Every finding on record at Valley View Home

Based on observations, interviews, and record review, the facility failed to provide meaningful activities for residents for 2 (#s 43 and 44) of 10 memory care residents. This deficient practice increased the risk of the residents becoming bored or escalating their behavior. Findings include: 1. During an observation on 6/16/26 at 2:45 p.m., staff members G and L were sitting at the nurses' station in the memory unit. Resident #43 was sitting in the dining room at a table by himself. Resident #43 was not involved in any activity. Resident #43 got up from his chair and went to his room and came back out a moment later, wandering in the hallway, and then to the common room where he sat in the recliner watching television. Resident #43 got back up a few minutes later and wandered back to his room. There was not an activity occurring at the time. 2. During an observation and interview on 6/16/26 at 3:10 p.m., resident #44 slept on the couch in the common area. Staff member G stated that resident #44 preferred to sleep on the couch throughout the day and night. Staff member G stated that resident #44 had a fear of sleeping in her room. After this surveyor questioned why the resident slept all day on the couch, as it was noted there was no activities occurring at the time, staff member G got the resident up by offering the resident a Dilly Bar and taking her out for some fresh air outside in the common area. During an interview on 6/16/26 at 3:13 p.m., staff member G stated the CNAs did not have regular activities in the memory unit. Staff member G stated, We just let things happen naturally. They (the facility) have a calendar (for activities), but we don't really do those things. Staff member G stated there was not even a copy of the activity calendar back in the memory unit. Staff member G then turned the television to a music concert. Staff member L entered the interview and stated the television had been on the same show for two days straight. Staff member L stated they did not understand why the show had not been changed. During an interview on 6/17/26 at 8:01 a.m., staff member B stated she had seen a few activities occur in the memory unit, including towel folding, and tactile boards were provided for the residents to use. Staff member B stated there had been discussion around needing more activities in the memory unit, but she had not had time to address the concerns yet. During an interview on 6/17/26 at 1:18 p.m., NF3 stated resident #43 needed more activities. NF3 stated the facility did not provide quality of life for the residents residing in the memory unit, and CNAs sit at the nurses' station, ignoring the residents. NF3 stated the residents needed more time outside in the nice weather, more music activities, and more ambulation/exercise. NF3 stated she believed resident #43 was restless, and this led to more of his behaviors. NF3 stated she voiced these concerns with staff member K on multiple occasions and again during the care conference. During an interview on 6/17/26 at 2:25 p.m., staff member E stated the activities provided to the memory unit residents included the Buzz newspaper being passed out, towel folding, dietary treats being served, church services if wanted, tactile boards, and coloring supplies being provided to staff to use, and one resident had her nails painted. Staff member E, who provided oversight for activities, stated there was no specific calendar developed to meet the needs of the memory unit population. Staff member E stated she thought the CNAs on the unit were doing activities with the residents in the memory unit. During an interview on 6/17/26 at 4:23 p.m., staff member C stated she had voiced concerns to management about the resident's behaviors and lack of activities in the memory unit. Staff member C stated she had noticed on many occasions that residents were bored, and no activities were occurring in the memory unit. Staff member C stated she believed the lack of activities in the memory unit played a role in the number of behavioral incidents occurring in the memory unit. 3. During an interview on 6/16/26 at 10:50 a.m., NF1 stated that often staff on the memory care unit were just kind of sitting there with no interaction between staff and residents. NF1 stated the orientation board, which should detail the day, weather, upcoming holidays, etc. was often not updated, and activities staff did not go around and gather residents who may not be able to bring themselves to the scheduled activity at the time, so they would not participate in an activity. During an interview on 6/17/26 at 10:21 a.m., NF2 stated they hadn't seen much going on for entertainment in the memory care unit. NF2 stated, Basically, all them gals do is watch TV. During an interview on 6/17/26 at 2:26 p.m., staff member E stated that if a resident had participated in an activity, activity documentation would be found in the medical record. Staff member E stated they did not think the activities staff were documenting what they were doing for the resident(s). Review of the facility's policy, Activities, dated 11/2020, showed: - . 5. Special considerations will be made for developing meaningful activities for residents with dementia and/or special needs.

Based on observations and interviews the facility failed to ensure boxes of resident food and drinks were stored off the floor in the kitchen area, and the improperly stored foods may be exposed to dust, pests, moisture, and other environmental hazards, affecting any resident eating food prepared or served by the kitchen. Findings include:During an observation on 6/16/26 at 7:42 a.m., one box of supplemental drinks was found on the floor upon entering the kitchen.During an observation on 6/16/26 at 7:46 a.m., two cases of Gatorade, one case of green beans, and one case of supplemental drink were on the dry storage floor.During an observation on 6/16/26 at 2:30 p.m., a box of supplemental drinks were found on the floor, propping open the kitchen door.During an interview on 6/17/26 at 8:35 a.m., staff member M stated the food delivery truck came late the previous day, she was aware of the food not being put away, and it was on the floor. Staff member M stated she was also aware of the supplemental drink being used to prop open the kitchen door. Staff member M stated that had been the practice since their door stopper went missing, they would grab something nearby to prop the door open. Staff member M, who provided oversight for the kitchen policies and procedures, stated she knew they should not store boxes of food on the floor.

Based on observations, interviews, and record review, the facility failed to ensure the IDT team verified a resident who was self-administering medication was determined to be clinically appropriate to self-administer medications, and medications were left for the resident to take independently, without supervision, for 1 (#4) of 26 sampled medication administrations. Findings include:During an observation on 6/17/26 at 11:27 a.m., staff member K prepared two acetaminophen 500 mg tablets for resident #4, placing them in a pill cup and taking them to the resident's room. Staff member K placed the medication cup on the bedside table and left the room without observing the administration of resident #4 taking the medications. During an interview on 6/17/26 at 11:28 a.m., staff member K stated resident #4 did not appear to have a self-administration of medication assessment. Staff member K stated she did not think about it before she left the medication without observing him taking the pills. Staff member K stated she knew she should stay with residents when administering medications and usually did. Review of resident #4's EHR on 6/17/26 did not reflect a self-administration assessment, self-administration noted in the care plan, or an order for self-administration of medications. Review of the facility's policy, Resident Self-Administration of Medication, dated 11/16/23, showed:- . 4. If the resident requests to be able to administer medications independently, a nursing team member will complete the Self-Administration of Medication Observation in [EHR software].- 5. Upon notification of the use of bedside medication by the resident, the care plan will be updated to reflect the resident's wishes, and the MAR will be updated to reflect the resident's self-administration capability.

Based on interviews and record reviews, the facility failed to ensure two vulnerable residents were not subjected to abuse, neglect, or psychosocial harm, when a staff member P physically and mentally abused resident #47 when the resident was resisting care, and when the same staff member left resident #43 unattended at an out of town appointment, neglecting her safety and supervision needs, for 2 (#s 43 and 47) out of 18 sampled and supplemental residents. Using the reasonable person perspective, both vulnerable residents may have ongoing psychosocial harm, fear, or behavior related to the abuse and neglect events involving staff member P. Findings include: 1. Review of a written warning, dated 3/5/26, showed staff member P left a cognitively impaired resident alone at an out-of-town appointment while the resident was in his care, neglecting the resident's safety. The resident was left in the corner of a corridor for at least an hour, with the wheelchair locked, and no one was there to assist or help the resident. When the resident was found by witnesses, she was observed to be choking on her supplement. The facility documented this incident as abuse, neglect, and use of restraint(s). Review of the facility's incident report dated 3/12/26 showed the facility determined resident #47 was dropped off at an out-of-town dental office by staff member P and was left unattended for over an hour due to the dental office being closed for lunch. Staff member P neglected to ensure the resident has supervision at the time. Resident #47 was found by nearby concerned individuals to be in distress and in need of assistance. When found, resident #47 appeared to be coughing/choking and had spilled a supplemental drink on herself. The concerned individuals stayed with resident #47 until the dental office staff returned from lunch. This incident was reported to the facility by the concerned individuals who found resident #47. Upon returning to the facility, staff member P received a disciplinary write-up, was immediately suspended from work without pay, and would be required to complete education on neglect, restraints, abuse, and safe transportation of residents before being considered to return to work. Review of resident #47's medical record showed a BIMS of 10; moderately impaired cognition. Resident #47 had diagnoses of traumatic brain injury, quadriplegia, and major neurocognitive disorder. During an interview on 6/17/26 at 3:15 p.m., staff member Q stated they drove residents to and from the facility for various appointments. Staff member Q stated, I am with them the whole time unless the resident doesn't want me in the room. Staff member Q stated they were told to do this by other staff. Review of education provided to staff member P, dated 3/16/26, showed staff member P was educated on not leaving residents unattended at medical appointments, clinics, or other off-site locations unless prior arrangements had been made and approved by nursing, leadership, or administration. Review of the facility's resident transportation and scheduling policy, dated 3/21/23, failed to address leaving cognitively impaired residents unattended. 2. Review of a facility investigation report, dated 5/26/26, showed: - . The allegation of staff-to-resident abuse was verified through witness statements and the facility's internal investigation. Witness accounts confirmed that the staff member used inappropriate physical interventions while attempting to assist the resident, including grabbing the resident by the hair, arm, and beard. [sic] Review of the facility's witness statement from [staff member O], dated 5/27/26, showed: - Staff member O observed staff member P holding resident #43's right forearm and holding his hair on top of his head. Staff member P pushed resident #43 against a wall, and resident #43 sat onto the bedside table against the wall. Staff member O stated that staff member P then let go of resident #43's hair on his head and grabbed his beard, pulling his head forward. Staff member O stated she then yelled at staff member P, and he released resident #43's hair and walked him to the bathroom with the assistance of staff member G, without resident #43 resisting, hitting, kicking, or yelling. Although staff member P had been educated on resident abuse in March 2026, related to leaving the resident unattended at an appointment, staff member P continued to disregard the safety and care needs of the residents. Review of the facility's witness statement from [staff member G], dated 5/27/26, showed: - Staff member G stated she found resident #43's toilet was covered in feces and requested staff member P's assistance in cleaning up resident #43. Staff member G stated that resident #43 was being aggressive toward staff. Staff member G stated she was in the bathroom when she heard resident #43 yell, and she looked back to find staff member P holding resident #43 by the top of his head and his chin. Staff member G stated she heard staff member O yell, [Staff Member P's name] that's enough! and staff member P released resident #43. Staff member G stated she then coaxed resident #43 into the bathroom, and he continued to resist, but she was able to get him cleaned up. During an interview on 6/16/26 at 8:23 a.m., staff members G and L both stated resident #43 had a history of hitting staff and being aggressive during ADL care. Staff member G stated that when resident #43 became aggressive, they would step away, unless he was really dirty, then the staff would use 2-person assistance approach, with one redirecting his hands while the other staff member hurried to clean him up. Staff member G stated, It just has to be done, while staff member L stated, Yes, it (cleaning him up) needs to get done. During an interview on 6/17/26 at 1:18 p.m., NF3 stated she was very upset and broken hearted by the staff abuse incident involving resident #43. NF3 stated she did not feel the facility handled the situation appropriately, specifically not having resident #43 assessed in the emergency room immediately after the incident occurred. NF3 stated she was aware that resident #43 could be difficult when he was forced to do things he did not want to do. NF3 stated she felt the staff involved should not have forced him to clean up and should have stepped back and let him calm down. NF3 stated that resident #43 would get angry and defensive when staff forced him or yelled at him in a rushed voice. NF3 stated she had shared this concern with staff member K on multiple occasions. NF3 stated she did not understand why they were forcing him to toilet and not reapproach him later. NF3 stated staff member K wanted to give him a shot (medication) to sedate him so they could change him and get him cleaned up after the incident, and she again reminded staff member K she did not want resident #43 sedated and to wait for him to calm down and reapproach him. NF3 stated that when she arrived at the facility on 5/28/26, resident #43 was lying in his bed, fiddling with his hands, acting as if he was not allowed to get up while staring at the bedroom door. NF3 stated she chose to take NF3 to the emergency room herself to be assessed for any injuries related to the abuse incident. Review of All staff meeting, dated 1/2026, showed staff members G, L, and O had attended, Resident Abuse Prevention and Reporting. Review of the facility Education labeled, Resident Abuse Prevention and Reporting, not dated, showed: -Page 7, slide 1: . Physical Abuse: . Controlling behavior through corporal punishment (using physical force as a means of discipline). Review of staff member P's employee file showed:

