the hospice agency to inform them of the burn to resident #1's left foot and leg. NF7 stated staff member B told her the resident's leg had fallen off the bed and came to rest on the baseboard heater. Staff member B stated the resident had not experienced an increase in pain. NF7 stated that staff member B told her it was a significant burn with blistering to the left foot, from the heel to the toes. NF7 stated that the case manager for the resident, who was from the hospice agency, arrived at the facility after the resident passed away. During an interview on 3/12/26 at 7:56 a.m., staff member C stated the resident regularly kept putting her leg on the heater, which was by the bed, and she did not know how long the resident's leg was on the heater (for the burn to occur). Staff member C stated, Her (#1's) leg was on the (heater) for quite a while. Staff member C stated that staff checked on the resident often, saying it was almost every hour. Staff member C stated she didn't hear about the accident with resident #1's burn until after breakfast that morning. Staff member C stated the resident was very agitated in the days leading up to her death due to the pain she had from lung cancer. Staff member C stated the resident was not able to express her pain verbally, but she expressed non-verbal signs and symptoms of pain. During an interview on 3/12/26 at 10:47 a.m., staff members A and B were interviewed together. Staff member B stated she was in the facility at the time when the incident with resident #1 was reported to her. Staff member B stated she assisted the other staff member in putting the resident's leg back on the bed, and then cool cloths were put on the resident's leg and foot. Staff member B stated that resident #1 had sustained a burn from the baseboard heater. Staff member B stated she reported the incident to the administrator and compliance. Staff member B stated that the morning meeting then took place, and the staff was divided up and assigned to complete auditing of other resident rooms and heaters. Staff member B stated that the maintenance staff checked the boiler and temperatures (for burn risk temperatures). Staff member A stated the facility camera footage (during the time preceding the resident's burn) showed the staff were active in the unit all night. Staff member A stated that hospice staff were notified of resident #1's burn incident. Staff member A stated all rooms were assessed for safety regarding the baseboard heaters, and all the furniture was moved 24 inches away from the heaters. Staff member A stated that resident #1's leg was on top of the baseboard heater which was inconsistent with other accounts of the incident. During an interview on 3/12/26 at 11:28 a.m., staff member F stated that when she came on shift on 2/20/26 at 5:30 a.m., staff member E stated to her, This is really bad, when discussing resident #1's left leg burn injury. Staff member F stated the staff was pretty shook up about the accident, and when she saw the resident, there was a lot of liquid and blood draining from the left leg burn. Staff member F stated the resident's leg did not get wrapped (for treatment) until after the resident passed away. Staff member F stated the resident's clothing and bedding had to be changed due to the amount of fluid and blood coming from the leg wound. During an interview on 3/12/26 at 11:48 a.m., staff member E stated the event with resident #1 happened when the morning shift was coming on to start their shift. Staff member E stated she had to have another staff member come assist her in getting resident #1's leg back on the bed. Staff member E stated she wrapped cool, wet cloths (rags) on the resident's foot and leg. Staff member E stated she notified staff member B of the accident, and staff member B notified the hospice nurse. Staff member E stated she left before the bedding was changed. Staff member E stated the resident required a two-person assist with turning and repositioning. Staff member E stated she had gone home before the arrival of the hospice nurse, and stated the resident was actively dying and had received morphine every two hours through the night. Staff member E stated the resident passed away a short time after the accident/incident. During an interview on 3/30/26 at 3:34 p.m., NF8 stated resident #1 was seen daily by hospice. NF8 stated she was on call the day resident #1's burn occurred, and she immediately traveled to the facility. NF8 stated resident #1 had passed away before she arrived. NF8 stated she unwrapped the burn on resident #1's foot and found, a significant second degree burn from her toes to her heel covering the whole bottom of the foot. NF8 stated she did not see the burn on resident #1's leg because the burn was on the calf, and she did not want to aggressively move the resident's body to see the burns with family present. NF8 stated she had given the facility orders for the resident to get morphine before the burn event occurred, and it was to be given every hour. NF8 stated the staff should have been in the room hourly, checking on the resident. During an interview on 3/31/26 at 7:47 a.m., staff member D stated, We are supposed to check on every resident every 30 minutes, even at night. During an observation and interview on 3/31/26 at 8:26 a.m., staff member K stated after the burn occurred on resident #1, the facility moved all resident beds 20 inches away from the walls. Staff member K stated the wall heating units have been damaged a lot over the years, and he tried to maintain them, but the floor staff needs to notify him when a heat register is damaged or coming apart. Staff member K stated many of the room's heaters have missing parts, leaving sharp metal edges exposed. Staff member K stated the rooms should be a 72-82 degrees Fahrenheit and heat registers should be maintained at 140-150 degrees Fahrenheit. Staff member K stated the damaged heat registers in rooms 119, 120, 121, and 123 had not been reported to him, and he had not received any work orders for the heat registers. Staff member K stated the facility had not completed temperature checks on the heaters since the burn occurred on 2/20/26. Temperature checks were completed on the resident room heaters using a facility temperature gun, with the surveyor present, found the following: - room [ROOM NUMBER]: 190 degrees Fahrenheit, - room [ROOM NUMBER]: 190 degrees Fahrenheit, Staff member K stated he needed to turn the boiler down to lower the temperature of the heat registers. During an observation and interview on 3/31/26 at 9:20 a.m., staff member L used the facility temperature gun to test the following rooms and found: - room [ROOM NUMBER]: 209 degrees Fahrenheit, and very warm to the touch, - room [ROOM NUMBER]: 200 degrees Fahrenheit, and the family member and resident were in the room and told staff member L, It's too damn hot. - room [ROOM NUMBER]: 201 degrees Fahrenheit, and very warm to the touch, - room [ROOM NUMBER]: 195 degrees Fahrenheit, and very warm to the touch. Staff member L stated staff member K had left for personal reasons after the initial walk-through with the surveyor and was the only one who knew the plan for managing the boiler. Staff member L stated staff member K had not shared the plan (boiler management) with him, so he was not sure what steps to take to lower the heat register temperatures. During an interview on 3/31/26 at 6:00 p.m., staff member E stated she was in resident #1's room every two hours the night she was burned. Staff member E stated she had given resident #1 Ativan because she was restless, fussing, and had slid down in the bed. Staff member E stated she went into the room at 5:30 a.m. and found resident #1's foot was wedged in the heater, and she needed assistance to get the foot out. During an interview on 3/31/26 at 7:36 p.m., staff member C stated resident #1 was agitated, was moving a lot, and did not like being in bed. Staff member C stated that when she worked, she was always in resident #1's room every hour because She was so antsy and moving her legs around. During an interview on 4/1/26 at 9:30 a.m., staff member J stated, [Resident #1] would swing her legs off the bed a lot, we were always repositioning her legs. Staff member J stated she was not aware the heater was a concern. Review of a document, titled Burn Injury Identification and Prevention, dated 2/20/26, showed resident #1 was found at 5:25 a.m. with her left leg hanging off the bed, and it was on top of the baseboard heater. Review of resident #1's medication administration record, dated 2/9/26 through 2/20/26, showed the resident's morphine was changed on 2/19/26, from an as-needed medication to a scheduled medication, and it was to be given every two hours for shortness of breath and pain. This was due to non-verbal signs of pain such as being uncomfortable, sitting forward, fussing around her back and lungs, and restlessness. The resident was lethargic and unable to state the need for pain medication at times, and she was restless and grimacing at times. The resident went in and out of responsiveness but was not able to express pain verbally. Review of resident #1's Treatment Administration Record, for turning and repositioning, dated 2/1/26 through 2/28/26, showed turning and repositioning on 2/19/26 and 2/20/26. Nine entries were documented at 5:09 p.m., four entries were documented at 5:10 p.m., three entries were documented at 3:57 a.m., and two entries were documented at 9:01 p.m. This reflected there were four documented times out of 24 opportunities for the resident's turning and repositioning. There was no further documentation provided for the turning and repositioning of resident #1, showing the resident was being checked on for her positioning. Review of resident #1's care plan, dated 2/10/26, showed nursing staff were to evaluate the effectiveness of pain interventions every shift, monitor and document for probable cause of each pain episode, monitor and document side effects of pain medication, monitor and document signs and symptoms of non-verbal pain, monitor and record loss of appetite, and monitor and record the resident's complaints of pain. There was nothing on the care plan for resident #1 related to the risk of burns from the heater prior to the accident occurring, although the resident had a history of moving her legs and placing them on the heater, per staff. Review of resident #1's, Pain assessment vitals, dated 2/10/26 - 2/20/26, showed: 2/20/26 at 12:30 a.m., rated as 6/10, moderate pain, 2/20/26 at 3:05 a.m., rated as 3/10, mild pain, 2/20/26 at 5:45 a.m., rated as 0/10, no pain Review of the facility surveillance video, dated 2/20/26 from midnight to 5:30 a.m., showed the following: - 1:07 a.m., staff member E entered resident #1's room, with medication and exited within one minute, - 1:49 a.m., staff member E entered resident #1's room and exited within one minute, - 3:36 a.m., staff member M entered to drop off water and exited within one minute - 4:48 a.m., staff member M entered resident #1's room and exited in 11 seconds, and - 5:24 a.m., staff member E entered resident #1's room and exited after 7 minutes when the wound was reportedly found. The video failed to show the nurse entering the room every two hours and failed to show the CNA checking on the resident every 30 minutes. The last person to enter resident #1's room was staff member M at 4:48 a.m., until 5:24 a.m., when resident #1's foot was found wedged in the heater. During an interview on 3/11/26 at 1:41 p.m., NF6 stated resident #1's left leg was wrapped when she picked her up and transported her to the funeral home. NF6 stated she did not see a burn on the resident's foot/leg due to the foot/leg being wrapped. 2. Resident #2 - Rib Fractures During an interview on 3/11/26 at 2:24 p.m., NF1 stated they were in the dining room assisting another resident eating when a dietary staff member said something looked wrong with resident #2. NF1 stated there were two other nursing staff members present, but the nurse hesitated. NF1 stepped in to perform the upward thrust (Heimlich) to stop resident #2 from choking. NF1 stated they were not sure how weak resident #2 was, so he was left in the chair, and then the upward thrust around the chair was performed. NF1 stated resident #2 had the correct diet provided, but believed the diet was changed after a second choking incident occurred, and the upward thrust was performed a second time. NF1 stated they wrote a handwritten witness statement on the details for the first choking incident for resident #2 when he provided the upward thrust for the resident. During an interview on 3/11/26 at 2:49 p.m., NF2 stated resident #2 was placed on hospice after a bad fall in December 2025, where the hospital found the resident had complex pelvis fractures and rib fractures, and the family elected not to do surgery on the resident. During an interview on 3/12/26 at 8:32 a.m., staff member D stated resident #2 had a regular diet and had choked, and someone performed the Heimlich maneuver on the resident. After a second choking incident, the facility downgraded the resident's diet. The resident was placed on hospice after this event. Staff member D stated resident #2 did have right rib fractures found on the x-rays from the hospital visit for a later fall, with a pelvis fracture, but there were no X-rays done after the choking incidents when the resident complained of rib pain. Staff member D stated resident #2 was very confused during this time, and throughout the period when he was passing (end of life changes). During an interview on 3/12/26 at 10:16 a.m., staff members A and B stated after resident #2 choked, and they were in the process of reviewing the incident information and details, when he had another choking incident. Staff member B found resident #2 had a medication, Reglan, discontinued before the choking incidents occurred, because the provider believed it was contributing to the resident's insomnia, and none of the facility staff were aware of why he was taking the medication. They reordered the medication after the second choking incident, then the resident's diet was downgraded (modified) because the medication was to assist with swallowing. Staff members A and B stated the resident did not have any treatment related to the rib pain, other than 72-hour monitoring after each choking incident, because the resident was the one who determined if they wanted to be sent out for treatment. Staff member B stated resident #2 was placed on hospice after a fall, and when the resident was at the hospital for the fall, the hospital identified the resident's rib and pelvis fractures. Staff member A stated they did not review the rib fractures as a concern because the resident was placed on hospice, and nothing was done for rib fractures other than overall pain management when a resident was on hospice. During an interview on 4/1/26 at 1:25 p.m., staff member B stated the kitchen had been using a new brand of apple pie filling that had slices rather than the small chunks of apples on the day of resident #2's second choking incident. Staff member B stated she did not know why the care plan was missing in the EHR for resident #2. Staff member B stated resident #2 did not have a speech/swallow evaluation because the hospital speech therapist position had not been filled, and the agency used the hospital speech therapy for all swallow evaluations. Review of resident #2's EHR showed the care plan was no longer present in the EHR for resident #2. Review of resident #2's BIMS, for cognition, showed the resident had severe cognitive impairment. The facility reportedly went by the resident's choice to be sent out to the hospital, not addressing the cognitive barriers to a safe decision in the medical record. The resident's BIMS scores included: -12/9/25, score of 4 (severe cognitive impairment) -1/7/26, score of 0 (severe cognitive impairment, and the lowest score possible) Review of resident #2's nursing progress notes showed: -11/28/25 at 1:26 p.m., a choking incident occurred at breakfast, and the Heimlich maneuver was used. -11/28/25 at 2:15 p.m., Resident has c/o of soreness to his right side just at the bottom of his ribcage. Relayed to resident that he might be sore d/t having the Heimlich maneuverer done in dining room. Resident encouraged rest and laying down to facilitate less pain. [sic] -11/29/25, the resident had complaints of pain which were relayed in report, and he was offered to have a provider assess, and the resident stated no. -11/29/25 at 9:58 a.m., the resident had complaints of pain in the right lower ribs at a 7/10 level (10 being the worst). The POA was contacted and was okay following what the resident wanted, which was not going to the hospital. -11/29/25 at 2:16 p.m., resident #2 continued to complain of right lower rib pain. -11/29/25 at 10:17 p.m., resident #2 complained of right rib pain, and the resident declined a PRN Tylenol. -11/30/25 at 4:09 p.m., resident #2 had complaints of pain at 3/10 level and accepted a PRN Tylenol, stating he could tolerate it if he did not take a deep breath. -12/1/25 at 1:26 p.m., resident #2 was still reporting right rib pain which was tolerable with Tylenol. There were no further notes showing the responsible party was recontacted about the pain or sending the resident out for an evaluation of the pain. -12/2/25, a second choking incident occurred at breakfast, and resident #2 needed the Heimlich maneuver to be used again. The provider ordered the staff to monitor the resident for pain. -12/3/25, resident #2 continued to complain of right rib pain. -12/4/25, resident #2 continued to complain of right rib pain and declined going to the hospital. The notes did not show the responsible party was contacted, due to the resident's cognitive impairment, to see if they wanted the resident to be assessed further for the pain. -12/5/25, resident #2 continued to complain of right rib pain and requested to see the provider in the clinic the following day. -12/5/25, resident #2 fell in the bathroom and hurt his left hip. He was sent to the ER and came back with an identified injury, which was a complex pelvis fracture. The hospital also identified the right 6th and 7th nondisplaced rib fractures. Review of the hospital discharge records for resident #2, on 12/5/25, showed he was found to have nondisplaced fractures of the right 6th and 7th ribs. Review of resident #2's MAR, from 11/28/25 through 12/5/25, showed he was given a PRN Tylenol, 650 mg, on 11/30/25, for a pain level of 4/10, and again on 12/1/25, for a pain level of 6/10. No further pain medication was provided. Review of resident #2's vital signs for a pain level ranging from 0-10 (10 being the worst) from 11/28/25 through 12/5/25, showed: -11/28/25, none documented. -11/29/25, none documented. -11/30/25 at 7:30 a.m., numerical pain level of 4. -11/30/25 at 7:57 a.m., numerical pain level of 3. -12/1/25 at 7:40 a.m., numerical pain level of 6. -12/1/25 at 12:18 p.m., numerical pain level of 3. -12/2/25, none documented, and the 2nd choking incident occurred this day. -12/3/25, none documented, although the nurse documented the resident had pain in the progress notes. -12/4/25, none documented, although the nurse documented the resident had pain in the progress notes. -12/5/25 at 10:48 a.m., numerical pain level of 8. -12/5/25 at 10:55 a.m., numerical pain level of 8. Review of the facility policy, Terminal, Dying Resident, Caring for the, dated 10/26/25, showed: - .8. As the resident approaches death, monitor him or her frequently. Report all changes in the resident's condition to the Nurse promptly. 24. Try to be with the resident as much as possible during this time. Review of the facility policy, Pain Assessment and Management, dated 10/2022, showed: - .Acute pain (or significant worsening of chronic pain) should be assessed every 30 to 60 minutes after the onset and reassessed as indicated until relief is obtained. Review of the facility policy, titled Repositioning, with a revision date of 2/2/26, showed: .14. A turning/repositioning program includes a continuous consistent program for changing the resident's position and realigning the body. A program is defined as a specific approach that is organized, planned, documented, monitored and evaluated . 16. Residents who are in bed should be on at least an every-two-hour (q2 hour) repositioning schedule . 19. If ineffective, the turning and repositioning frequency will be increased .