Based on interview and record review, the facility failed to designate a full time DON. Findings include:During an interview on 1/29/26 at 9:48 a.m., staff members B and C stated the facility was without a DON for a little over a month. Staff member C stated the DON tasks were divided between the IDT.Review of an email from staff member A showed an advertisement for the DON position with a posting date of 9/8/25. The email goes on to show the IDT took over the DON tasks.During an interview on 1/29/26 at 10:00 a.m., staff member A stated the new DON started on 10/16/25.Review of an email sent by staff member A, dated 9/8/25 at 2:34 a.m., showed the previous DON no longer worked at the facility. There was no documentation available to show the prior DON's duties were specifically reassigned to an RN (or multiple RNs), until a new DON was recruited. Review of an email sent by staff member A, dated 10/16/25 at 3:26 p.m., showed staff member B started as DON on 10/16/25. The facility was without a DON for 37 days.

Based on interview and record review, the facility failed to ensure an incident was reported within 24 hours of the date of the incident for 1 (#8) of 10 sampled residents. Findings include:During an interview on 1/29/26 at 9:48 a.m., staff members B and C stated the time frame for reporting incidents was 24 hours. Staff member B stated that as soon as we hear about a reportable, we start the investigation. Staff member B stated that the staff abuse training is done yearly. Staff member B stated there are in-services on abuse and reporting timelines throughout the year.During an interview on 1/29/26 at 10:00 a.m., staff member A stated the administrator, DON, and Social Services are responsible for obtaining statements from staff and residents. Staff member A stated the time frames for reporting to the State Survey Agency were two hours for serious bodily injury, or 24 hours if there is no serious bodily injury. Staff member A stated the findings are to be reported to the State Survey Agency within five days. Review of an incident of abuse submitted to the State Survey Agency, on 8/18/25, was more than 24 hours after the date of the incident. The date of the incident was on 8/16/25. The incident involved a resident-to-resident altercation between residents #8 and #10.Review of the facility policy, titled Mandatory Reporting for Montana Nursing Facilities, showed:7 .Resident to Resident Abuse was not to exceed 24 hours from the discovery of the incident .There is a 2-hour reporting requirement for crimes resulting in serious bodily injury .Investigation results must be sent to the state agency within 5 working days of the receipt of the report of abuse .

Based on interview and record review, the facility failed to ensure necessary and beneficial interventions were identified and implemented for the supervision of a resident (#1) who displayed various behaviors and this resident wandered into other residents' rooms which increased her risk of harm if others acted out on her. Resident (#1) had interactions with male residents, which were sexual in nature, and on one occasion, she was found in the male's room when the encounter was occurring. The facility implemented behavioral and medication interventions to help intervene in her behaviors but failed to implement a monitoring and supervision program that would meet resident #1's safety needs as related to her wandering and the sexual encounters she experienced. Staff documented she continued to have her baseline behaviors, and her behaviors changed in some areas, such as refusing medications and or care, but these were not clearly linked to the interactions she had with the two male residents. Resident #1 later transferred to the hospital and had not returned. Findings include:During an interview on 1/28/26 at 3:00 p.m., staff member E stated that abuse training for staff was assigned annually. Staff member E stated that if allegations of abuse were received, the charge nurse was to be notified immediately, and if the allegations happened at night, the DON was to be notified. Staff member E stated she also received Dementia training, but could not remember the date.During an interview on 1/28/29 at 3:10 p.m., staff member D stated she heard resident #1 yelling one day, saying, help me. Staff member D stated resident #1 was found lying crossways on the bed, and a male resident was lying on top of resident #1. The male resident had no clothing on the bottom half of his body. Resident #1 was completely dressed. Staff member D separated the residents and redirected the male back to his room. Staff member D stated resident #1's behaviors had worsened following the incident. Staff member D stated that resident #1 liked to dance, and staff would take her outside when the weather permitted. During an interview on 1/28/26 at 3:05 p.m., staff member E stated resident #1 had a history of trauma but could not remember what the trauma was related to. Staff member E stated that staff tried several interventions to attempt to calm the resident when she was upset, such as giving her snacks and showers. The physician made medication changes for her behaviors, but the resident was still experiencing an increase in her behaviors over time. Staff member E stated that other staff who worked off the unit would come and try to help calm the resident when resident #1 was displaying behaviors, such as running around the unit, aggression, or yelling at staff.During an interview on 1/28/26 at 3:18 p.m., staff member F stated that if a resident-to-resident altercation was observed, he would separate the residents from each other (to protect them) and report the incident to the nurse. Staff member F stated that staff were told resident #1 had been abused previously (before coming to the facility). Staff member F stated that resident #1 did not like black hair or black clothing. During an interview on 1/28/26 at 5:02 p.m., staff member A stated that when resident #1 was in the hospital, she had auditory and visual hallucinations. Staff member A stated the resident would say, He's coming, for her. Staff member A stated the resident blamed everything that went wrong on her sister. Staff member A stated that resident #1's behavior was verbal and physical toward staff. Staff member A stated the resident would go in and out of other residents' rooms. Staff member A stated that staff were documenting resident #1's behaviors, and there was an increase in physical behaviors towards the staff. The resident was also refusing medications and care and was slamming doors. Staff member A stated the resident was very disruptive to the care environment. Staff member A stated that resident #1 was taking her clothes off and attempting to follow male residents into their rooms. During an interview on 1/29/26 at 9:02 a.m., staff member I stated they were monitoring resident #1's behaviors after the event where the male was found in her room lying on top of her, where she had her clothes on, but he had his bottoms off. The staff wanted to see if resident #1 had an increase in behaviors. Staff member I stated that abuse training was completed at least annually. Staff member I stated there had been behavioral and dementia training for staff within the last year. Staff member I stated that if an altercation occurred, she would separate the residents to ensure their safety. Staff member I stated she would notify the physician, family, the resident representative, charge nurse, DON, and Social Services about the event. Staff member I stated the resident's interventions for behaviors depended on what was in the care plan. Staff member I stated, We used to give resident #1 back rubs, provide music, food, and drinks when she displayed behaviors. Staff member I stated there was an incident in which the resident had been locked in her room, which happened before she came to the facility.During an interview on 1/29/26 at 9:48 a.m., staff member B stated that when there was an altercation between two residents, staff would need to intervene. The incident would need to be investigated and get both sides to determine what triggered the incident. Staff member B stated that staff members A and B do the reportable incidents. Staff member B stated that the staff tried multiple interventions with resident #1, including aroma therapy, redirection, food, fluids, and quiet time. Staff member B stated the interventions would work sometimes. Staff member B stated the resident was living with a family member, and the family member would get frustrated and lock her in her room. Staff member B stated it was unclear what other incidents contributed to her trauma before she came to the facility. Staff member B stated that the staff was trained in abuse and behavioral health yearly.Review of resident #1's Nursing Progress Notes, dated 7/1/25 - 12/23/26, showed the following:12/3/25 - A male resident was found in resident #1's room with his hands down the front of resident #1's pants. Resident #1 was saying, I don't like you. The male resident was redirected to his room. The provider reviewed resident #1's medications and made changes. There was documentation that showed the staff were to monitor resident #1 for increasing behaviors, but the documentation did not show how long this would occur or the level of monitoring that was to occur and how the staff were to keep resident #1 safe. 12/4/25 - The nurse documented the resident keeps shirt tucked in walking around with hands in pants, and later in the day it was also documented on that day that she had no changes due to the incident with the male resident on 12/3/25. Documentation showed that between 12/4/25 and 12/22/25 the resident continued to have ongoing behaviors, and on many days, was documented to be at her baseline (for behaviors). 12/22/25 - Resident #1 was found in a male resident's room, lying on the bed. Resident #1 was fully clothed. The male resident had no pants on, and he was lying on top of resident #1. The male was making thrusting downward movements with his body. Staff heard resident #1 say, Get off, repeatedly. Staff separated the residents, took resident #1 back to her room, and staff were to monitor the resident more closely. There was no documentation showing how long the monitoring was to occur or to what degree she would be monitored for the safety of herself or others. 12/23/25 - Resident #1 was very emotional, angry, and upset. The resident was going in and out of other resident rooms, trying to take their belongings. The resident had extreme agitation and displays of behavior while menstruating. The staff implemented interventions for her behaviors with little to no improvement during her stay. On this day, the resident was given Haldol 5 mg intramuscular as a one-time dose. The medication took 30 minutes to be effective. Review of resident #1's monthly behavior review, for the various behaviors she displayed, dated 7/1/25 - 1/9/26, showed:7/2025 - Resident #1 displayed: wandering, pacing, physical action towards staff, wandering into other residents' rooms, yelling, she was resistant to care, and was displaying paranoia.8/2025 - Resident #1 displayed: wandering the halls, going into other resident rooms, yelling, pushing away from staff, refusing medication, she was resistant to care, and displayed physical and verbal aggression towards staff.9/2025 - Resident #1 displayed: wandering halls, going into other resident rooms, refusing staff redirection, crying, verbal hallucinations, mumbling, refusing to use briefs, pacing, ambulating quickly, and jogging on the unit. 10/2025 - Resident #1 displayed: crying, wandering, yelling, pacing, cursing, and agitation. 11/2025 - Resident #1 displayed: yelling, aggression, cursing, wandering into other residents' rooms, was tearful, refusing care, and pacing. 12/3/25 - The first incident with the male resident occurred where resident #1 was found in her room with the male. 12/22/25 - The second incident with another male resident occurred. Resident #1 was found in a male resident's room. There was no documentation in the behavior review documentation for what occurred in the male resident's room (it was included in the nursing notes). 12/22/25 - Resident #1 was wandering, pacing, she had her hands in her pants, was verbally abusive to staff, screaming, running, and agitated. The resident tried to pull her pants down in the common area of the unit. Having her hands in her pants and removing her clothing were not documented prior. After 12/22/25, resident #1 continued to refuse her meals and medications, she would yell and curse, displayed aggression toward staff and or other residents. She was slamming and banging on doors and chairs, windows or walls. Resident #1 knocked the table/chairs over and stated that people were trying to kill her or be mean to her. The resident continued to experience challenging behaviors, which put herself and others at risk of harm, and the facility did not attempt to identify if any of her behaviors displayed were stemming from the interactions with the male residents, which were sexual in nature. Review of resident #1's Behavior Review notes, dated 7/1/25 - 1/9/26, showed resident #1 had triggers including incontinence, reportables (reportable events), shingles-exacerbated behaviors possible, dental increased behaviors-pain? Did not like clothes picked out some days-increased behaviors, and phone calls with family. Interventions included room change on 2/4/25, snacks, one-on-one, walking with staff, back rubs, conversations, aroma therapy, warm towels, new face (different staff), pain management, toileting, hair brushing, lavender, and offered different comforters. Under thoughts, it showed the resident's medication was managed by the physician and a psychiatrist's involvement with her care. The notes showed, Meeting sooner about behaviors to implement psychiatrist? Review of resident #1's care plan showed:9/23/24-Cognitive Loss/Dementia. Interventions included If I lose attention during the conversation please attempt to regain my attention and repeat what was said. There was a start date of 9/26/24, and the care plan showed, provide me with consistent caregivers and routine when able. All other interventions were implemented 9/26/24.10/11/24-Psychosocial Well-Being. Interventions included, I have a history of trauma that affects me negatively. All interventions had a start date of 10/11/24, including for staff to encourage the resident to express her feelings, concerns, and thoughts in a safe place. Staff were to assist resident #1 with recovery and avoid (trauma) triggers. The care plan showed, My history of trauma includes car accidents, fires, heart attacks, death in my family, and the murder of my aunt. There were no triggers related to prior sexual abuse identified on the plan. 9/10/24-Behavioral Symptoms. Interventions started on 12/28/25, which included attempt to assess me (resident #1) for pain when I am experiencing agitated behaviors, attempt to offer different staff members, during my menstruation I am known to have worsening behaviors, if I am observed to be agitated, attempt to provide me with aroma therapy, and offer me a warm towel to help soothe me if I am observed to be agitated.The resident's care plan failed to show attempts to identify new contributing factors and interventions implemented in an attempt to prevent behaviors, to protect her due to her behaviors, or what level of monitoring and oversight the resident needed to remain safe. Review of the Behavior Review document, dated 7/1/25 - 1/9/26, showed the following medication changes:Scheduled daily:7/15/25; Abilify, an antipsychotic, 15 mg two times daily6/5/25 - 7/15/25; Abilify 10 mg two times daily9/17/24; fluoxetine, an antidepressant, 20 mg every morning6/4/25 - 11/7/25; Seroquel, an antipsychotic, 50 mg two times daily12/9/25 - 12/30/25; Seroquel 100 mg three times daily12/30/25 - 1/2/26; Seroquel 200 mg three times daily1/2/26 - 1/4/26; Seroquel 200 mg three times daily1/4/26 - 1/6/26; Seroquel 200 mg three times dail7/3/25 - 7/9/25; Haloperidol, an antipsychotic, 5 mg every nightResident #1's Seroquel was changed multiple times with little to no effect, as evidenced by her behavior documentation.Resident #1 had Seroquel (antipsychotic), Haloperidol (antipsychotic) and Ativan (antianxiety), as needed.Resident #1 was transferred to the hospital on 1/6/26 and did not return to the facility as of the survey.

Based on interview and record review, the facility failed to document resident declinations and education regarding the Covid-19 vaccine, for 2 (#s 11 and 27) of 5 sampled residents for immunizations. Findings include: A review of resident #11's preventive health care report, with a creation date of 12/14/23, showed, resident #11's resident representative refused the administration of the Covid-19 vaccination. A review of resident #27's preventative health care report, with a creation date of 12/14/23, showed, resident #27's resident representative refused the administration of the Covid-19 vaccination. A request was made on 7/17/24 at 10:16 a.m., for the signed declinations for resident #11 and #27. The signed declinations were not provided prior to the end of the survey. During an interview on 7/17/24 at 1:03 p.m., staff member J stated she did not have any signed declinations or documentation for resident #11 or #27's Covid-19 vaccinations. Staff member J stated she did not provide any education regarding the risks and benefits to the resident representatives for resident #11 or #27. A review of a facility policy titled, Influenza, Pneumococcal, and SARS-COV-2 Immunizations-Residents, dated, 7/19/23, showed: . 8. If the resident or responsible party refuses an immunization, it will be documented in the permanent medical record. The resident or responsible party will be provided with an education program and the resident or responsible party will be offered the immunization, annually.

Based on observation, interview, and record review, the facility failed to screen visitors for signs or symptoms of Covid-19, prior to entering the building, during a Covid-19 outbreak; failed to post transmission based precaution signage on the doors of Covid-19 positive residents, and failed to follow transmission based precautions for 4 (#s 15, 21, 26, and 27); failed to practice proper hand hygiene during a laundry pass for 2 (#s 14 and 31); and failed to follow enhanced barrier precautions for 3 (#s 14, 31, and 42) of 22 sampled residents. This deficient practice increased the risk of an individual contracting Covid-19, other viruses, or infections, for all residents, staff, or visitors. Findings include: 1. During an observation on 7/15/24 at 2:24 p.m., the facility had printed signs on the entrance doors showing there was a Covid-19 outbreak. Upon entrance into the facility, there was a sign in log, and N-95 masks. There was no staff member present, no screening equipment, or a questionnaire asking visitors about signs or symptoms of Covid-19. During an observation on 7/16/24 at 7:07 a.m., upon entrance into the facility there was a sign in log, and N-95 masks. There was no staff member present, no screening equipment, or a questionnaire asking visitors about signs or symptoms of Covid-19. During an observation on 7/17/24 at 7:08 a.m., upon entrance into the facility there was a sign in log, and N-95 masks. There was no staff member present, no screening equipment, or a questionnaire asking visitors about signs or symptoms of Covid-19. During an interview on 7/17/24 at 1:03 p.m., staff member J stated the facility was not screening visitors when they entered the building. Staff member J stated, All the family members were called and asked to perform hand hygiene and wear a mask when they entered the building, other than that there is no screening in place. Review of a facility document titled, COVID-19, undated showed: . staff and visitor screening upon entrance into the facility will be by active or passive means. Review of a facility document titled, Infectious Outbreak or Pandemic, dated, 8/1/23, showed: . 4. Screening visitor and staff include questions about signs and symptoms, possible exposure, PPE compliance, and temperature checks, etc. 2. During an interview on 7/15/25 at 2:30 p.m., staff member A stated the facility was in a Covid-19 outbreak. Staff member A stated, We have two staff members, and two residents test positive for Covid-19. During an observation on 7/15/24 at 4:19 p.m., resident #27 was sitting in a recliner in her room. A plastic container with three drawers was placed outside the room. The container stored personal protective equipment. Resident #27's door to her room was open to the hallway. There was not a transmission-based precaution sign placed outside the room, on the door/entry to room, to notify staff what type of personal protective equipment was to be used when providing care for #27. During an observation on 7/15/24 at 4:25 p.m., resident #15 was sitting in a recliner in his room. Resident #15 was coughing. A plastic container with three drawers was placed outside the room. The container stored personal protective equipment. Resident #15's door to his room was open to the hallway. There was not a transmission-based precaution sign placed outside the room to notify staff what type of personal protective equipment was to be used when cares were provided. During an observation on 7/15/24 at 4:26 p.m., resident #21 was sitting in his wheelchair in the doorway of his room. Resident #21 was coughing. A plastic container with three drawers was placed outside the room. The container stored personal protective equipment. Resident #21's door to his room was open to the hallway. There was no transmission-based precaution sign placed outside the room to notify staff what kind of personal protective equipment was to be used when cares were provided to the resident. During an interview on 7/15/24 at 4:27 p.m., staff member C stated, We have three residents who are confirmed to be Covid-19 positive. We keep their doors open so they (the residents) do not feel isolated. During an observation on 7/16/24 at 7:44 a.m., and 7:46 a.m., the resident room doors for #15, 21, and 27 were open, and no transmission-based precaution signs were placed outside the rooms. During an observation on 7/17/24 at 8:01 a.m., and 8:03 a.m., the doors to resident #15, 21, and 27's rooms were open, and no transmission-based precautions signs were placed outside the rooms. During an interview on 7/17/24 at 8:10 a.m., staff member H and staff member I stated they knew a resident was on transmission-based precautions because there was personal protective equipment provided outside the rooms. Staff members H stated, I had no clue there were different types of transmission-based precautions. Staff member I stated, I did not know that there were different types either, I did ask staff member J if signs should be up outside the doors though. During an observation on 7/17/24 at 11:36 a.m., resident #s 15, 21, and 27 had specific contact/droplet precaution signs posted outside their rooms. During an interview on 7/17/24 at 1:03 p.m., staff member J stated she educated staff on infection control practices bi-annually and as needed. Review of a facility policy titled, Infectious Outbreak or Pandemic, dated, 8/1/23, showed: . Isolation Precautions . 3. The facility will use standard approaches, as defined by the CDC, for transmission-based precautions: airborne, contact, and droplet precautions. The category of transmission-based precautions will determine the type of personal protective equipment (PPE) to be used. 3. During an observation on 7/16/24 at 8:33 a.m., staff member G was distributing resident clothing. Staff member G entered resident #14's room. No hand hygiene was performed prior to entering resident #14's room. Staff member G opened resident #14's closet and hung up the clothing. No hand hygiene was completed after exiting resident #14's room. Staff member G walked back to the laundry cart and picked up more clothing and entered resident #31's room. No hand hygiene was completed prior to entering resident #31's room. Staff member G opened resident #31's closet and hung up the clothing and exited resident #31's room. No hand hygiene was completed after exiting resident #31's room. During an interview on 7/16/24 at 8:38 a.m., staff member G stated, I just forgot, it's that simple. I have been here long enough to know better. I am supposed to clean my hands before I get the clean clothes off the cart and after I exit a resident's room. I have been educated on hand hygiene through staff in-services and trainings. Review of a facility document titled, Hand Hygiene, undated, showed: The use of gloves does not replace hand hygiene . Hand hygiene is indicated and will be provided before entering and exiting residents room . 46400 4. During an observation on 7/15/24 at 4:00 p.m., there was no signage or supplies for the use of enhanced barrier precautions in resident #42's room. Resident #42 had a foley catheter bag hanging at the side of his bed. Review of the medical record showed resident #42 had an indwelling foley catheter since 4/6/24. During an observation on 7/17/24 at 8:12 a.m., there was no signage or supplies for enhanced barrier precautions in resident #42's room. During an interview on 7/17/24 at 1:03 p.m., staff member J stated enhanced barrier precautions were placed for residents with chronic wounds or catheters. Staff member J stated each resident on enhanced barrier precautions had a yellow and black striped magnet on the doorway and personal protective equipment in the room. During an interview on 7/17/24 at 1:35 p.m., staff member M stated the yellow and black striped magnets on the doorways were the signals to staff for enhanced barrier precautions. Staff member M stated someone would have this indicator for precautions if they had a catheter. Staff member M stated resident #42 did have a catheter, and she was unsure why he didn't have the yellow and black magnet on his door. During an observation on 7/17/24 at 1:40 p.m., resident #14 had a yellow and black striped magnet on the doorway. Resident #14 had a chronic indwelling foley catheter. The catheter was contained in a cover and hanging from the underside of the resident's wheelchair. Resident #14 did not have any personal protective equipment located inside or outside of the room. During an observation on 7/17/24 at 1:42 p.m., resident #31 had a yellow and black striped magnet on the doorway. Resident #31 had a chronic indwelling foley catheter. The catheter was contained in a cover and hanging from the underside of the resident's wheelchair. Resident #31 did not have any personal protective equipment located inside or outside of the room. Review of the facility policy, Enhanced Barrier Precautions, dated 3/26/24, showed, .An order for enhanced barrier precautions will be obtained for residents with any of the following: . urinary catheters . According to the CDC article, Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), dated 4/2/24, showed: . Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROS . The use of gown and gloves for high-contact resident care activities is indicated, when Contact Precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization . indwelling medical devices e.g., central line, urinary catheter .