Based on interviews and record review, the facility failed to ensure adequate pain management for 2 (#s 1 and 2) of 10 sampled residents. This deficient practice resulted in residents #1 and #2 having moderate and severe pain during the last day of life. Findings include:1. During an interview on [DATE] at 7:53 a.m., staff member N stated resident #1 was always in a lot of pain when staff did checks and changes.During an interview on [DATE] at 4:10 p.m., staff member O stated she and the physician were doing walking rounds, and the physician wanted resident #1 to have PRN pain medications immediately due to signs of significant pain. Staff member O stated she had notified staff member B, who then instructed the floor nurse to administer pain medication immediately. Staff member O stated the floor nurse did not administer the PRN pain medication for more than four hours after she was told to give the PRN medication. Staff member O stated the floor nurse was fearful of giving the pain medication because she had been reprimanded the prior day for giving too much PRN pain medication to a resident. Therefore, the resident's pain was not addressed in a timely manner. During an interview on [DATE] at 8:03 a.m., staff member J stated she second-guessed herself about giving resident #1 pain medications because she had been told she was giving too much pain medication to a resident the prior day. Staff member J stated resident #1 would mumble what she thought was no when asked if she was in pain, but her grimacing face indicated she was in a lot of pain. Staff member J stated resident #1 was not very verbal, and non-verbal indicators such as facial expressions were used to indicate signs of pain, but she always asked the resident as well. During an interview on [DATE] at 9:03 a.m., staff member J stated resident #1's medication orders were a debacle. Staff member J stated orders were not matching, and the facility was not getting the medications. Review of resident #1's, Pain assessment vitals, dated [DATE]-[DATE], showed:[DATE] at 12:30 a.m., rated as 6/10, moderate pain, for which pain medication was administered at 1:07 a.m. per video below[DATE] at 3:05 a.m., rated as 3/10, mild pain, no intervention[DATE] at 5:45 a.m., rated as 0/10, no pain, no interventionReview of the facility surveillance video, dated [DATE] from midnight to 5:30 a.m., showed the following:- 1:07 a.m., staff member E entered resident #1's room and exited within one minute, with medication,- 1:49 a.m., staff member E entered resident #1's room and exited within one minute,- 3:36 a.m., staff member M entered to drop off water and exited within one minute,- 4:48 a.m., staff member M entered resident #1's room and exited within 11 seconds, and- 5:24 a.m., staff member E entered resident #1's room and exited after seven minutes, when the wound was reportedly found.The video failed to show staff member E entering the room every two hours or 30-60 minutes after each medication administration, and failed to show staff member M checking on the resident every two hours. 2. Review of resident #2's EHR progress notes, dated [DATE]-[DATE], showed the following:- [DATE]: Resident #2 was found lying on the floor of his neighbor's room. He was lying on his right side but complained of pain in his left hip. Upon assessment, resident #2 was unable to move without crying out in pain. Due to the resident crying out if moved 911 was called. Notes indicate resident #2 had a complex pelvic fracture and rib fractures, but the family opted not do surgical procedures. Resident #2 returned to the facility on [DATE] on comfort care. Family requested hospice services on [DATE]. [Hospice Agency] called back on [DATE] and reported they would continue to work on the referral on Monday, [DATE]. Resident #2 admitted with Hospice services on [DATE].- [DATE]: Resident #2 was complaining of pain and agitated, trying to crawl out of bed and pulling on his foley catheter.- [DATE]: Resident #2 complained of left hip/leg pain at 7:00 p.m., and he was given his scheduled pain medication, which was ineffective. At approximately 9:00 p.m., the patient was still having pain; PRN morphine, repositioning, and a lidocaine patch were all ineffective. The patient was given another PRN dose of morphine at approximately 11:00 p.m., which was also ineffective. At 1:00 a.m., the patient was given a PRN dose of oxycodone, which was finally effective, and the patient was able to rest after that. - [DATE] at 2:45 p.m.: Resident agitated and calling out most of the afternoon and unable to redirect. He was offered snacks, repositioned, and given PRN pain meds, and they were ineffective. Hospice was contacted about PRN anxiety/agitation medications, and no order was received; hospice just increased Risperdal to twice daily. - [DATE] at 3:54 p.m.: Resident #2 was yelling and trying to throw himself on the floor and was unable to be redirected. PRN pain medicine was ineffective. Snacks and repositioning were ineffective. Called hospice, and no PRNs or new orders were received. Hospice called back at 4:01 p.m. and gave an order for Haldol. - [DATE]: Contacted hospice agency regarding the resident's status. Reported that [resident #2] did not fall asleep until 5:00 a.m. and required one-to-one assistance. As reported by the charge nurse, resident #2 was agitated, attempting to throw himself on the floor, cursing, and attempting to pull his catheter out. Resident #2 was experiencing delusions: talking about going to get in his pickup to go pick up an order at the cafe, wanting to show staff his new 4-[NAME] sitting outside the facility. Reported resident #2 was not eating or drinking much. Reported resident #2 received three doses of Haldol last evening, without effective results. Discussed that Ativan was discontinued, but unsure why it was not available. Discussed Lexapro being stopped. Hospice would fax new orders to clarify the Haldol order and restart Ativan. Hospice will present issues the resident is having at Hospice's Friday morning meeting and will address his need for Lexapro versus Risperidone, and his continued need for his catheter. Hospice will return on Friday for an in-person visit and bring medications for a refill. New orders and updated orders will be put into PCC as they come. Hospice restarted lorazepam oral concentrate for anxiety PRN. - [DATE]: Hospice stated they talked about restarting the resident's Lexapro in their morning meeting; however, they would like to give Risperdal time to reach a therapeutic level first. No medication changes given.- [DATE]: Resident sleeping in bed most of the evening. Began to move around and holler help around 11:00 p.m. Morphine was administered at 11:20 p.m., and the resident stated it was effective at first, but then would call out, looking distressed and trying to sit up while belching. He motioned that the pain was mid-chest. He continued to be restless. Ativan was administered at 12:05 a.m. He continued to be restless. Mag-al was administered for signs of indigestion and appeared to be ineffective. Additional morphine was administered at 12:40 a.m. This did not help as well. The nurse and another staff member assisted him to the toilet with no results. The resident then agreed to be placed in his recliner. - [DATE] at 4:06 a.m.: Resident #2 was restless this shift. He was calling out and attempting to get out of bed and/or recliner most of the night. Fluids were offered, but the resident was unable to swallow. The mouth was swabbed and moistened for comfort. Reaching out and yelling, help me! PRN medications were administered as ordered and repositioned often. Staff attempted to console constantly. Minimally effective. - [DATE] at 8:49 a.m.: Resident #2 was super restless, moaning and agitated; gave morning oxycodone and PRN morphine at 8:15 a.m. and was ineffective, still moaning and grimacing. Hospice was notified about pain management and about the resident's fall last night. Oxycodone liquid was getting too hard for the resident to swallow the amount of liquid. Hospice stated they were going to get back to the facility. - [DATE] at 10:07 a.m.: Resident #2 was still agitated and restless; moaning and grimacing grabbing at staff; requiring one-to-one staffing. Resident #2 was repositioned, and PRN Ativan was given at 10:00 a.m. - [DATE] at 12:12 p.m.: Hospice arrived, and the facility received new orders to change morphine from PRN to scheduled every three hours and add Biotene PRN up to five times a day for dry mouth; hold Ativan and discontinue oxycodone. - [DATE] at 1:30 p.m.: Resident #2 was groaning and grimacing in recliner. He was repositioned and oral swabs done. No PRN medications were available. Next scheduled pain medications were available at 3:00 p.m. - [DATE] at 2:05 p.m.: Hospice aware and wants to give scheduled morphine time to work. - [DATE] at 12:13 a.m.: Resident passed away at 11:48 p.m.During an interview on [DATE] at 4:10 p.m., staff member O stated she re-admitted resident #2 after his fall on [DATE]. Staff member O stated he was very agitated, trying to pull his catheter out, and only had morphine and Ativan on orders. Staff member O stated the Ativan had expired, and she contacted the physician for a new order. Staff member O stated the physician was upset that he would need to return to the hospital to write an e-script and wanted her to use the expired medication. Staff member O stated she refused to use the expired medication and had to wait for the new medication to arrive. Staff member O stated she was present when resident #2 passed away. Staff member O stated resident #2 was very agitated and in pain, requiring three CNAs to help keep him in the Geri chair in the hallway. Staff member O stated the only medication resident #2 had available was Phenergan suppositories. Staff member O stated she did call and talk to the hospice case manager nurse, but she was rude and not helpful, so she called over to the hospital on-call physician to get orders. Staff member O stated she was later told she cannot call the on-call physician when the resident is on hospice services.During an interview on [DATE] at 8:03 a.m., staff member J stated that resident #2, was always in so much pain. Staff member J stated she would give the medications if they were ordered, and then kept trying non-pharmacological interventions. Staff member J stated she did not attempt to call the physician, Director of Nursing, or the Hospice agency for additional pain management medications. Staff member J stated she thought the day shift nurse had contacted the physician and made the plan with the new medications, and she did not feel she should call in the middle of the night to change the medications again. Staff member J stated she did not know she could contact hospice when resident #2 was in pain on the night shift. Staff member J stated she received no training on the process of dealing with hospice residents or end-of-life residents. Staff member J stated she was new and had no experience with end-of-life care and death.During an interview on [DATE] at 1:25 p.m., staff member B stated staff member J had not had training on end-of-life care or hospice. Staff member B stated, We have a training opportunity here. Staff member B stated her expectation was that the nurses should administer medications as ordered and reassess in 30-60 minutes, continuing to get medications and non-pharmacological interventions until pain was relieved. If all options were exhausted, staff member B stated she expected the nurses to contact the appropriate on-call nurse, her, or the on-call physician, depending on each patient's situation. Review of resident #2's EHR Pain vitals, dated [DATE], reflected:[DATE] at 2:57 a.m.: 10/10 pain, maximum severe pain,[DATE] at 10:18 a.m.: 6/10 pain, moderate pain,[DATE] at 2:20 p.m.: 8/10 pain, severe pain, and[DATE] at 5:25 p.m.: 5/10 pain, moderate pain.A request for review of surveillance video was made on [DATE] at 10:30 a.m. Staff member A stated the video was no longer available before [DATE].During an interview on [DATE] at 1:25 p.m., staff member B stated she did not know why the care plan was missing in the EHR for resident #2. Review of the facility policy, Pain Assessment and Management, dated 10/2022, showed:- .Acute pain (or significant worsening of chronic pain) should be assessed every 30 to 60 minutes after the onset and reassessed as indicated until relief is obtained.- . Monitoring: 5. Contact the prescriber immediately if the resident's pain or medication side effects are not adequately controlled.