Based on interview and record review, the facility failed to ensure a resident received, or had the opportunity to receive, the pneumococcal vaccine series, for 1 (#15) of 5 sampled residents for vaccinations. Findings include: Review of resident #15's immunization record showed resident #15 had received one pneumococcal vaccine on 4/4/2018. The immunization record did not show what type of pneumococcal vaccine resident #15 had received. A review of a facility document titled, Pneumococcal Vaccine Informed Consent/Decline, showed, resident #15's resident representative signed for resident #15 to receive pneumococcal vaccines on 4/16/24. During an interview on 7/17/24 at 1:03 p.m., staff member J stated, [A Facility Name] works with us on providing vaccinations. Pneumococcal vaccines are not one the facility keeps in house. I just have not set up a clinic (vaccination) yet. It is just something I have not thought about doing yet. I am behind on looking at the immunizations. I have started asking the hospital to provide the pneumococcal vaccine prior to discharge. Review of a facility document titled, Influenza, Pneumococcal, and SARS-COV-2 Immunizations-Residents, dated, 7/19/23, showed: . 5. Pneumococcal Vaccine: Residents will be assessed for eligibility to receive this vaccine series with in 5 working days of admission and will be offered the vaccine. . 12. 8. Vaccines not supplied in house will be provided by outside resources such as [Facility Names], and other alternative methods. [sic]

Based on observation, interview, and record review, the facility failed to ensure food items placed in the unit's nourishment refrigerator were dated and labeled with a resident name. This deficient practice increased the risk of a resident receiving incorrect, or out dated, food items. Findings include: During an observation on 7/17/24 at 7:54 a.m., there was an unlabeled and undated Tupperware container in the resident nourishment refrigerator, which was located at the end of the 100 hall. The contents of the container included a homemade, unknown yellow liquid substance. There was no indication of which resident the food belonged to or how long it was in the refrigerator. During an interview on 7/17/24 at 10:11 a.m., staff member L stated it was the responsibility of housekeeping to clean refrigerators in the resident common areas. Staff member L stated family members would often place items in the refrigerator without staff knowing. Review of the facility policy Use and Storage of Food Brought in by Family or Visitors, dated 12/27/18, showed, All food items that are already prepared by the family or visitor brought in must be labeled with content and dated . The prepared food must be consumed by the resident within 3 days. If not consumed within 3 days, food will be thrown away by facility staff.

Based on observation, interview, and record review, the facility failed to follow outlined interventions for 1 (#25) of 3 residents sampled for weight loss. This deficient practice increased the risk of further weight loss for the resident who had a severe weight loss over a three month period. Findings include: During an observation on 7/16/24 at 8:11 a.m., resident #25 was asleep in her bed. Across the room, on her desk, was her full breakfast tray. During an observation on 7/16/24 at 9:00 a.m., resident #25 was still asleep and her full breakfast tray had been removed. During an observation on 7/17/24 at 8:09 a.m., resident #25 was sitting at the desk in her room with her breakfast tray. She was pushing eggs around with her silverware, but not consuming anything. During an observation on 7/17/24 at 12:07 p.m., resident #25 was sitting at the dining table in the resident common area. Her lunch was untouched in front of her. There were no staff around to cue the resident to eat. She got up from the table and wandered away down the hall. Review of resident #25's care plan, with a review date of 7/9/24, showed under problems: I am at nutritional risk for weight loss as evidenced by poor intake, uninterest in food, and requiring encouragement during meal times . [sic] Interventions for resident #25's weight loss included: - Please offer me finger foods as I like to ambulate throughout the facility frequently throughout the day and my attention span for meals is very short. - Please obtain my weight monthly. - Please provide me encouragement/cueing during mealtimes. Review of resident #25's monthly weights, dated January 2024 - July 2024, showed the resident weighed 96.6 lbs. on 7/1/24. Three months prior on 4/1/24 she weighed 106.4 lbs. This represented a 9.2% severe weight loss in three months. Review of the facility policy titled, Weight Monitoring, dated May 2024, showed, . Residents with weight loss - monitor weight weekly . The newly recorded resident weight should be compared to the previous recorded weight. A significant change in weight is defined as: a. 5% change in weight in 1 month (30 days) b. 7.5% change in weight in 3 months . A phone call for interview on resident #25's weight loss was placed to staff member M on 7/17/24 at 10:55 a.m. and was not returned by the end of the survey. During an interview on 7/17/24 at 2:15 p.m., staff member B stated the facility had implemented a Resident at Risk meeting that would occur biweekly and address resident issues including weight loss. The meeting on 7/11/24 had identified resident #25 as having a significant weight loss, and the team identified new interventions to be put in place. Staff member B stated the biweekly meetings were new and were intended to catch issues sooner than the quarterly QAPI meeting.

Based on observations, interviews, and record review, the facility failed to monitor a cognitively impaired resident with a known history of elopement attempts, which resulted in the resident leaving the building unsupervised, putting the resident at risk for serious injury or death for 1 (#2) of 2 sampled residents for elopements. Findings include: Review of a Facility Reported Incident, sent to the State Survey Agency for resident #2, dated 4/14/24, showed, Call received from another resident who was outside of facility reporting resident [#2] was outside at [School Name] playground alone. [Staff member name] received a call from [staff member] that she found resident at [School Name] and she would not get in her vehicle to bring her back to facility. [Staff member] arrived at [School Name] and [resident #2] was returned to facility by [staff member] in private vehicle. During an observation on 6/3/24 at 2:45 p.m., resident #2 was asleep in her room, one door away from the exit door. During an interview on 6/3/24 at 3:10 p.m., staff member D stated all residents at risk for elopement reside in the secure unit, and not out in non-secured unit. Staff member D stated resident #2 could go outside by herself to walk, and staff call the transit bus for her to go to appointments. During an interview on 6/3/24 at 3:16 p.m., staff member E stated resident #2 eloped on 4/14/24 at 7:00 p.m. to [School Name], which was 0.4 miles away, and it took about 8 minutes to walk to, per her internet search. Staff member E stated resident #2 had told staff she was going to walk around the building. During an observation and interview on 6/4/24 at 7:50 a.m., staff member E stated resident #1 was the only elopement risk out on the non-secured unit. Staff member E stated the facility had an elopement book, but she could not locate the book at the time of the interview. Staff member E asked staff member D where to locate the book and staff member D stated the book was supposed to be on the desk. Staff members D and E located the book in a wall file behind stacks of papers. Staff member E reviewed the book and stated two residents were at risk of elopement, including residents #1 and #2. During an interview on 6/4/24 at 7:55 a.m., staff member F stated she was not aware resident #2 was on the elopement risk list. During an interview on 6/4/24 at 8:02 a.m., staff member H stated she was not aware residents #1 or #2 were on the elopement risk list. During an interview on 6/4/24 at 8:04 a.m., staff member G stated she was not aware residents #1 or #2 were on the elopement risk list. During an interview on 6/4/24 at 8:06 a.m., staff member C stated, [Resident #2] forgets easily, and the family told us that at admit, and it was obvious from day one too. During an observation and interview on 6/4/24 at 9:06 a.m., resident #2 was walking very fast down the hall, using a four wheeled walker. Staff member G told resident #2 to slow down. Staff member G stated resident #2 was a fast walker and staff had to remind her to slow down so she would not fall. Resident #2 declined to speak with the surveyor. Staff member G stated staff could usually talk to her and she would respond, but most of her speech is unintelligible. During an interview on 6/4/24 at 10:35 a.m., staff member A stated the facility was not doing a great job ensuring the elopement risk residents and their interventions were communicated to the staff on the floor. Staff member A stated the facility was planning to add an elopement huddle to the morning huddle meetings, but had not done so yet. During an interview on 6/4/24 at 1:30 p.m., staff member B stated she was not aware resident #2 was a elopement risk until 6/3/24. Staff member B was new to her position and felt that resident #2's elopement was likely a result of the change in weather. Staff member B stated when the weather is warmer, several residents can leave on their own. Staff member B stated she felt resident #2 saw other residents leaving the building and thought she could too. Staff member B stated she wished the facility had an elopement bracelet system but could not explain why staff did not know resident #2 had left the facility and had made her way to the park before another resident noticed her at the park. Review of resident #2's Fact sheet, with a print date of 6/3/24, showed the following mental health diagnoses: - Fetal alcohol syndrome - Schizophrenia - Moderate intellectual disability - Depression - Developmental disorder of scholastic skills Review of resident #2's MDS, with an assessment date of 4/24/24, showed resident #2 had a BIMS of 12. Review of resident #2 PASRR II, dated 8/7/23, showed: - . Behavioral and Functional Impacts relating to Mental Health Past 3/6 Months: Going outside without supervision, walking and wandering away. Patient is easily confused and needs frequent redirection and continuous supervision to keep her safe. Patient has lack of awareness and insight into what her needs are and is unable to make rational or reasonable judgements concerns regarding her well-being. - . The uncle reports that the biggest concern for the patient is her wandering away unsupervised. When this has occurred, she ended up in very dangerous and unsafe situations due to her lack of awareness and lack of comprehension. Review of resident #2's Elopement Care Plan, with a problem start date of 7/14/23, showed resident #2 was . at risk for elopement as evidenced by a history of wandering outside at nighttime. The Approach (interventions) included: - .Provide me with continuing education on importance of not leaving facility as due to my cognitive impairment I am forgetful. (start date 7/14/23) - Use verbal cues and gentle touch to redirect my exit-seeking behaviors. (start date 7/14/23) - I have my information and photo in a binder at each nurse's station so staff is aware that I am at risk for elopement. (start date 7/14/23) - Ensure I do not accidentally follow visitors out of the building (start date 7/14/23) - I enjoy dogs and cats very much and I will attempt to follow them out of the building as I am forgetful. Please remind me not to follow visitors and pets out of the building. (start date 7/18/23) - If I am overheard talking about leaving facility to go do something, please provide me reminder that I am unable to go by myself. (start date 4/15/24) . Staff members D, E, F, and G were unaware of resident #2's risk of elopement, and were unaware of the interventions to prevent elopement for resident #2. Review of resident #2's progress note, dated 4/14/24, showed resident #2 had .asked for someone to take her but no one wouldn't (would). [sic]

Based on observation, interview, and record review, the facility failed to implement sufficient measures to prevent skin breakdown and treat pressure ulcers timely, for 2 (#18 and 45) of 2 sampled residents, resulting in the development of two Stage II pressure ulcers, and a Stage IV pressure ulcer after admission, to the facility. This resulted in infections for both residents and increased pain for resident #45. Findings include: 1. A review of resident #45's electronic resident progress notes, dated 3/18/23 through 6/5/23, reflected: - On 3/18/23 resident #45 developed an .open area of skin to his right buttock. Open area is about 1 cm in diameter . - On 3/23/23 resident #45's right buttock wound was listed as a Stage II right gluteal wound . measuring 2.5 x 1.5 superficial in depth . Staff member L's office was called and a message was left. - On 3/27/23 the wound dressing change noted: Unstageable due to eschar presence. - On 3/28/23 staff member J noted on a wound assessment: moderate amount of seropurulent drainage with measurements of 3.1 x 1.5, unable to measure depth due to wound being covered with adherent yellow/brown slough covering wound bed . photo taken . [staff member L] in house, photo of wound showed to PCP, PCP down to room to discuss offloading . - On 4/7/23 an air mattress was ordered. - On 5/2/23 the right gluteal wound measured 5.3 cm x 3.5 cm x 3.5 cm. - On 5/2/23 the MDS Quarterly Assessment and Interview reflected, . 3/18/23, resident developed a Stage 2 Pressure Injury to R Buttocks, 3/28/23 wound declined and became unstageable, 4/14 resident seen general surgery at [Hospital] where wound surgically debrided. Noted per general surgery note, wound debrided and abscess was removed from area. Stage 3 wound continues to be present, dressing changes ordered Q3Days and PRN . [sic] - On 5/23/23 a wound care progress note showed, . Measurements obtained, 4.5 x 3.3 x 3.6. Noted area of tunneling in wound at 12o clock, tunneling area measuring 0.5 cm. Noted scant amount of serosanguinous drainage coming from wound. Stage IV buttocks wound . [sic] - On 6/1/23 at 12:20 a.m., the nurse noted a change in resident #45's condition, and the resident was lethargic, refusing meals, and answering questions inappropriately. The resident's blood pressure was abnormally low, with increased pulse, body rash, and yellow tinting of the skin. Photos of the rash and an explanation of symptoms were sent to staff member L. Nursing also noted the Night Shift reported resident #45 was restlessness and tearful due to pain. The nurse reported calling the clinic for assistance with the resident's pain management and lab workup. - On 6/1/23 at 7:00 a.m., the nursing note reflected, . loud, uneven breathing, pulse of 108, oxygen saturation of 76%, a blood pressure of 86/57, and respirations 40. Resident denies pain, but moaning and squirming in bed stating he is trying to get comfortable . The nurse note reflected the nurse contacted the spouse to offer an emergency room assessment, but the spouse declined and wanted resident #45 to be kept comfortable at the facility. The nurse note showed the emergency room was called to obtain an order for oxygen and pain management. emergency room staff stated they would return the call after visiting with the provider. The nurse also called [staff member L] and left a message with updates on resident #45's condition. - On 6/1/23 at 7:30 a.m., nursing noted, Resident continues to moan and try to get comfortable in bed. No call or orders received back from ER or Clinic at this time. Resident given standing order Tylenol 650 mg for pain. - On 6/1/23 at 8:00 a.m., nursing noted resident #45 passed away at 7:55 a.m. During an interview and record review on 7/19/23 at 10:01 a.m., staff member I stated reasons why there were delays in antibiotic administration from the time signs and symptoms of infection appeared to the time of diagnosis and treatment, was due to a combination of communication problems with the hospital lab, having to leave voice mails for [staff member L], and waiting for a response as [staff member L], since he doesn't work on Saturdays, Sundays or nights, and has no on call coverage. We can call the ER if we have to, but it's up to nurse if it's emergent enough to send to ER or whatever, but it's not encouraged to do so. Then [staff member L] has to send orders to the pharmacy, and we have a common issue getting medications from the pharmacy. During an interview on 7/19/23 at 11:25 a.m., staff member J stated, [Resident #45's] wound antibiotic treatment was delayed because we kept waiting on [staff member L], it took a while before the antibiotics were started, and the delay of adding an air mattress was due to a limited number of mattresses, and maintenance issues. I think the wound did contribute to his death. During an interview on 7/19/23 at 2:33 p.m., staff member L stated, On 3/18 they used a standing order for wound care, then on 3/23 [staff member J] messaged me about a Stage 2, and on 3/28 staff member J showed me a photo, it did not really look infected to me. I then looked at it myself on 4/11 and said it definitely needed debridement, but still didn't think it really seemed infected. I made a referral and it was debrided, and antibiotic was ordered by the surgeon on 4/14. I think his death was multifactorial comorbidities that led to wound and compounded death, but he did have increased ascites that last week and had liver failure. Staff member B informed staff member J the facility does not receive copies of lab cultures, they must manually request them, contributing to the delays. Staff member L then left the meeting. Staff member B stated, The mattress issue is a lack of supply, I wish it wasn't, but the reality is they are expensive, and we only have so many so we move them onto an air mattress as soon as one becomes available. Staff member B stated, I recognized a communication issue covering [staff member L's] time off months ago and sent an email about how coverage needed to happen, and was told that it was not an issue, and there it stayed. We don't have a contract or anything, so it's kind of like they (hospital emergency room staff) are on volunteer duty if they want to help us. [Staff member L] is off on Fridays, Saturdays, Sundays, and evenings. We have his Nurse Practioner help on Friday during the day, and then we have to use the ER staff outside of that. 2. During an observation and interview on 7/19/23 at 8:23 a.m., staff member K completed wound care on resident #18's left ankle, right foot, and sacrum. Resident #18 reported there was no pain in the wound area of the left ankle, and stated, It's kind of numb. Staff member K then completed wound care on resident #18's right foot and stated, It's superficial redness now, with about a quarter size opening. Resident #18 stated her leg hurt on the side of her right thigh, just above the knee. Staff member K then assisted resident #18 to a standing position, with her walker, while her sacrum was assessed. Staff member K cleansed the wound area. Staff member K stated she could see a little spot on the sacrum. Staff member K stated, I think I will just put protection cream on. Don't think you need a patch. Staff member K stated she would, stage the one sacrum and foot as Stage I, and the ankle is a Stage II, looks almost like the ankle is getting worse, but no odor. Staff member K stated, The wound nurse will see it tomorrow, and she will know if it's worse. During the observation there was no assessment completed by the nurse of resident #18's complaint of right thigh pain, just above the knee. Staff member K stated she was not aware of how the pressure wounds started, but knew the wounds started after resident #18 was admitted to the facility. Review of resident #18's electronic medical record reflected the following: - A physician note, Long Term Care Visit, dated 4/4/23, reflected, Noted on her right foot that she has developed a small ulcer that is 3mm in size and 1mm in depth. The concern is that there is surrounding cellulitis that goes down towards her toes and surrounds the whole side of her foot. [sic] - Physician Order report, dated 3/15/23 through 7/20/23, reflected: - Order started for the right foot wound care on 3/29/23. - Order started for the left elbow pressure injury on 4/12/23. - Order started for a Stage II pressure wound care on sacrum on 4/27/23. - Order for a left lower leg ulcer wound care on 5/30/23. A review of resident #18's Admission MDS, with an ARD of 3/29/23, reflected resident #18 admitted to the facility on [DATE], and did not have any unhealed pressure ulcers. The MDS reflected resident #18 had an open lesion on the foot. The MDS also reflected resident #18 was at risk of developing pressure ulcers/injuries.

Based on interview and record review, the facility failed to ensure a designated, qualified individual was onsite, who is responsible for implementing Antibiotic Stewardship programs, and activities to prevent and control infections, resulting in increased risk for antibiotic resistant infections. Findings include: During an interview on 7/18/23 at 3:22 p.m., staff member I stated, I really don't know anything about antibiograms, and I admit I am behind on infection surveillance. I look at them every day, but tracking I am just now starting to print off all of them for July. Oh, I guess I still have to do the ones for April, May, and June. I just printed off the numbers for the QAPI meeting, but haven't done the tracking. I am still learning. I still work the floor 12 hours a week and then the rest of my time is all for infection control. A record review of the facility's Infection Reports Binder reflected the influenza, pneumococcal, and covid vaccine policy was dated by the medical director on 7/18/23. There were no other interdisaplinary team memeber signatures showing the policies had been reviewed and approved. The Tuberculosis policy was not signed by the administrator or the board of directors. A stack of event suspected infection documents were found in the front of the binder, however staff member I stated, they have not been reviewed or charted yet. Staff member I stated, I'm really behind. I look at stuff daily, but I haven't had a chance to get to the tracker spreadsheet. During an interview on 7/18/23 at 3:22 p.m., staff member I stated, I was a med aide and hired into this position in March of 2022 as the Infection Preventionist. I had to figure out how to do the job from the job description and go to the DON with questions, but I have been just learning by trial and error. The DON did help with Covid stuff, but the rest I've been on my own. I was also in school starting in August 2022 to get a nursing degree (LPN) and just got my license July 3rd, 2023. I took the CDC IP course and finished it April 2023. I worked the floor quite a bit with all the outbreaks. No one sat down and taught me, I just went through the binders I could find and figured it out. I really didn't get the training I should. During an interview on 7/19/23 at 2:33 p.m., staff member B stated, She (staff member I) definitely needs more training. We are putting her in another Infection Prevention course. We've had a med aide in this position since 2018 without an issue, but I can see the regulation says otherwise. I am just trying to keep the doors open. We have many systematic things to work on. I'm the only one here with long term care experience. Review of staff member I's employee file reflected: -Payroll change to Infection Preventionist position on 4/19/22. - Completion of the CDC Nursing Home Infection Preventionist Training Course on 4/6/23. -State of Montana Practical Nurse License with expiration date of 12/31/24. -Completion of new graduation licensed nurse competency form on 7/13/23.

Based on interview and record review, the facility failed to develop an Antibiotic Stewardship Program that promotes the appropriate use of antibiotics and includes a system of monitoring to improve resident outcomes and reduce antibiotic resistance, resulting in increased risk for antibiotic resistant infections, and poor outcomes for all residents who receive antibiotic therapy. Findings include: During an interview on 7/18/23 at 2:38 p.m., staff member I stated, The infection control policy is outdated, last date is 6/27/19. You'll have to talk to [staff member A]. We just hand them in. I know we talk about them in QAPI. Review of the facility's record, Infection Prevention Control Program document binder reflected the documents were last updated in 2019, including the risk assessment, antibiogram, and policies. Infection tracking was last completed in December 2022. During an interview on 7/18/23 at 3:22 p.m., staff member I stated, Flu tracking is horrendous, but I have a plan for future flu seasons. HR will do staff education and consents and I will do the residents. I'm working on a PIP for it. I'm working on making up some Cath care audits because I noticed catheter associated UTIs are high, so I'm working on making up some audit forms. I'm worried about hand hygiene between residents. I really don't know anything about antibiograms, and I admit I am behind on infection surveillance. I look at them every day, but tracking I am just now starting to print off all of them for July. Oh, I guess I still have to do the ones for April, May, and June. I just printed off the numbers for the QAPI meeting, but haven't done the tracking. We were really [NAME]-nilly prescribing antibiotics, so I instituted McGeers, and I hate when they prescribe without waiting for cultures. My goal is to have them follow McGeers and wait for cultures. I'm just trying to figure out the why, so I'm planning to start audits and have the team all help with audits. I am still learning. I still work the floor 12 hours a week, and then the rest of my time is all for infection control. A record review of the facility's Infection Reports Binder reflected the influenza, pneumococcal, and covid vaccine policy was dated by the medical director on 7/18/23. There were no other interdisaplinary team memeber signatures showing the policies had been reviewed and approved. The Tuberculosis policy was not signed by the administrator or the board of directors. A stack of event suspected infection documents were found in the front of the binder, however staff member I stated, They have not been reviewed or charted yet. Staff member I stated, I'm really behind. I look at stuff daily, but I haven't had a chance to get to the tracker spreadsheet. A review of the facility's, Event Suspected Infection documents, dated January 2023 through May 2023, reflected seven catheter associated infections, eleven non-catheter related infections, eleven skin infections, sixteen reports with incomplete data, and six antibiotics were changed after culture results were received. Staff member I was surprised by the number of reports without complete data. Of the sixteen without complete data, staff member I was able to find the information in the residents' electronic medical record for eight of the sixteen incomplete reports. Staff member I was unable to reconcile the remaining eight Event Suspected Infection reports.