Based on interview and record review, the facility failed to protect a resident from staff to resident abuse for 1 (#5) of 10 sampled residents. Findings include:During an interview on 3/12/26 at 10:44 a.m., staff member A stated the staff were educated on abuse immediately during the investigation, which was related to a abuse allegation involving resident #5 and NF9, on 2/14/26. Staff member A stated IDT reviewed every incident and adverse events including abuse were reviewed in QAPI. The facility followed its policy in reporting and investigating abuse. NF9 was no longer employed by the facility after the investigation.During an interview on 3/12/26 at 10:57 a.m., staff member B stated she was home when she got the call from staff for an allegation of verbal abuse of resident #5 by NF9. Witness statements and the camera showed NF9 pulling the [resident #5's] walker with gestures to hurry, and the staff member directed resident #5 from the dining area to her room. Staff member B stated the provider, staffing agency, and family were notified of the alleged abuse. Staff member B stated the actions of NF9 went against the facility practice of using a gait belt and behavior and she was let go after suspension and investigation. All staff that were witnesses were educated on the requirement to intervene when witnessing potential abuse on 2/15/26. Then all staff were trained on the abuse process. During an interview on 4/1/26 at 12:18 p.m., staff member P stated that she witnessed NF9 being aggressive with resident #5 entering her room. Staff member P stated she stayed by the resident's door once she witnessed the abuse and did not leave. She did not intervene because NF9 was putting items away and was no longer touching resident #5, who was sitting in her recliner. Staff member P stated she motioned for another staff member to get the nurse. Once NF9 left the room, staff member P went to report the abuse to the nurse for what she witnessed. Staff member P stated she wrote out a witness statement and was interviewed. Staff member P stated resident #5 could be difficult with behaviors but was not different than her baseline after the incident, and was still participating in activities, going to meals, and had no changes in her routine. Staff member P stated she was disciplined for not following the policy of intervening further on the alleged abuse and had to complete online reeducation on top of in-person education for abuse. Review of the facility investigation for an abuse allegation on 2/14/26, showed a charge nurse notified staff member B on 2/14/26 at 7:00 p.m., NF9 was verbally abusing resident #5. NF9 had left right after, as it was the end of her shift. NF9 was suspended pending investigation. The allegation was reported to the State Survey Agency, as required. All staff witnesses wrote statements and were interviewed and educated on abuse reporting and the need to intervene when suspecting abuse. Staff were disciplined that did not follow the policy to intervene in suspected abuse. All facility staff were reeducated. Resident #5 was assessed, and monitoring did not show any adverse effects after the incident. NF9's contract was ended with the investigation substantiating that they did not follow facility practices on 2/15/26.

Based on interview and record review, the facility failed to initially report an incident of suspected resident-to-resident abuse to the State Survey Agency within the required timeframe for 2 (#s 5 and 6) of 10 sampled residents. Findings include: Review of a facility reported incident sent to the State Survey Agency, showed on 7/5/25 (a Saturday) residents #5 and #6 got into an altercation. The nurse did not immediately report the incident up the chain of command to the DON or Administrator. The delay in the nurse reporting continued the risk to the residents until the altercation was identified on 7/7/25 (a Monday) during a chart review. The facility attempted to report the initial abuse allegation on 7/7/25, but the submission was not saved. The facility did not attempt to resubmit the incident to the State Survey Agency. The facility submitted the full investigation, including the initial report, on 7/11/25. The initial report was late. During an interview on 3/12/26 at 10:44 a.m., staff member A stated the incident between residents #5 and #6 happened over the weekend and was found (the following Monday) when reviewing chart (medical record) notes. Staff member A stated they attempted to submit the initial report on 7/7/25 to the State Survey Agency. The submission did not save in the reporting system, so the full investigation, with the initial report and final investigation, was submitted on 7/11/25. Staff member A stated the nurse was reeducated of the requirement to notify the necessary staff of any incident or potential abuse immediately, and all staff had abuse reporting training. Review of facility staff abuse training logs for the last 12 months showed staff member T had completed, on 4/13/25, the course titled, Preventing, Recognizing, and Reporting Abuse.