Based on observation, interview and record review, the facility failed to ensure proper hand hygiene was used during water pass, wound care, and peri-catheter care, for 5 (#s 6, 18, 33, 46, 49) of 5 sampled residents, resulting in increased risk for infections. Findings include: 1. During an observation and interview on 7/17/23 at 3:58 p.m., staff member E was observed passing water to residents on the new wing. - Staff member E entered the room, obtained an old cup from resident #49's room, and emptied the remaining water from the cup into the bathroom sink. Staff member E then brought the cup out to the cart in the hallway, filled the cup with ice, and added water from the cooler. Then staff member E returned the cup to resident #49's room, and placed it on the bedside table. - Staff member E then entered resident #6's room, and emptied the cup into the bathroom sink. Staff member E then brought the cup out to the cart in the hallway, filled the cup with ice, and added water from the cooler. Staff member E then took the filled cup back to resident #6's room. - Staff member E then entered resident #46's room, obtained the water cup and emptied it into the bathroom sink. Staff member E then went to the hallway and added ice to the cup, filled the cup with water, and returned the cup to the resident's bedside table. Staff member E stated she attended hand hygiene training, and she should use hand hygiene anytime she entered or exited a resident's room, when having contact with a resident, and when visibly dirty. Staff member E failed to use hand hygiene when entering or exiting resident #6's, 46 and 49's rooms while filling the residents' water cups and handling soiled cups, and then using the same ice scoop to fill all the cups. 2. During an observation and interview on 7/19/23 at 8:23 a.m., staff member K changed the wound dressings for resident #18. - Staff member K completed hand hygiene, repositioned the resident, gloved her hands, set up the table with wound supplies, and began wound care for resident #18's left leg wound. Staff member K removed the resident's dirty sock and bandage, and stated, It looks like we're trying Santyl sav now. Staff member K completed hand hygiene, gloved her hands again, and washed the wound. Resident #18 stated, There's no pain, it's kind of numb. Staff member K put dressing prep around the wound, removed her gloves, and marked the new dressing with a date and initials. Staff member K put on new gloves, added ointment to the gauze, and on her finger, then applied ointment into the wound bed, and placed the bandage over the wound. Staff member K failed to complete hand hygiene after cleaning the wound, before starting the dressing prep, and before putting on gloves after dating and initialing the new bandage. -Staff member K then began the dressing change for resident #18's right foot wound. Staff member K removed resident #18's sock, gloved her hands, opened the wound supplies, and set up the table. Staff member K wrote on the new bandage, removed the old bandage, and cleaned the resident's right foot wound. Staff member K completed hand hygiene, gloved her hands again, applied dressing prep around the wound, added triad ointment to the wound, and applied a new dressing to the site. Staff member K removed her gloves, and wrapped the resident's legs with ace bandages. -Staff member K removed the footrests from resident #18's wheelchair, prepped wound care supplies, marked the new bandage, and donned gloves. Staff member K then assisted resident #18 to a standing position with her walker while the sacrum wound was assessed. Staff member K cleansed the wound area and stated, she could see a little spot. Staff member K patted the wound with a 4x4 gauze to dry, and doffed gloves. Staff member K stated, I think I will just put protection cream on. Don't think you need a patch. Staff member K donned gloves and applied cream to the sacrum, assisted the resident with pulling up her brief and sitting back down in the wheelchair. Staff member K removed her gloves, left the room, and completed hand hygiene. Staff member K stated she, would stage wound on leg as a Stage II, looks almost like it's getting worse, but no odor. Staff member K failed to complete hand hygiene after wrapping resident #18's legs and before handling new bandages for the sacrum wound. Staff member K failed to perform hand hygiene prior to donning gloves to apply cream to resident #18's sacrum wound. 3) During an observation and interview on 7/19/23 at 8:50 a.m., staff member F and M completed peri care and catheter care for resident #33. Staff members F and M completed hand hygiene and donned gloves. Staff member F wet a wash cloth in the sink, while staff member M gathered a brief and wipes. Staff member F added soap to the wash cloth, lowered the head of the bed down, and removed the resident's brief. Staff member F cleaned the resident's stomach, and skin folds. The cleansed areas were dried with a cloth. Staff member M rolled resident #33 to the side facing staff member M, tucked a new brief under resident #33's hip, removed bowel movement with peri wipes and cleansed the resident's buttocks with the wet wash cloth. Resident #33 stated, My butt itches. Staff member M stated, I can't remove all the cream because it's macerated skin on left cheek and the right. Staff member M removed gloves, put on new gloves, added more barrier cream to resident #33's buttocks, and put on the new brief. Staff member M assisted the resident to roll onto the other side facing staff member F, then removed the old brief. Staff member F put on new gloves. Staff member M put on new gloves. Staff member M cleaned the catheter from the peri area to the large tube, and assisted resident #33 up to the head of the bed. Staff member M removed her gloves, emptied the waste baskets in the resident's bathroom and bedside. Staff member M and F then washed their hands. During an interview outside resident #33's room, staff members K and M stated they were educated on hand hygiene but stated they knew they missed hand hygiene opportunities on multiple occasions during resident #33's care. During an interview on 7/19/23 at 2:33 p.m., staff member B stated, QAPI showed hand hygiene audits as part of Quality Measures concern for UTIs, so plan is each department does one audit per month with set up as: -Week 1: Dietary, -Week 2: Activities, -Week 3: Nursing, and -Week 4: Housekeeping. We started in April. Review of facility audit reports showed missing audits for: -Housekeeping in April, -Housekeeping in May, and -Activities and Dietary in June. Staff member B stated, The Infection Preventionist is responsible to notify [staff member A] of any missing, and [staff member A] is responsible to hold department managers responsible.

Based on interview and record review, the facility failed to have a physician available, 24 hours a day, to respond to resident emergencies that do not require medical care in an alternative setting, for 1 (#45) of 1 sampled resident which resulted in a delay of care, resulting in increased pain at the end of life. Findings include: A review of resident #45's electronic medical record, Resident Progress Notes, dated 3/18/23 through 6/5/23, reflected: -On 6/1/23 at 12:20 a.m., the nurse noted a change in resident #45's condition. Resident #45 was lethargic, refusing meals, and answering questions inappropriately. Resident #45's blood pressure was abnormally low, with an increased pulse, a body rash, and yellow tinting of the skin. Photos of the rash and an explanation was sent to staff member L. Nursing also noted the Night Shift reported resident #45 was restlessness, and tearful due to pain. The nurse reported calling the [staff member L's office] for assistance with pain management and lab workup. -On 6/1/23 at 7:00 a.m., nursing noted, .loud, uneven breathing, pulse of 108, oxygen saturation of 76%, a blood pressure of 86/57, and respirations 40. Resident denies pain, but moaning and squirming in bed stating he is trying to get comfortable . The nurse contacted the spouse in regards to his change in condition and offered to send the resident to the emergency room for an assessment. The spouse declined, and wanted the resident kept comfortable at the facility. The emergency room was contacted to obtain orders for oxygen and pain management. The nurse noted, emergency room staff stated they would return call after visiting with provider. This nurse also called [staff member L] and left message with updates. -On 6/1/23 at 7:30 a.m., nursing noted, Resident continues to moan and try to get comfortable in bed. No call or orders received back from ER or Clinic at this time. Resident given standing order Tylenol 650 mg for pain. -On 6/1/23 at 8:00 a.m., nursing noted resident #45 passed away at 7:55 a.m. During an interview and record review on 7/19/23 at 10:01 a.m., staff member I stated reasons why there were delays in antibiotic administration from the time signs and symptoms of infection appeared to the time of diagnosis and treatment was due to a combination of communication problems with the hospital lab, having to leave voice mails for [staff member L], and waiting for a response from[staff member L], since he doesn't work on Saturdays, Sundays or nights, and has no on call coverage. We can call the ER if we have to, but it's up to nurse if it's emergent enough to send to ER or whatever, but it's not encouraged to do so. Then [staff member L] has to send orders to the pharmacy, and we have a common issue getting medications from the pharmacy. Staff member B stated, I recognized a communication issue covering [staff member L's] time off months ago, and sent an email to [hospital management] about how coverage needed to happen, and was told by [hospital management] that it was not an issue and there it stayed. I need regulations to hold them to, I could not find it. We don't have a contract or anything so it's kind of like they (hospital emergency room staff) are on volunteer duty if they want to help us. [Staff member L] is off on Fridays, Saturdays, Sundays, and evenings. We have his Nurse Practioner help on Friday during the day and then we have to use the ER staff outside of that.

Based on interview and record review, the facility failed to ensure resident POLST form's were complete, and including the provider's signature, date, and time, for 2 (#s 10 and 30) of 23 sampled residents. Findings include: Review of resident #10's POLST form, dated 4/12/21, failed to show a provider signature on the form. Review of resident #30's POLST form, not dated, showed a provider signature without the accompanying date of the signature. The form also failed to show the date when the form was completed. During an interview on 7/19/23 at 8:01 a.m., staff member C stated she was responsible for ensuring each resident's POLST was complete and accurate on admission to the facility. Staff member C said the POLST was reviewed during each quarterly care conference. Staff member C stated she was primarily concerned with the choice of treatment, and had not noticed the missing provider signature and date on the POLST for resident #s 10 and 30. Review of the facility policy titled, Advance Directives and Resident Rights Regarding Treatment, not dated, failed to show a review of the forms for completeness, including a provider signature and date, when necessary, was part of the process.

Based on observation, interview, and record review, the facility failed to ensure resident safety for 2 (#s 24 and 42) of 2 sampled residents related to smoking; failed to ensure resident safety for 1 (#24) of 1 sampled resident for elopement; and 1 (#21) resident for a fall with a major injury, and 1 (#104) resident for a fall with suspected head injury of 3 sampled residents. Findings include: A. Falls 1. During an interview on 10/12/22 at 3:08 p.m., staff member B stated the facility policy was to notify providers of all falls, and the time of notification would have been documented in the facility event report. Staff member B stated the facility nurse would usually have contacted the provider quickly after a fall for a resident with abnormal vitals, obvious injury, or suspected head injury. During an interview on 10/13/22 at 10:16 a.m., staff member B stated a provider should have been contacted immediately, and the facility neurological evaluation flowsheet for resident #104 should have been filled out completely after an unwitnessed fall with a complaint of head or back pain. Review of the facility document titled, Fall Documentation, dated 3/16/21, showed, .after a fall occurs .unwitnessed- If a fall was unwitnessed assume that head injury occurred and NEUROS must be completed via NEURO sheet. Review of the facility Event Report, dated 6/26/22, under the heading, notification guidelines, showed, BP - systolic >180, <90; Diastolic >110 .suspected head injury/abnormal neuro checks from resident baseline. Review of resident #104's Event Report, dated 6/26/22, showed the resident had an unwitnessed fall on 6/26/22 at 7:03 a.m. The resident had a pain level of 6 (1-10 scale) in her back and head. The drug review section showed a check mark in the box next to other-blood thinner. The provider notification section was charted as completed 6/26/22 at 2:11p.m., seven hours after the fall had occurred. Review of resident #104's Neurological Evaluation Flowsheet, dated 6/26/22, showed the evaluation post fall was started on 6/26/22 at 7:05 a.m. Resident #104 had a systolic blood pressure of 192 at 7:05 a.m., and 183 at 7:20 a.m. and 7:35 a.m. Charted systolic blood pressure values for 11:05 a.m. through 6/29 at 2:30 a.m. ranged from 133-171. The six columns for timed neurological checks and vitals from 7:50 a.m. through 11:05 a.m. were not filled out, and had a line drawn through them. The neurological checks from 11:05 a.m. on 6/26/22 through 2:30 a.m. on 6/28/22 were completed. Resident #104 was transferred to the hospital on 6/29/22. Review of resident #104's nursing progress note, dated 6/29/22 at 12:18 p.m., showed, Spoke to [outside hospital staff member] at [outside hospital], [outside hospital staff member] advises [resident #104] admitted to [outside hospital], due to bilateral subarachnoid [sic] hemorrhage and bilateral subdural hematomas. [Outside hospital staff member] mentioned CT scan results stated [sic] considerations would include trauma vs aneurysm leak. Refer to F658 - Services Meet Professional Standards for resident #104. 2. During an interview on 10/12/22 at 5:50 p.m., staff member A stated resident #21 had fallen and broken her shoulder at home and was admitted to the facility with it, so they did not provide her requested information. The surveyor clarified resident #21 did fall at the facility on 5/3/22 and sustained a broken elbow. Staff member A stated the facility would look for the information requested for resident #21. During an interview on 10/13/22 at 7:35 a.m., staff member A stated, they did find resident #21 fell and sustained a broken elbow at the facility, and the facility was working on gathering the requested information for the resident. During an interview on 10/13/22 at 8:28 a.m., staff member B stated, she would have to look into the fall for resident #21, as she was not up to date on it, and the facility was in the process of gathering the requested information. During an observation and interview on 10/13/22 at 10:10 a.m., staff member B stated resident #21's requested information for a fall on 5/3/22, at the facility, showed a nurse progress note recapitulated the post fall tracking. Staff member B summarized the nurse progress note, stating, resident #21 was observed falling onto her left elbow. The provider was contacted and advised the facility to monitor for worsening symptoms as there was no noticeable injury at the time of the fall. Resident #21 had complaints of pain level 6 (0-10 scale) and noticeable bruising and swelling continually worsening for several days. She was sent to the clinic for an appointment on 5/6/22, where they performed an x-ray. Observing the post fall event assessment report with staff member B, it only included the date and time of the fall filled out. All assessment pieces of the event were blank. Staff member B stated she did not realize the report was not completed. The linked progress notes for review showed neuros were completed, but none were provided by the end of the survey. Resident #21's 5/3/22 fall with a sustained broken elbow information was requested on 10/12/22 at 10:00 a.m. The request information included, the event investigation for resident #21's fall resulting in a broken elbow with assessment, neuros, witness statements, treatment provided, xray and lab results, progress notes, notifications, and any other related information. Review of resident #21's Family Practice Visit, dated 5/6/22, showed resident #21 sustained, Left arm severely ecchymotic and edematous, particularly over elbow. Decreased grip strength. Xray obtained. Completely distracted/displaced avulsion type fracture of the olecranon process from the proximal ulna. Resident #21 was transferred to the ER for further treatment. B. Elopement and Smoking 1. During an interview on 10/13/22 at 8:22 a.m., staff member B stated residents at the facility who were allowed to smoke were determined to be independent with smoking. The designated smoking area was down the sidewalk from the front door. Resident #24 had been reviewed by the interdisciplinary team, and had been escorted on trips to town, but the facility did not document the updated determination he was no longer considered an elopement risk. Review of a facility reported incident showed resident #24 had eloped from the facility on 4/23/22, a few days after being admitted to the facility. Resident #24's Care Plan, last revised 8/1/22, showed he had been allowed out of the facility, daily, by signing out at the nursing station. Review of resident #24's assessment list in the EHR showed he had not been assessed for elopement risk at admission, when the elopement happened, or later when he was allowed to sign himself out. The EHR assessments list did not show any smoking safety/risk assessments completed. Resident #24's elopement and smoking assessments were requested on 10/12/22, and none were provided by the end of the survey. 2. During an interview on 10/13/22 at 8:34 a.m., staff member C stated resident #42 was still smoking, and smoking risk assessments should have been completed quarterly. Review of resident #42's EHR, accessed on 10/13/22, showed one smoking risk assessment completed on 3/28/22. No smoking risk assessments were found after the one completed in March of 2022. Review of the facility's policy titled, Resident Smoking, last revision dated 12/27/18, showed the smoking risk assessments were to be completed on admission, quarterly, and with a significant change in condition.

Based on interview and record review, the facility failed to protect 1 (#70) of 19 sampled residents from several incidents of physical and verbal abuse from family members, which resulted in emotional and mental anguish for the resident. Findings include: During an interview on 1/8/20 at 9:31 a.m., staff member B stated resident #70 was no longer residing in the facility, but when he was a resident, staff had some concerns with his family being aggressive, but (it was) nothing serious. Staff member B explained that when staff had concerns about the way resident #70's family was interacting with him, staff would require the family to meet in the common area so staff could observe them. During an interview on 1/8/20 at 10:48 a.m., staff member E recalled interactions she had observed between resident #70 and his family. Staff member E stated resident #70's father would raise his voice and sometimes a hand at resident #70. Staff member E explained when staff observed this aggressive behavior, they would ask resident #70's father to leave the facility, and he would comply. Staff member E added staff required resident #70's family to have supervised meetings. Staff member E stated resident #70 had started yelling out and screaming a lot, but only a month or so after he had been admitted to the facility. Staff member E explained resident #70's yelling would irritate his family, who would then tell him to shut up. During an interview on 1/8/20 at 11:02 a.m., staff member A stated staff had to constantly monitor resident #70 because he would act out and yell for no apparent reason. Staff member A stated staff could not figure out what resident #70 needed. Staff member A continued to explain staff had witnessed resident #70's parents hitting, yelling, and threatening him, and forcing food into his mouth. Staff member A stated he witnessed resident #70's parents grab his hands and shake him, or grab resident #70's side while holding up a fist and telling him to shut up. Staff member A stated he had spoken with resident #70's parents to inform them that staff needed family visits to happen in the common area and to ask that they please keep their hands off of him. Staff member A stated requiring family visits in the common area alleviated a lot of the aggression, but he did witness resident #70's parents grab his wrists on either side following that intervention. Staff member A stated resident #70 was very difficult, loud, and would use a lot of foul language; staff tried every intervention they could think of to help him stay calm. During an interview on 1/8/20 at 11:51 a.m., staff member A stated the progress notes would clarify how this was a complicated case. Staff member A stated, We were going back and forth trying to decide if it was abuse. During an interview on 1/8/20 at 12:33 p.m., staff member A stated the facility protected resident #70 by implementing an intervention of ensuring family visits occurred in the common area. This intervention was put in place 11/2/18. Review of a Nursing Progress Note, dated 8/19/18, showed: Only yelling during cares and while family here to visit. Review of a Nursing Progress Note, dated 9/1/18, showed: Family here this afternoon, they were getting frustrated with (resident #70's) yelling and were telling him to be quiet and grabbing his face. There was no mention in the progress note of staff removing resident #70 from his family. Review of a Nursing Progress Note, dated 9/3/18, showed: Resident yelled out with parents throughout lunch time. Family members grabbed resident by shoulders several times trying to get him to stop yelling, family very short tempered overall today. There was no mention in the progress note of staff removing resident #70 from the situation. Review of a Nursing Progress Note, dated 10/4/18, showed resident #70 would yell out and (his father) would open hand pat his face. As (resident #70's) behavior increased the force of the 'pat' appeared to increase as well. (Resident #70) would glare at his father and attempt to elbow him and even rose a fist to him in a threatening manner. (Resident #70's father) responded by restraining (resident #70's) wrist. The note added no reddened skin from the face pats or wrist grab were noted. There was no mention of staff removing resident #70 from the situation. Review of a Nursing Progress Note, dated 10/6/18, showed resident #70 was yelling and spitting at his parents. Both mom and dad smacked resident in the face several times. Staff removed resident #70 immediately. Review of Social Services Progress Notes, dated 10/24/18, showed resident #70 admitted to the facility [DATE]. The note showed: (Resident #70) has been historically observed acting out more frequently and louder than his normal baseline when his father is around. He normally continues this behavior for quiet (sic) some time after his family departs the facility as well. (Resident #70's) behavior appear (sic) on the defensive around his father due to the possibility of his father placing a hand over (resident #70's) mouth to attempt to stop him from yelling at times .family stated that they may decline the amount of trips to visit with (resident #70) in order to see if time away may help. This writer informed them that (resident #70) frequently acts out even on days they are not visiting so although that could be a possible type of help it may not too. Review of a Quarterly Activities Note, dated 11/14/18, showed: Family comes to visit frequently but do have tendencies to become aggressive . Review of a Restorative Nursing Note, dated 11/14/18, showed: When family is close to resident he hollers out but when at distance he calms down. Resident was moved to recliner a distance away from dad and sister and resident was then quiet. Dad moved closer to recliner where resident was sitting and resident started hollering again. Resident was spitting and cursing at dad. Review of a Nursing Note, dated 12/2/18, showed: Today this nurse and CNA witnessed the dad grabbing resident's wrist which increased the volume on yelling. There was not mention of staff removing resident #70 from the situation. Review of resident #70's Care Plan, dated 10/30/18, showed: My family becomes aggressive at times while they are here to visit me .I will be safe while residing (in the facility). Interventions for this goal included: floor staff will report any negative behavior from family members to upper management immediately; staff will ensure all family visitation occurs in a common area; staff will separate resident from harm immediately upon witnessing. Review of resident #70's [DIAGNOSES REDACTED]. Review of the facility's policy, Abuse Prevention and Management Program, dated 4/25/19, showed: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse.Ensuring the health and safety of each resident with regard to visitors such as family members or resident representatives, friends, or other individuals subject to the resident's right to deny or withdraw consent at any time and to reasonable clinical and safety restrictions. Additionally, the policy showed, following an allegation of abuse, the facility would: Respond to the needs of the resident and protect him/her from further incident. The facility failed to proactively protect resident #70 from physical and verbal abuse by family members; and failed to remove resident #70 from situations in which family members became aggressive. After implementing an intervention of requiring supervised family visits, staff members continued to observe aggressive behavior by family members towards resident #70, without intervening at all times. A review of resident #70's final MDS showed resident #70 discharged the facility on [DATE], and he did not return to the facility.