Based on interviews and record review, the facility failed to ensure nurses were competent to provide pain management for hospice and end-of-life care for 2 (#s 1 and 2) of 10 sampled residents. This deficient practice resulted in unnecessary pain for residents #1 and #2. Findings include:1. During an interview on 3/31/26 at 4:10 p.m., staff member O stated she and the physician were doing walking rounds, and the physician wanted resident #1 to have PRN pain medications immediately due to signs of significant pain. Staff member O stated she notified staff member B, who then instructed the floor nurse to administer pain medication immediately. Staff member O stated the floor nurse did not administer the PRN pain medication for more than four hours after she was told to give the PRN medication. Staff member O stated the floor nurse was fearful of giving the pain medication because she had been reprimanded the prior day for giving too much PRN pain medication to a resident. During an interview on 4/1/26 at 8:03 a.m., staff member J stated she second-guessed herself about giving resident #1's pain medications because she had been told she was giving too much pain medication to a resident the prior day. Staff member J stated resident #1 would mumble what she thought was no when asked if she was in pain, but her facial grimacing expressions showed she was in a lot of pain.2. During an interview on 4/1/26 at 8:03 a.m., staff member J stated resident #2 . was always in so much pain. Staff member J stated she would give the medications that were ordered and would then keep trying non-pharmacological interventions. Staff member J stated she did not attempt to call the physician, Director of Nursing, or the Hospice agency for additional pain management medications. Staff member J stated she did not know she could contact hospice when resident #2 was in pain during the night shift. Staff member J stated she received no training on the process of dealing with hospice residents or end-of-life care. Staff member J stated she was new and had no experience with end-of-life care and death.Review of resident #2's EHR Pain vitals, dated 8/16/25 - 1/9/26 reflected:1/9/26 at 2:57 a.m.: 10/10 pain, maximum severe pain,1/9/26 at 10:18 a.m.: 6/10 pain, moderate pain,1/9/26 at 2:20 p.m.: 8/10 pain, severe pain, and1/9/26 at 5:25 p.m.: 5/10 pain, moderate pain.A request was made on 4/1/26 at 12:20 p.m., for education and training for staff member J for hospice and end-of-life care. During an interview on 4/1/26 at 1:25 p.m., staff member B stated staff member J did not have training on end-of-life care or hospice (from the facility). Staff member B stated, We have a training opportunity here. The nurses should contact the hospice or the on-call nurse. Staff member B stated her expectation was that the nurses should administer medications as ordered and reassess the resident in 30-60 minutes, continuing to provide medications and non-pharmacological interventions until pain was relieved. If all options were exhausted, staff member B stated she expected the nurses to contact the appropriate on-call nurse, her, or the on-call physician, depending on each patient's situation. Staff member B stated the facility recently changed the training to Relias (training program) and was just starting to assign training. The training would be spread out over a 12-month period. Staff member B stated Relias did have courses covering pain management and end-of-life care, but she had not assigned them to the nurses yet. Review of staff member J's employee file reflected that no education was provided from the facility on hospice care or end-of-life care. Review of the facility Assessment Tool, updated 12/15/25, showed:- . Training in an ongoing process for all staff. The following in services/Relias trainings are assigned during the year to ensure all staff are knowledgeable on these topics.- .Hospice, End of Life Care.

Based on observation, interview, and record review, the facility failed to prevent an incident of physical and verbal abuse for 1 (#1) of 12 sampled residents. The event was identified as past non compliance due to the facility's actions. Findings include: Review of the facility reported incident, dated 12/18/24, showed resident #1 was seated in the dayroom, with his left leg elevated in a recliner. Staff member E had moved resident #1's wheelchair due to another event in the dayroom. Resident #1 became upset, yelled for his wheelchair to be replaced next to his recliner. Staff member E aggressively replaced his wheelchair next to his recliner, hitting his left leg with the wheelchair. When staff member E left the dayroom, she yelled, Is that what you wanted. Resident #1 was notably upset, assessed for injuries, with a dime sized reddened area noted on his left lower leg. Staff member E was removed from further interactions with any of the residents, while an investigation took place. Review of staff member E's employee file, on 4/8/25, showed she was last educated on the facility's abuse policy on 4/23/24. During an interview on 4/7/25 at 1:10 p.m., resident #1 stated he did not recall an incident when a staff member was unkind to him or had hurt him. Review of resident #1's Quarterly Minimum Data Set, with an Assessment Reference Date of 3/11/25, showed a BIMS (Brief Interview for Mental Status) of 9, moderately impaired cognition. Review of resident #1's Incident Note, dated 12/18/24 at 5:10 p.m., showed resident #1 was assessed after the incident of alleged abuse. The physical assessment showed a dime size red mark on his left leg, no open area noted, and no medical treatment was needed. The facility investigated the allegations of abuse with recorded video footage, and interviewed staff and residents present in the area at the time of the incident. The evidence the facility gathered showed the allegations of physical and verbal abuse, by staff member E was substantiated for resident #1. The facility continued to monitor resident #1 for any decline in his participation in activities of daily living or other psycho-social activities, which none were observed. Education to staff was completed on caregiver stress management and abuse after the incident, with documentation. The facility's QAPI (Quality Assurance Performance Improvement) committee included this abuse incident in their 1/15/25 meeting with a performance improvement project initiated. The facility had completed a root cause analysis, created a plan for improvement with additional education, and implemented continued monitoring of residents to sustain compliance. During an interview on 4/8/25 at 7:06 a.m., staff member C stated she witnessed staff member E's abuse of resident #1. Staff member C stated, she and staff member B interviewed resident #1 and assessed his leg for injury. Interviews took place with resident #1, other residents, and all the staff in the vicinity of the incident. Education was provided after the incident on CNA (Certified Nursing Assistant) burnout on 12/23/24 and abuse training on 1/28/25. Staff member C continued to monitor resident #1's psychosocial well-being for any changes, which there were none. During an interview on 4/8/25 at 10:56 a.m., staff member A stated abuse education was completed after the abuse incident, brought to QAPI, discussed with the medical director, and the facility's medical doctor. She stated additional education had been added to the onboarding process for staff and additional education for CNAs had been instituted. Staff member A stated during the abuse allegation interviews, there were areas identified to improve upon, including staff's understanding of abuse and additional educational information which was be provided to them. Review of the facility's policy titled, Abuse, Neglect, Exploitation, last reviewed 11/29/23, showed: - . Each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. - . 1. 'Abuse' means the willful infliction of injury . and - .3. 'Verbal Abuse' means the oral, written, or gestured language that willfully includes disparaging and derogatory terms to the resident .

Based on observation, interview, and record review, the facility staff failed to revise the care plans for 2 (#s 16 and 73) of 14 sampled residents. This deficient practice negatively affected resident #16 due to a lack of pain control in her legs, and after resident #73 was readmitted from the hospital, the staff did not have adequate directions for the provision of care and services for the resident. Findings include: During an observation on 4/8/24 at 3:23 p.m., resident #16 was sitting in her wheelchair, propelling herself down the hallway. Resident #16's shoes appeared to be tight, and her feet and legs appeared swollen. During an observation and interview on 4/9/24 at 9:24 a.m., resident #16 was sitting in a wheelchair and had propelled herself into her room. Resident #16's shoes appeared to be tight, the tops of her socks had left indentations on both her legs. Resident #16 pointed to her legs and stated, My legs are puffy all the time, and get uncomfortable from time to time. During an observation and interview on 4/10/24 at 8:40 a.m., resident #16 was sitting in her wheelchair, eating breakfast. Resident #16's shoes appeared tight, and both legs appeared swollen. Resident #16 had regular socks on. Staff member L stated the resident had edema to both of her legs but refused to elevate them to help with swelling. During an interview on 4/10/24 at 12:29 p.m., staff member H stated resident #16 did not like to put her feet or legs up to help with the swelling. Staff member H stated there was nothing on the care plan about resident #16's edema. Staff member H stated she had access to resident care plans but if she had questions, she would ask the nurse on duty. A review of resident #16's electronic medical record, dated 2/29/24, showed resident #16's Lasix, a diuretic, had been increased to 20 mg twice daily. A review of resident #16's care plan, with a revision date of 4/4/24, showed: No focus, goals, or interventions addressing resident #16's edema, diuretic use, or refusal to elevate bilateral legs. 47785 Review of resident #73's nursing progress notes showed resident #73 was readmitted to the facility at 12:00 p.m. on 4/4/24. She returned with a newly placed biliary tube the facility would be emptying, monitoring, and changing the dressing for. Review of resident #73's physician's orders dated 4/4/24, showed, .Biliary Tube Dressing Change- use non woven drainage sponge (you will have to cut sides down so that the tagaderm fits over the drainage sponge .Biliary tube - empty bag and record amount drained . [sic] Review of resident #73's most recent care plan, with a revision date of 3/21/24, showed: no mention of a biliary tube being in place and no instruction for monitoring or emptying of the biliary tube. During an interview on 4/9/24, at 3:09 p.m., staff members A and B stated All of us chip in at IDT meetings to talk about cares and changes and the MDS coordinator would put the orders in and update the care plan . Only the nurses have access to the (Physician's) orders. Review of the facility policy titled, Care Plan Policy and Procedure, dated 1/16/2024, showed: Each resident will have an individualized interdisciplinary plan of care in place . - .The Comprehensive Care Plan will be reviewed and revised on a quarterly basis, . on re-admission from inpatient hospital stay . - .Procedure: 1. The admitting Nurse will complete baseline care plan on admission within 48 hours to address the following areas: . - Resident/Resident representative's initial Goals . - Skin Prevention . - Specific Care Plan on the main reason for admission to the facility . . 3. Each discipline will be responsible for the initiation and ongoing follow up for care plans as related to their area of expertise. [sic]

Based on observation, interview, and record review, the facility staff failed to ensure medications were given within the one-hour time period before or after the prescribed administration time for 1 (#4) of 14 sample residents; and failed to ensure the residents safely swallowed the medications for 2 (#s 2 and 10) of 14 sampled residents. This deficient practice may result in an increased risk for adverse effects and/or complications with choking or aspiration. Findings include: 1. During an observation on 4/9/24 at 12:27 p.m., staff member J administered the medications: baclofen, cholecalciferol, TUMS, and desvenlafaxine to resident #2. Shortly after resident #2 had the medications in his mouth, staff member J turned and walked away from the resident without ensuring he had fully swallowed the medications. Resident #2's mouth was still moving and he was still swallowing the medication. During an observation on 4/9/24 at 12:56 p.m., staff member J administered the medications gabapentin and keflex to resident #10. Staff member J walked out of resident #10's room without observing the resident swallowing the medications safely. 2. During an interview and observation on 4/9/24 at 11:46 a.m., the EMR showed a late medication administration for resident #4. The EMR showed these medications were to be given during the AM Med Pass. Staff member J stated she did not give these medications to this resident yet as resident #4 likes to sleep in. When asked what the specific indicated hours were for the AM Med Pass, staff member J stated, I'm not sure when that is. During an observation on 4/9/24 at 1:01 p.m., staff member J had the medications: amlodipine, cholecalciferol, senna, levothyroxine, lisinopril, meloxicam, metformin, prenatal vitamin, seroquel and miralax pre-poured, and located in her medication cart for resident #4. Staff member J administered these ten medications to resident #4 at this time. During an interview on 4/9/24 at 1:08 p.m., staff member J stated, We go with her [resident #4's] flow because of [her] behavior. Staff member J stated, We should get it [resident #4's medications] ordered later [in the day], because it was not uncommon that medications were administered late for resident #4. During an interview on 4/9/24 at 3:09 p.m., staff member B stated the AM Med Pass is a two hour window that is from 6 a.m. to 9 a.m. When asked if morning medications could be given later than 9 a.m., staff member B stated, They shouldn't be. Record review of a facility document titled, Medication Admin Audit Report, generated on 4/9/24, showed resident #4's medications were due between 7:00 a.m. to 9:00 a.m. every day, but were given on: -4/1/24 at 9:52 a.m., 52 minutes late -4/2/24 at 11:15 a.m., 2 hours and 15 minutes late -4/3/24 at 9:36 a.m., 36 minutes late -4/4/24 at 10:41 a.m., 1 hour and 41 minutes late -4/5/24 at 10:52 a.m., 1 hour and 52 mintues late -4/7/24 at 9:36 a.m., 36 minutes late -4/8/24 at 9:33 a.m., 33 minutes late -4/9/24 at 1:06 p.m., 4 hours and 6 minutes late -Some of the medications resident #4 received late were metformin which was prescribed for diabetes mellitus II and scheduled to be given twice a day.1 The resident's lisinopril and amlodipine that were prescribed for hypertension, seroquel that was prescribed for schizoaffective disorder, and meloxicam that was prescribed for arthritis pain. Record review of a facility policy titled, Administering Medications, revised 11/28/23, showed, .Medications are administered in accordance with prescriber orders, including any required time frame . Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before or after meal orders) . This policy also showed a medication administration time of8 a.m. with a timeframe of medication administration to be from 7:00 a.m. to 9:00 a.m. References: 1When concerning diabetic medications (metformin), [NAME] and [NAME] states, Physicians recommend taking metformin consistently at the same time every day ([NAME] & [NAME], 2023). Resident #4 received the medication metformin twice daily. Resident #4 may be more at risk of medication side effects, gastrointestinal upset if the medication is not administered after food, hyperglycemia before the medication is given, and hypoglycemia if the medication is not administered at the proper time. Poorly managed blood sugar can result in blindness, kidney disease, heart disease and nerve damage ([NAME], 2012). -[NAME], C., & [NAME], T. F. (2023, August 17). Metformin. Retrieved from National Library of Medicine: https://www.ncbi.nlm.nih.gov/books/NBK518983/ -[NAME], H. D. (2012, June 30). Diabetic Complications: Current Challenges and Opportunities. Journal of Cardiovascular Translational Research, 375-379. https://link.[NAME].com/article/10.1007/s12265-012-9388-1#citeas

Based on observation, interview, and record review, the facility failed maintain a system to ensure cloth recliners in the resident dayroom were monitored for necessary cleaning for infection control prevention. This deficient practice had the potential to affect all residents who utilized the dayroom, and used the recliners, as it increased the risk for the spread of infectious agents. Findings include: During an observation on 4/8/24 at 3:43 p.m., a strong urine smell was noted in the resident dayroom. In the dayroom eight recliners were cloth like material with a brown, cloth chair like cover placed over the original cloth recliners. Six of the recliners had residents sitting in them. During an interview on 4/8/24 at 3:44 p.m., staff member K stated she did not know when the recliners were cleaned or what the cleaning schedule was for the recliners. During an interview on 4/8/24 at 4:11 p.m., staff member O stated the chair covers are taken off and washed weekly, on night shift. Staff member O stated if the chair cover is soiled, it was taken off right away and sent to laundry, and housekeeping or maintenance will try and clean the recliner. During an interview on 4/10/24 at 9:00 a.m., staff member B stated the chair covers on the recliner were washed weekly on night shift, unless they are soiled. If the chair covers are soiled, they are washed right away. Staff member B stated, Maintenance or housekeeping will steam clean the recliners if they are soiled. Staff member B stated there was not really a cleaning schedule for the recliners, just if they were soiled. Staff member B stated, I know the recliners are considered uncleanable surfaces, and the cloth fabric is a magnet for bacteria, infections, and germs. If there was something like a virus or some type of infection present on the chairs, it could never be tracked or traced. We need to get rid of the cloth recliners. A review of a facility document titled, Non-Critical Cleaning of Surfaces (NOC Shift) dated, May 9, 2023, showed: .PURPOSE: Infection Control related to use of Equipment and non-critical items. . Saturday Night-Chair covers in dayroom, -remove and put to laundry every Saturday NOC shift, -Spray with Lysol . [sic] A review of a facility document titled, Infection Prevention and Control Program Policy, with a revision date of 11/29/23, showed: To establish and maintain an infection prevention and control program (IFCP) designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. . h. environmental cleaning and disinfection . The Centers for Disease Control infection control standard for cleaning non-critical equipment shows, . Strategies for decontaminating blood or body fluids . In patient care areas . cleaning and than disinfecting using an intermediate-level germicide or EPA registered germicide. .Barrier protection of surfaces and equipment is useful, especially if these surfaces are: - touched frequently by gloved hands during the delivery of patient care, - likely to become contaminated with body substances, or - difficult to clean. Impervious-backed paper, aluminum foil, and plastic or fluid-resistant covers are suitable for use as barrier protection. https://www.cdc.gov/infectioncontrol/guidelines/environmental/background/services.html

Based on observation, interview, and record review, three staff members (E, F, and G) failed to perform hand hygiene during meal service or when moving from dirty to clean linen tasks; and, the facility failed to provide hand hygiene education to 1 new staff member (G). Findings include: 1. During an observation and interview on 3/13/23 at 6:09 p.m., staff member E pushed a resident in a wheelchair to the dining room. Staff member E walked back to the meal cart and passed a resident meal tray without performing hand hygiene. Staff member E stated she should have used hand sanitizer before passing the meal tray. During an observation and interview on 3/13/23 at 6:20 p.m., staff member F, was passing meal trays from the kitchen to the dining room. Staff member F was not wearing gloves. Staff member F was observed setting the dinner plates in front of the residents, and touched drinking glasses, tables, and wheelchairs. Staff member F walked back to the kitchen and grabbed two more resident dinner plates and served them without performing hand hygiene. Staff member F stated she did not realize she needed to perform hand hygiene after touching different surfaces. 2. During an observation on 3/15/23 at 8:18 a.m., staff member G grabbed clean linen from the laundry cart and went into a resident room. She went back to the laundry cart and grabbed clean linen and went into another resident room with out hand sanitizing. During an interview on 3/15/23 at 8:40 a.m., staff member G stated she was not trained on proper hand hygiene. During an interview on 3/15/23 at 12:05 p.m., staff member C stated hand hygiene training was done on hire and annually for all staff members. Staff member C also stated she did monthly, random hand hygiene audits on staff. Review of the facility's new hire orientation packet for staff member G, reflected the hand hygiene portion of the training was not completed. Review of a facility document titled Handwashing-Hand Hygiene, with a revision date of 4/25/22, showed: .1. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene .

Based on observation, interview, and record review, the facility failed to ensure a power of attorney understood the risks and benefits of psychotropic medications for 1 (#7) of 4 sampled residents. Findings include: During an observation on 3/13/23 at 2:45 p.m., resident #7 was sitting in a recliner in the dayroom. The resident was sleeping. During an observation on 3/14/23 at 8:46 a.m., resident #7 was sitting in a wheelchair by nurse's station. The resident's eyes were closed, and she appeared to be sleeping. Review of resident #7's Admission MDS, with an ARD of 9/27/22, showed the resident was severely cognitively impaired with a diagnosis of dementia. During an interview on 3/14/23 at 9:19 a.m., NF1 said she had concerns about resident #7 being over-medicated. NF1 said several psych medications were added after the resident was admitted to the facility. NF1 said she did not know if those medications were really necessary. NF1 said she had not received any paperwork from the facility explaining the risks and benefits of the psychotropic medications being given to resident #7. Review of resident #7's medication administration record, dated March 2023, showed the resident was receiving: - Depakote sprinkles 125 mg two times a day by mouth for outbursts/anxiety-mood stabilizer, started 11/3/22, - Aricept 10 mg by mouth in the morning for dementia, started 11/11/22, - Namenda 10 mg two times a day by mouth for dementia, started 11/11/22, and - Seroquel 25 mg by mouth in the afternoon for dementia with behaviors, started 12/27/22. Signed risks and benefits for resident #7's Depakote, Aricept, Namenda, and Seroquel were requested on 3/15/23 at 1:33 p.m. The requested doucmentation was not provided by the time the State Survey Agency left the facility. During an interview on 3/16/23 at 9:16 a.m., staff member A said the facility did not have risks and benefits documentation for resident #7.

Based on interview and record review, facility staff failed to ensure provider orders for life-sustaining treatment (POLST) was completed for 1 (#7) of 15 sampled residents. Findings include: During an interview on 3/15/23 at 3:10 p.m., NF1 said the doctor was at the facility when resident #7 was admitted . NF1 said she completed section A of the POLST, but was waiting for the doctor to discuss the rest of the POLST with her. NF1 said the doctor was a happy, jovial guy who was going 90 miles an hour, and he did not have time to talk with her. NF1 said facility staff contacted her on 3/15/23 just a few minutes before this interview, and wanted her to complete and sign resident #7's POLST. Review of resident #7's POLST, dated 9/15/22, showed the resident's power of attorney had signed the document. Sections B, C, and D had not been completed. The document had not been signed by the physician. During an interview on 3/16/23 at 9:16 a.m., staff member A said a POLST was not valid if a medical provider had not signed it since September 2022. Review of the facility's current Admission packet, not dated, included a blank POLST.

Based on observation, interview, and record review, the facility failed to implement a person-centered care plan to meet the resident's medical, mental, and psychosocial wellbeing, for a resident with PTSD, which contributed to some of his self isolation, for 1 (#25) of 5 sampled residents. Findings include: During an interview on 3/15/23 at 3:20 p.m., resident #25 stated he had PTSD and staff had never asked him about it. He stated the social worker would rarely visit with him. Resident #25 stated he got PTSD from fighting in Vietnam, and it still affected him. He stated his episodes are better than they used to be. Resident #25 stated, The only person to ask me about my PTSD was [staff member M], and all he did was put me on a new medication.Resident #25 stated he stayed in his room most of the time because, TV and the news are big triggers' for him. Resident #25 stated his faith helped him a lot, and he attended services at a local church. Resident #25 stated, Prior to coming here, I attended a PTSD support group for Vietnam vets. Here they don't have anything like that, I don't have anyone to talk to that understands. Resident #25 stated he had never been offered an appointment with a mental health provider. Resident #25 stated he is just keeping things bottled up at this time. Review of resident #25's care plan, with a revision date of 02/2023, showed there were no goals or interventions identifying concerns with the resident's PTSD, triggers, psychosocial wellbeing, or possible self isolation.

Based on observation, interview, and record review, the facility failed to ensure a resident with a Foley catheter had a valid medical justification for its' continued use; failed to identify an increased risk for urinary tract infections through the use of a Foley catheter; and failed to assess for its removal for 1 (#17) of 1 sampled resident. Findings include: During an observation on 3/13/23 at 3:39 p.m., resident #17 was observed in the day room with a Foley catheter bag off to the side of her chair. Review of resident #17's medical diagnoses showed: - Overactive bladder, and - Urinary Tract Infection There was a lack of an acceptable diagnosis for the use of a Foley catheter. Review of resident #17's nursing progress notes, dated 12/5/22, showed, Talked with [provider name] about [resident #17's] skin sensitivity and that now she has a stage 1 .and she cannot wear briefs of any kind .this nurse believes that it would be beneficial for her to have a Foley catheter . [sic] During an interview on 3/15/23 at 11:08 a.m., staff member D stated resident #17 did not have any current pressure concerns to her skin. During an interview on 3/15/23 at 1:54 p.m., staff member B stated she thought the provider had listed neurogenic bladder as a diagnosis for resident #17, but she was not seeing that in his notes or on the diagnoses list. She stated the resident had never been sent to a urologist. Review of the facility policy, Urinary Catheter Associated Infection Prevention, updated March 2022, showed: . 6. The attending physician /practitioner has provided a written rationale for the use of a urinary catheter consistent with evidence-based guidelines. 7. Residents with indwelling urinary catheters are assessed regularly for continued need for the catheter, and the need is documented .

Based on observation, interview, and record review, the facility failed to label oxygen supplies with initials, and the date the tubing and humidifier bottles were changed, and follow a physician's order for oxygen therapy for a resident requiring continuous oxygen for 1 (#1) of 7 sampled residents. Findings include: During and observation on 3/13/23 at 2:50 p.m., resident #1 was laying in bed with oxygen in place at 4 liters via nasal cannula. The humidifier bottle was empty. Staff member E was notified. The tubing and the humidifier bottle did not have a date of when the tubing or the humidifier bottle had last been changed. During an observation on 3/13/23 at 3:47 p.m., resident #1 was sitting in the day room in his wheelchair with a portable oxygen tank attached to the back of his wheelchair. The oxygen setting was at 1.5 liters, and the bottle was empty. Staff member E was notified the oxygen tank was empty. Staff member E did not change the tank at that time. During an observation and interview on 3/13/23 at 4:57 p.m., resident #1's oxygen tank was empty. Staff member E was notified, a second time. Staff member E was observed to change the oxygen tank. Resident #1's oxygen saturation was at 90%. Staff member E stated oxygen tanks were to be checked every time they are turned on and frequently while they were in use. During an interview on 3/13/23 at 5:10 p.m., staff member C stated oxygen tubing and supplies were changed every two weeks, and dated and initaled by the staff member that changed them. During an observation on 3/14/23 at 8:20 a.m., resident #1 was sitting in his wheelchair in the dining room, with his portable oxygen tank. Oxygen was placed on resident #1, but was not turned on. Staff member B was notified. Staff member B turned resident #1's oxygen on to two liters. Review of resident #1's physicians orders, dated 9/21/22, showed resident #1 was to be on two to four liters of oxygen via nasal cannula and oxygen saturations were to be checked twice daily. Review of a facility document titled, Oxygen and Nebulizer Tubing, with an original and effective date of 4/21/2020, showed: .Policy: Changing and cleaning of equipment related Oxygen and Nebulizers. Procedure: 1. All tubing will be changed every 15 days and PRN. .c. Tubing will be dated and initialed by the person changing the tubing. 2. All humidifier bottles will be changed monthly. .b. Bottles will be dated and initialed by the person changing the bottles .

Based on interview and record review, the facility failed to identify and address PTSD concerns for a resident, and provide trauma-informed care to the resident, that was within professional standards that accounted for a resident's experiences and preferences to manage and prevent or attempt to minimize PTSD triggers, for 1 (#25) of 1 sampled resident. Findings include: During an interview on 3/15/23 at 3:20 p.m., resident #25 stated he had PTSD, from fighting in Vietnam, and it still affected him to this day. He stated that his episodes are better than they used to be. Resident #25 stated, The only person to ask me about my PTSD was [staff member M], and all he did was put me on a new medication. Resident #25 stated he stayed in his room most of the time because, TV and the news are a big triggers' for him. Resident #25 stated that his faith helped him a lot, and he attended services at a local church. Resident #25 stated, Prior to coming here I attended a PTSD support group for Vietnam vets. Here they don't have anything like that, I don't have anyone to talk to that understands. Resident #25 stated he had never been offered an appointment with a mental health provider. Resident #25 stated, I just keep things bottled up at this time. Resident #25 stated he would like to start attending a support group again. Review of resident #25's admission assessments, dated 1/12/23, failed to show any assessments identifying his psychosocial preferences, traumatic experiences, or PTSD triggers. Review of resident #25's progress notes, dated 1/23 - 3/23, failed to show documentation from social services related to the resident's PTSD, and the nursing notes did not address traumatic experiences, mental health, or PTSD triggers.

Based on observation, interview, and record review, the facility failed to provide behavioral health services, for a resident with PTSD, who had previously attended support groups to assist with managing his mental health, and wanted to attend again. The resident felt staying in his room would help with preventing PTSD Triggers from occurring, for 1 (#25) of 5 sampled residents. Findings include: During an interview on 3/15/23 at 9:31 a.m., staff member H stated she had never thought about doing any referrals for mental health, or behavioral health, for any of the residents in the facility. Staff member H stated she knew [resident #25] had PTSD, but did not know any information regarding it. During an interview on 3/15/23 at 3:20 p.m., resident #25 stated he had PTSD. Resident #25 said none of the facility's staff had ever talked to him about his PTSD. Resident #25 stated he got PTSD from fighting in Vietnam, and it still affected him to this day. Resident #25 stated, The only person to ask me about my PTSD was [staff member M] and all he did was put me on a new medication. Resident #25 stated he stayed in his room most of the time because TV and the news are big triggers for him. Resident #25 stated, prior to coming here I attended a PTSD support group for Vietnam vets. Here they don't have anything like that, and I don't have anyone to talk to that understands. Resident #25 stated he had never been offered an appointment with a mental health provider. Resident #25 stated,I just keep things bottled up at this time. Resident #25 stated he would like to start attending a support group again. Review of resident #25's electronic medical record, dated January 2023 to March 2023, failed to show the resident had been referred for mental or behavioral health services.

Based on observation, interview, and record review, the facility's designated social services worker failed to identify and provide appropriate behavioral and mental health services causing the resident to self isolate and keep his feelings to himself for 1 (#25) of 1 sampled resident. Findings include: During an observation and interview on 3/13/23 at 2:45 p.m., resident #25 was sitting in his room putting a puzzle together. Resident #25 stated he preferred to do activities in his room, but went down to the dining room for meals. During an interview on 3/15/23 at 9:31 a.m., staff member H stated she talks with the residents, but I do not document that I do. Staff member H stated she had never thought about doing any mental or behavioral health referrals. Staff member H stated she knew [resident #25] had PTSD but, did not know any information regarding it. During an interview on 3/15/23 at 3:20 p.m., resident #25 stated he had PTSD, and the social worker rarely visited with him. Resident #25 attended a PTSD support group for Vietnam veterans prior to admission. Resident #25 stated, Here they don't have anything like that. Resident #25 stated that he feels no one here understands what its like to have PTSD and there was no one at the facility to talk to about it. Review of resident #25's care plan, dated 1/23/23, showed there was no social services section addressing the resident's preferences, needs or triggers for his PTSD. Review of resident #25 progress notes, dated January 2023 to March 2023, failed to show any notes from the social worker, nursing staff or physician that addressed his psycho-social, behavioral or mental health needs. Review of a facility document titled Madison County Montana-Job description. .Social Services Director- - Essential Functions (major duties and responsibilities) These duties are the essential functions and are not all-inclusive of all the duties that the incumbent performs. - .Interviews residents interested family members, legal representatives and significant others to obtain and update information needed to develop individualized plan of care, to accommodate individual needs and preferences and to protect and promote resident's rights., - Works cooperatively with members of the interdisciplinary team to develop, implement and evaluate plan of care ., - .Provides or arranges for social work or other mental health counseling services as need to attain or maintain highest practicable mental and psychosocial well-being ., - Records progress notes in the clinical record including subjective findings, objective symptoms, observations of behavior, interventions provided to the resident and resident's responses to interventions, and . - Provides information, about community resources .

Based on interview, observation, and record review, the facility failed to provide adequate supervision resulting in multiple falls, one with a left [MEDICAL CONDITION], and one with a right [MEDICAL CONDITION]; failed to monitor, modify, and implement measurable interventions; and failed to adequately identify root causes for the prevention of falls for 1 (#2) of 16 sampled residents. Findings include: During an observation on 6/25/19, for approximately one and a half hours, resident #2 was sitting in her wheelchair in the dayroom. No staff were present in the dayroom or in the immediate area monitoring or supervising the resident, for safety. Review of resident #2's Baseline Care Plan, dated 2/26/19, showed the resident was at a high risk for falls. Review of the facility Fall Reports showed resident #2 fell seven times between 2/5/19 and 5/26/19. On 2/5/19 at 5:45 p.m., resident #2 fell and fractured her left hip. The [DIAGNOSES REDACTED]. The interpretation of the original x-ray 2/5/19 did not have a conclusion of a left [MEDICAL CONDITION]. During this two day period, the resident had increased reports of pain. On 5/26/19 at 5:10 p.m., resident #2 fell and fractured her right hip. Review of the resident #2's Care Plan, dated 1/15/19, showed resident fell on [DATE], at the facility, with a laceration to her head resulting in a concussion with increased sleeping, confusion, and poor appetite that comes and goes. The resident's Brief Interview for Mental Status (BIMS) at that time showed the resident had severe cognitive impairment. 1. Review of resident #2's Incident/Accident Report for the fall on 2/5/19 at 5:45 p.m., showed the resident lost her balance, hit her head on the corner of the wall, and landed on her left hip and arm. The conclusion of the investigation for the fall on 2/5/19, dated 2/7/19, showed: -Advanced dementia and does not use her call light. -Frequent checks. -Needs limited assistance. Review of the Incident/Accident Report investigation, dated 2/7/19, did not define frequent checks or how frequent checks would be communicated to the staff, monitored, and documented. 2. Review of resident #2's Incident/Accident Report for the fall on 2/9/19 at 11:00 p.m., showed the resident was found sitting on the floor by her bed. The type of assistance the resident was receiving at the time of the fall was alone and unattended. The conclusion of the investigation for the fall on 2/9/19, dated 2/11/19, showed: -Bed in low position. -Combative and refusing assist. -Approach in calm manner. -Have favorite CNAs sit with her when agitated/resistive. Review of the Incident/Accident Report investigation, dated 2/11/19, did not provide specifics regarding a CNA sitting with the resident when the resident was agitated/resistive or a back up plan if that CNA was not present. 3. Review of resident #2's Incident/Accident Report for the fall on 2/10/19 at 12:45 p.m., showed the resident was found by housekeeping lying on her bedroom floor. The type of assistance the resident was receiving at the time of the fall was alone and unattended. The conclusion of the investigation for the fall on 2/10/19, dated 2/11/19, showed: -Unable to reason with resident due to advanced dementia. -Behaviors- becomes easily agitated. -Forgets to use call light. -Sent for x-ray and found subcapital [MEDICAL CONDITION] femoral neck. Review of accident reports between 2/9/19 and 2/10/19, show the fall on 2/10/19 was the second fall, in the resident's room, in a 14 hour period. No interventions were initiated to monitor the resident's unsupervised self transfers. Review of resident #2's Nursing Progress Notes, dated 2/13/19, showed the resident was transported to the hospital for left hip surgery. Review of resident #2's Nursing Progress Notes, dated 2/26/19, showed the resident was readmitted to the facility. 4. Review of resident #2's Incident/Accident Report for the fall on 3/2/19 at 1:10 a.m., showed the resident was found on the floor in her room, and the bed was in the low position. The type of assistance the resident was receiving at the time of the fall was resident was sleeping in her bed. Summary of the fall team's meeting, dated 3/4/19, showed: -Tab alarm to chair/recliner in the day room and wheelchair switching back and forth. -Pressure alarm to bed. -Frequent checks. -Limited to extensive assist for all transfers. Review of resident #2's Baseline Care Plan, dated 2/26/19, showed the intervention for a pressure alarm to the bed and tab alarm on the wheelchair was not dated until 3/4/19, after the resident fell on [DATE]. The resident had just been readmitted and had a history of [REDACTED]. 5. Review of resident #2's Incident/Accident Report for the fall on 3/23/19 at 7:45 p.m., showed the resident was in the dayroom, the alarm sounded on her wheelchair, the nurse responded to the alarm, the resident was half way out of her chair. The resident stated she wanted to go to her room. The nurse asked the resident to wait until she could give get her medications, and the resident agreed. The nurse returned to the medication room, the alarm sounded on the resident's wheelchair again, and the nurse found the resident on the floor. The type of assistance the resident was receiving at the time of the fall was assisted per care plan. The conclusion of the investigation for the fall on 3/23/19, dated 3/25/19, showed: -When the resident gets restless, toilet and/or change her from the wheelchair to the recliner chair or the bed or vice versa. -Do not leave her alone when she is wanting to go to her bed or get up from the bed. She is impulsive and will try to transfer herself if left unattended. Review of the Incident/Accident Report investigation, dated 3/23/19, did not provide measurable interventions to prevent falls or impulsive ambulation when the resident was left unattended. The investigation did not address resident #2's poor cognition of instructions and the staff did not anticipate and assist the resident's needs in a timely manner. 6. Review of resident #2's Incident/Accident Report for the fall on 4/10/19 at 5:50 p.m., showed the resident tried to get out of her recliner in the dayroom. The resident's family member alerted the nurse, and the resident stood up and fell on her bottom. The conclusion of the investigation for the fall on 4/10/19, dated 4/11/19, showed: -Do not leave the resident alone when she is wanting to transfer on her own. -Stay with the resident and have her wait until help arrives with the alarm on. Review of the Incident/Accident Report investigation, dated 4/11/19, did not provide any new interventions to prevent falls. Review of resident #2's Temporary Care Plan, dated 4/11/19, listed frequent checks without defining how these checks would be performed, measured, or documented. 7. Review of resident #2's Incident/Accident Report for the fall on 5/26/19 at 5:10 p.m., showed the resident had an unwitnessed fall from her recliner, in the dayroom. The type of assistance the resident was receiving at the time of the fall was alone and unattended. The investigation for the fall on 5/26/19, dated 5/28/19, showed the root cause of the fall was: -Resident ambulated by herself, lost her balance, and fell . -Staff were busy with other residents and the nurses were finishing report. -There was no alarm to alert staff of unsupervised ambulation. The summary of the Falls Team Meeting, dated 5/28/19, showed: -Resident needs extensive assist of two when walking in corridor or the dayroom, with gait belt with wheelchair to follow. -Not steady, only able to stabilize with staff assistance. -Resident has tab alarm to her recliner chair and is able to remove herself. -Severely dementia impaired. Review of resident #2's Nursing Progress Notes, dated 5/26/19 at 10:05 p.m., showed the resident had a right [MEDICAL CONDITION] and was transported to the hospital for surgery. Review of resident #2's Nursing Progress Notes, dated 6/4/19, showed the resident was readmitted to the facility. During an interview on 6/26/19 at 10:33 a.m., regarding resident #2, staff member C stated, her definition of frequent checks was, Whatever the nurse in charge on duty wants the checks to be. During an interview on 06/26/19 at 10:42 a.m., regarding resident #2, staff member N stated, We have done as much supervision as we can. Staff member N stated The resident waits until no one is around, and she tries to do things on her own. Staff member N stated The problem is it's hard to do 1:1 staffing and it seems like the resident waits until no one else is around. Staff member N stated, her definition of frequent checks was, constantly down the hall, in the day room making sure she is okay, being observant of her when anybody is around. During an interview on 06/26/19 at 10:50 a.m., regarding resident #2, staff member L stated, her definition of frequent checks was, every time I walk by her room. She has a bed alarm on. We all keep an eye on her. During an interview on 6/26/19 at 10:52 a.m., regarding resident #2, staff member K stated, her definition of frequent checks was, I go in and see if she is comfortable or if she is in the recliner, if she would like to go to activities. I delegate and assign staff to certain halls. I would ask all the staff to just check on her to see if she needs anything, needs to use the bathroom, needs to get up. During an interview on 6/26/19 at 10:04 a.m., staff member A stated, Falls are difficult because you cannot use alarms. Staff member A stated they have tried to lower the facility's fall rates by graphing and trending falls and adding extra staff at times of the day when falls are occuring. They perform medication reviews, frequent checks, and indentify residents who are unaware of their safety concerns. Staff member A stated the process for root cause analysis starts with the witness of the fall drawing the scene of the fall, then fills out the rest of the form. The fall information is then reviewed in the quality assurance improvement process meeting as an interdisplinary approach. During review of resident #2's seven falls in a four month period, seven out of seven of the falls occured between 5:00 p.m. and 1:10 a.m.

Based on observation, interview, and record review, the facility failed to provide meaningful activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being status for 3 (#s 18, 20, and 25) of 22 sampled residents. Resident #20 experienced sadness due to the lack of activities, and the resident had not been able to pursue activities which had been a life long pattern. Resident #18 was moved to a new room, and away from the window, restricting his ability to see the outside light and shadows, which was potentially the only things the resident could see. The new roommate was bothered by the activities staff provided resident #18, so the activities were not always carried out or provided. Resident #25 wandered daily; searching for family. Findings include: 1. Resident #18 was admitted to the facility with communication deficits and [DIAGNOSES REDACTED]. Review of resident #18's Significant Change MDS, with an ARD of 9/8/17, showed the resident had no speech, and had severely impaired vision. His primary mode of transportation throughout the facility was a specialized wheelchair, propelled by the facility staff. The resident was totally dependent on staff to assist with activities of daily living, including transfers to and from his bed and wheelchair. Section F 0300, showed the resident should not have an interview for daily and activity preferences conducted because the resident was rarely/never understood and family/significant others were not available. Review of resident #18's Annual MDS, with an ARD of 6/6/17, Section F 0300, showed the resident should not have an interview for daily and activity preferences conducted because the resident was rarely/never understood and family/significant others were not available. Review of resident #18's Care Plan, revised on 3/11/18, showed: 1. Staff to turn on music or TV when (resident's name) is in his room. 2. Sun catcher (sic) over bed provided. 3. An essential oil diffuser has been placed in his room to promote a relaxing environment and decrease agitation. Review of resident #18's (MONTH) (YEAR) activities log showed: - Animal visits; 1 of 4 opportunities - One on one visits; 5 of 60 opportunities Review of resident #18's (MONTH) (YEAR) activities log showed one on one visits for 2 of 10 opportunities. Review of resident #18's (MONTH) (YEAR) activities log showed: - Animal visits; 2 of 9 opportunities - One on one visits; 11 of 28 opportunities Review of resident #18's (MONTH) (YEAR) activities log showed: - Animal visits; 1 of 12 opportunities - One on one visits; 6 of 16 opportunities - Sensory stimulation; 1 of 12 opportunities During an observation on 4/30/18 at 11:30 a.m., resident #18 was alone in his room. The door to the resident's room was wide open, and the resident was laying on his left side staring at the wall. The lights were turned off, and the curtain which separates the resident from his roommate was pulled shut, and resident #18 did not have access to look outside. The radio, TV, diffuser and Homedics with nature sounds were not on. The Sun-catcher was hung on the curtain rod above the window, and not provided to resident #18. During an observation on 4/30/18 at 2:50 p.m., resident #18 was alone in his room. The door to the resident's room was wide open, and the resident was laying on his back looking at the ceiling. The radio, TV, diffuser and Homedics with nature sounds were not on. The Sun-catcher was hung on the curtain rod above the window, and not provided to resident #18. During an interview on 5/1/18 at 9:33 a.m., staff member S stated resident #18 had not received any activities on 4/30/18, and the resident stayed in his room most days because the resident required total assistance from staff. During an interview on 5/1/18 at 9:44 a.m., staff member H stated resident #18 sometimes received weekly 1:1 activities; reading, music, and animal visits. Staff member H stated the activities department tried to do 1:1 daily but it did not always occur. Staff member H stated the facility had hired an Activities Aide, approximately three weeks ago, and that she had been providing activities alone in the facility for the past year. During an interview on 5/2/18 at 11:58 a.m., staff member N stated resident #18's current roommate did not like having the radio, TV, diffuser, or Homedics with nature sounds machine on, when he is in the room with resident #18. Staff member N stated resident #18 was moved to his current location on 4/5/18. During an interview on 5/3/18 at 12:05 p.m., NF5 stated resident #18 seemed to really enjoy his previous room, near a window, where the resident could enjoy sunlight on his face. She stated resident #18 had very poor vision, but thought resident #18 could possibly see light, and shading changes. NF5 became tearful when discussing the new room that resident #18 had moved to. NF5 stated the only activity she was aware of was putting (resident #18) in front of the birds for a few hours in the morning. NF5 stated she and her spouse had never been asked about activities that resident #18 enjoyed prior to moving to the facility. 2. Resident #20 was admitted to the facility with [DIAGNOSES REDACTED]. Review of resident #20's Admission MDS, with an ARD of 3/12/18, Section F 0500, showed it was very important for the resident to do her favorite activities, go outside when the weather was good, and participate in religious services. Review of resident #20's Care Plan, initiated on 3/13/18, showed family involvement with her care was very important to her. Provide her with music, pet visits, going outside, religious services, and doing activities with groups of people which are very important to her. Activities Director to do 1:1 visits. During an observation on 4/30/18 at 1:20 p.m., resident #20 was seated in her room, in a recliner, looking at a blank wall in her room. During an interview on 4/30/18 at 2:22 p.m., resident #20 stated she did not like playing BINGO, which is offered almost daily, and stayed in her room most days. NF4 stated resident #20 had owned her own business, had a garden and green house, and had a very active lifestyle, which included rattlesnake wrangling. Resident #20 stated she required a lot of assistance from the staff, and did not want to bother the staff, or ask for assistance to join in the activity room. NF4 stated the facility did not offer many activities that resident #20 enjoyed. NF4 stated resident #20 really never enjoyed watching TV, but felt this was her only comfort these days, and resident #20 agreed. NF4 states he had a new TV, with Direct TV (satellite) installed, in her room, that day. NF4 stated resident #20 spent most of her time in her room alone, or in the Day room with the other residents watching TV. Resident #20 stated it made her sad. Review of resident #20's (MONTH) (YEAR) activities log showed: - Animal visits; 4 of 4 opportunities - Arts and crafts; 1 of 30 opportunities - Manicures; 1 of 30 opportunities - One on one visits; 1 of 30 opportunities - Religious services; 1 of 30 opportunities During an interview on 4/30/18 at 3:25 p.m., resident #20 stated she would really enjoy repotting some plants, and doing things that required her to work with both of her hands. Resident #20 stated she had a stroke, which made her left arm weak, and would like activities that would help strengthen her arms. During an observation on 5/2/18 at 9:32 a.m., resident #20 was seated in the day room, in a recliner, against a window, beside the TV. The TV was on, but the resident was not watching the TV. 3. During observations from 4/30/18 to 5/3/18, resident #25 was observed wandering through the facility on a daily basis. The resident was constantly looking for her daughter. Review of resident #25's activity participation records showed: -March (YEAR), two animal visits, seven 1 to 1 visits, and one event. That was a total of ten activities the resident participated in a 31 day month. -April (YEAR), three animal visits, one art activity, one beauty activity, two exercise activities, one game activity, and one manicure activity. That was a total of seven activities the resident participated in a 30 day month. During an observation on 5/02/18 at 2:30 p.m., resident #25 sat in the dining room all afternoon. Patio Time was the scheduled activity for that afternoon. Resident #25 did not participate in that activity. Review of resident #25's Significant Change MDS, with an ARD of 3/26/18, Section F, showed the resident's activity interests to be: books, newspapers, magazines, listening to music, animals, participation in favorite activities, spending time outdoors, and religious participation. During an interview on 5/03/18 at 12:00 p.m., staff member H said residents did a lot of activities that did not get documented on the activity logs. Staff member H said the activity assistant had been hired recently. Staff member H said the new activity aide was really helping out with activities.

Based on observation, interview, and record review, the facility failed to monitor and provide interventions for a weight loss of 14 pounds in six months, for 1 (#2) of 10 sampled residents. Findings include: 1. Resident #2 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual MDS, section K300, with an ARD of 12/13/14, showed the resident weighed 162 pounds. Review of resident #2's significant change MDS, section K300, with an ARD of 6/14/15, showed the resident weighed 148 pounds. The resident had a weight loss of 8.6% or 14 pounds in six months. Review of a form titled Data Collection/Evaluation Nutritional and signed by the registered dietician on 12/04/14, showed the dietician recommended resident #2 needed 1:1 table for prompting and assistance, feeds self. The registered dietician stated under the Nutrition Plan/Diet Order: soft diet, finger foods, 8 oz suppl. TID. The dietician also noted, Problem: potential for decline in oral intake & wt (sic). At this time, the resident did not show a significant or severe weight loss. On the 7/15/15 nutritional evaluation, the dietician noted, Problem: Inadequate oral intake. The dietician documented under Signs and Symptoms (defining characteristics): wt loss of 10.4# (6.6%) in one month and an 8.5% weight loss in 90 days for resident #2. The registered dietician wrote under the Nutrition Plan/Diet Order: soft diet, finger foods, 8 oz healthshake TID, comfort care measures in place. The registered dietician again recommended resident #2 needed 1:1 table for prompting and assistance. During an interview on 11/4/15 at 3:20 p.m., staff member B stated, A comfort care situation would require a doctor's order. Resident #2 is not on comfort care. We just try to keep her comfortable and it's mostly due to her mental status. She can be hard to handle. Review of a document titled, Special Needs for Residents showed resident #2 was to eat at the 1 to 1 table, or was to receive 1 to 1 assistance while she ate. Despite the identified weight loss and the inadequate oral intake, the registered dietitian did not recommend any additional nutritional interventions to assist the resident with gaining or maintaining her weight. Review of the physician progress notes [REDACTED]. During an observation on 11/02/15 at 12:20 p.m., resident #2 was not in the dining room eating lunch. At 12:25 p.m., resident #2 was observed in her room lying on her bed. During an interview on 11/03/15 at 8:10 a.m., resident #2 was not in the dining room for breakfast. Staff member N said resident #2 eats in her room [ROOM NUMBER]% of the time. At 8:20 a.m., resident #2 was lying on her bed in her room and was dressed for the day. She did not have a food tray in her room and staff were not observed in the area and were not available to assist her with breakfast. During an interview on 11/03/15 at 10:20 a.m., staff member P said when resident #2 had room trays, it depended on her mood whether or not someone stayed with her while she ate. Staff member P said if resident #2 was in a bad mood, staff would not stay with her because it seemed to make resident #2 more agitated. During an observation on 11/03/15 at 12:15 p.m., resident #2 was not in the dining room eating lunch. Resident #2 was observed lying on her bed and appeared to be sleeping. Staff were not observed in the area or available to assist her with lunch. During an observation on 11/04/15 at 8:10 a.m., a tray was on the bedside table, and the table was placed next to resident #2's bed. The lids were in place on the plates and the drinks were covered by plastic wrap. Staff were not in the room prompting or assisting the resident to eat. The resident was lying on her bed with her eyes open. During an observation on 11/05/15 from 8:10 a.m. to 8:29 a.m., resident #2 was lying on her bed. A bedside table was next to the bed, but not over the bed. A tray of food had been placed on the bedside table, with the food and the drinks uncovered. Staff were not in the resident's room assisting with the meal. Sitting on the resident's night table was a package of cookies and two packages of crackers. The crackers and the cookies had not been opened. At 8:20 a.m., resident #2 was still lying on her bed. The food on the tray at bedside remained untouched. At 8:22 a.m., staff member Q was in resident #2's room. The head of the bed was elevated and resident #2 was sitting up. Staff member Q was standing over resident #2 and encouraging her to eat. At 8:25 a.m., staff member Q was seated on the edge of the bed in front of resident #2. Resident #2 had picked up food and was feeding herself. At 8:29 a.m., staff member Q and the tray of food were gone from the resident's room. The bedside table was still in front of the resident, and she was still in a sitting position. The resident had received assistance from 8:22 a.m until not later then 8:29 a.m., seven minutes. During an interview on 11/05/15 at 8:35 a.m., staff member Q said resident #2 ate one slice of toast, 1/2 cup of fruit, and drank her shake. Resident #2 was not in the dining room at any of the meals from 11/2/15 through 11/5/15. Review of average food intake for October 2015 was 36.7% breakfast, 23.3% lunch, and 33.3% of Dinner. Resident #2 was to receive health shakes, 8 ounces, three times a day. During the month of October 2015, her average intake of shakes was 4.3 ounces at breakfast, 5.7 ounces at lunch, and 4.3 ounces at dinner. Review of resident #2's care plan showed on, Problems/Needs or Strengths that she needed encouragement to eat her meals and she was at risk for decline. The Interventions/Approaches included: 1. CNA staff will assist/encouraged (sic) resident #2 to eat at the assist table. 6. Nsg/CNA to bring resident #2 to a quiet area or dayroom for meals if too agitated to eat in D.R. (sic). Need assist with eating. During an interview on 11/03/15 at 2:30 p.m., staff member B said resident #2 was hard to handle at times. If she did not want to eat, she would throw food at you. Staff member B said if you tried to get resident #2 out of bed and she didn't want to get out of bed, she would kick and scream. Staff member B said there were times resident #2 refused to eat in the dining room because, she just can not eat with these people. Staff member B said resident #2's behaviors have affected her ability to eat and maintain her weight. During an interview, on 11/04/15 at 10:40 a.m., staff member H said the CNAs weigh the residents when the resident receives a bath. If the bath aide saw a weight loss, she would tell the nurse. Staff member H said when nursing knows of a weight loss, they get together with the dietary manager and discuss options to prevent further weight loss. During an interview on 11/4/15 at 10:50 a.m., staff member R said she was the bath aide and she did the residents' weights when she did their baths. Staff member R said if she had identified a weight loss, she would have notified the charge nurse. Review of the nursing notes from 3/03/15 to 11/03/15 did not reflect any evidence a charge nurse or any nurse had been notified by a bath aide of a weight loss for resident #2. During an interview on 11/05/15 at 9:45 a.m., staff member O said she was not aware resident #2 had a weight loss problem. Staff member O said she started working at the facility in August of 2015, and she had not done a report on resident #2 since she had started. Staff member O said if she had identified severe weight loss, she would have notified nursing and would have addressed diet changes. Staff member O said she would have also identified resident #2's behaviors that were affecting her dietary intake.