On 4/28/16 at 12:15 p.m., the facility administrator was notified that an immediate jeopardy situation existed for 4 of the 15 sampled residents. After the immediacy was removed, the severity and scope remained at a H. Based on observation, interview, and record review, the facility failed to identify individual resident risk factors; failed to use the residents fall history to analyze the trends and patterns in order to identify and implement interventions for future falls; failed to adequately educate staff on the individualized fall interventions; failed to notify the physician/responsible party timely of falls; failed to accurately document fall details; and failed to utilize the quality assurance process to identify deficient practices relating to the fall program for the future prevention of falls; specifically, for a resident who had a fall which resulted in a change of condition, and being admitted to the hospital for dehydration and anemia for one (#7); for a resident who was alert and had repeated falls, and lacked the ability to recognize safety deficits for one (#13); for a resident who had a change of condition and repeated falls, and the facility failed to follow up on the resident's change for one (#5); and for a resident who had falls that resulted in increased pain, increased hallucinations, a decline in ADL's, and weight loss for one (#4) out of 15 sampled residents. Findings include: 1. Resident #7 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. A review of the resident's Annual MDS, with an ARD of 12/9/15, showed the resident had moderately impaired cognition, exhibited no mood or behaviors, and rejected care 1-3 days of the assessment period. The resident was either independent or needed supervision of one person assistance for all of her activities of daily living. The resident was occasionally incontinent of bowel and bladder. During an interview on 4/25/16 at 3:00 p.m., staff member E stated the resident would walk short distances, but had no concerns relating to care. Staff member E provided care for the resident regularly. During an observation on 4/26/16 at 9:00 a.m., the resident was in her recliner. She was leaning forward in the chair. The resident's walker was by the end of the bed. The resident stated she received assistance with dressing, and staff would help her to the bathroom if she needed it. During an observation on 4/27/16 at 9:40 a.m., the resident was walking down the hall, unattended. She was using a walker. The resident took small, purposeful steps. She stopped about every 3-4 steps to rest. She stated, I get tired easy. The resident was on her way to the dining room, which was an extended distance from her room. The resident was breathing deeply as she walked. It took the resident over five minutes to get to the dining room with rest periods. When the resident got to the outer doors of the dining room, staff assisted the resident the rest of the way. A review of the resident's Progress Notes, Neurological Assessment Forms, and Event Reports showed the resident had five falls which were on: 10/4/15, 12/22/15, 1/7/16, 2/25/16, and 3/28/16. The details for the falls showed: - The resident hit her head in three of the falls. - The resident's injuries included bruises to the thigh, forehead, nose, and pain. The clinical record lacked information for the following: - Lack of monitoring after the falls occurred; - Five of the five falls lacked information relating to the investigation for details pertaining to the resident and the environment leading up to the fall, utilizing root cause analysis, and also after the fall for needed interventions; - Five of the five falls lacked interventions for future fall prevention; - Four of the falls lacked adequate neurological assessments; - Five of the five falls lacked a comprehensive assessment to show how the facility utilized root cause analysis for assessing the resident, and the prevention of future falls. A review of the facility Falls - Clinical Protocol policy showed the nurse shall assess and document the resident's assessment, and: Musculoskeletal function, observing for change in normal ROM or weight bearing; Frequency of falls since the last physician visit; Current medications, especially those associated with dizziness or lethargy; and the resident's active diagnoses. A review of the resident's Fall Care Plan, initiated on 4/5/16, lacked evidence relating to how the facility identified the resident's fall risk factors using her fall history, how they analyzed these fall risk factors and then implemented individualized fall interventions in an attempt to prevent future falls. During an interview on 4/25/16 at 4:00 p.m., staff member F stated she would utilize the residents' care plan and converse with other staff on resident care needs. During an interview on 4/27/16 at 8:30 a.m., staff members L and M stated they utilized the residents' care plan to identify care needs, or would ask a nurse. A review of the resident's Physician Orders, dated 4/26/16, showed the resident did not have any physician ordered fall precautions in place. A review of the Provider Progress Notes lacked evidence relating to falls, or documentation for any attempts made to reduce falls. On 3/16/16, the provider documented the resident had a balance disturbance and chronic vertigo, which was a long standing concern. During an interview on 4/28/16 at 2:55 p.m., the consulting pharmacist stated he reviewed the medications used by the residents once a month, and would provide the facility with a summary of concerns. He stated a meeting was being held to discuss concerns, because several areas of the pharmacy review were not being addressed by the facility. Further review of the resident's Progress Notes showed: - On 2/25/16 - 5:17 a.m. - The resident was very weak. She could not put pills into her mouth, or hold her cup without assistance. The resident stated she fell and hit her head before supper. The resident had stated a big man helped her, and a short girl. The resident was assisted to bed. The resident was incontinent, and could barely walk. She required a two person assistance. This was a change from the resident's prior patterns. During an interview on 4/27/16 at 12:00 p.m., staff member C stated the facility neurological policy showed staff were to complete neurological exams to monitor the resident, which would be documented on the neurological assessment form. - On 2/25/16 - 6:19 p.m. - The resident remained weakened. Staff had reported not assisting her from the floor, or witnessing a fall. The resident reported pain and tingling on the left side of her face and temple. The resident refused her evening medication due to difficulty with swallowing. The physician was notified, but the nurse documented Awaiting response. A response was not documented. During an interview on 4/28/16 at 12:15 p.m., staff member C stated if the physician was contacted during non-business hours, the call would go to the physician working at the emergency room at the local hospital. The medical record lacked evidence to say if the physician was notified of the fall. From 2/26/16 to 3/17/16 the resident continued to have a change in status after the fall. The resident was treated for [REDACTED]. (Refer to F224) The medical record lacked evidence to show the physician was aware of the resident's change in overall status. A review of the Monitoring and Follow-up section of the fall policy showed staff would monitor the resident until stable, and document the individual's response to the interventions intended to reduce the falls. Under the Treatment/Management section of the policy, it showed if an underlying cause cannot be readily identified or corrected, staff would try various relevant interventions based on the resident's assessment. During an interview on 4/27/16 at 10:30 a.m., the resident stated she was not sure why she fell . She said the two people who helped her up worked at the facility, but she could not recall their names. She stated she did not feel well for a long time, and had trouble swallowing. She thought she had a stroke, and had told the staff, but no one would listen. The resident stated she was very tired all the time, and did not want to do anything but sit or sleep. During an interview on 4/27/16 at 12:00 p.m., staff member C stated she had worked for the company for many years, and previously was assigned to oversee the clinical services at the facility. Staff member C stated upon arriving to the facility, which was at the beginning of February 2016, she began reviewing how residents were transferred, the use of the mechanical lifts, and resident falls. Staff member C stated the falls were discussed in the safety meeting each month. During an interview on 4/28/16 at 8:07 a.m., staff member C stated the facility fall log was found to be inaccurate. During an interview on 4/27/16 at 6:10 p.m., staff member O stated he had been working during the time period when the resident had fallen on 2/25/16. Staff member O stated he recalled she was frequently tired. Staff member O stated he did not assist the resident when she had fallen, and she was usually so independent he did not have to do anything for her. Staff member O stated, I just check on her, nothing else. Staff member O explained how the resident was very independent for her activities of daily living, but he may check for clutter in the room at times. During an interview on 4/28/16 at 8:00 a.m., staff member P stated she recalled the resident's behavior, from 2/25/16 to her hospital admission, and did not find a change from her normal behavior. Staff member P recalled working with the resident during the time she was being treated for [REDACTED]. During an interview on 4/28/16 at 8:07 a.m., staff member C stated she recalled discussing the resident's fall and change of status. The discussion occurred in the morning meeting. She recalled the resident having chronic anemia and lab work completed, and that the staff at the facility questioned if the resident had a stroke. The resident was put on the list for the FNP provider to be seen (3/16/16). Staff member C stated the resident Did not have a fall because she was not helped up by anyone, and didn't know what she was talking about, because she didn't fall. Staff member C referenced the resident being confused throughout the time period from the fall to the hospital admission. The medical record lacked evidence to show the resident was regularly confused, per staff member C's report. During an interview on 4/29/16 at 9:20 a.m., a family member stated she was not notified of the fall on the day it occurred. She stated she found out when she visited the resident and, I found her crumpled over in the chair. The family member tried to wake the resident, and immediately told the staff something was not right. 2. Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the resident's Admission MDS, with an ARD of 12/3/15, showed the resident was cognitively intact. For the majority of the resident's activities of daily living, he required extensive assistance of one person. The resident was not coded as having any functional limitations with range of motion on the left or right upper extremities. A review of the resident's Progress Notes, facility fall log, and care plan, showed the resident had the following falls between 12/5/15 to 4/9/16: 12/5/15, 12/9/15, 2/16/16, 3/22/16, 4/7/16 (2 falls), and on 4/9/16. The resident's falls occurred more frequently between the hours of 12:00 a.m., to 6:23 a.m., Two of the falls were in the bathroom, and the remaining five were in the resident's room. The resident had knee pain after the fall on 12/5/15, and a skin tear to the palm on 2/16/16. The medical record lacked information regarding the following details for the seven falls: - Physician and family notifications were not documented as completed. - The documentation in the clinical record lacked information relating to the nursing assessment completed immediately following the falls. - The nursing documentation lacked evidence for a thorough investigation on the falls in an attempt to determine a root cause for the fall, by analyzing the information of the fall, and the environment. - The facility failed to show how the resident's fall history was utilized in an attempt to prevent future falls. A review of the resident's Care Plan lacked evidence to show the facility adequately identified the resident's fall risk factors, or that they had analyzed the information to implement a care plan for future fall prevention. During an interview on 4/25/16 at 3:00 p.m., staff member E stated the resident was a fall risk, was hard of hearing, utilized a wheelchair and walker, and was an assist of two people for transfers. Staff member E was assigned to provide care for the resident regularly. During an interview on 4/28/16 at 8:00 a.m., staff member P stated the nurses, and herself, were required to document a resident event in the nursing notes and communicate with the oncoming nurses by using the 24 hour report or the task lists for the nurses. Staff member P stated the event report would also include details for the event (not part of the medical record). 3. Resident #5 was admitted to the facility on [DATE]. Review of the Resident Progress Notes for resident #5, dated 12/29/15, showed the resident was found on the floor at 7:45 p.m. Upon quick assessment, a minor red mark noted on the right knee. ROM performed without difficulty, vitals taken with WNL results. The resident denied hitting head and verbalized no complaints of pain when assess briefly. The room had no noted slipperiness on the floor, no clutter. Review of a Progress Note, dated 12/31/15, showed the resident had facial grimace, and complained of leg pain when changing position. Pain medication was provided. Review of a Progress Note dated 1/1/16 at 10:01 a.m., showed the resident was having increased pain to the right lower quadrant. The resident was crying, and stated it hurt so bad. Resident sent to ER for eval and tx. Review of a Progress Note dated 1/1/16 at 2:29 p.m., showed a return from ER, with no reports of fractures, and a new order for a Fentanyl patch 25 mcq was initiated. Review of a Progress Note dated, 1/02/16, showed A visitor saw resident fall while walking out of the dining room. Resident said that she tripped while walking. Vitals were WNL. Neuros were WNL but writer observed S/S of confusion. She C/O that the medial side of her hip did not feel right and pain in her right knee that was bruised in prior fall. She sustained a 1 cm skin tear on the back of her left hand. Review of a Progress Note dated 1/28/16 at 2:44 a.m., showed the resident had slid out of her chair. No injuries noted to resident. Review of the Progress Note dated 1/28/16 at 6:32 p.m., showed the resident was sent to ER at 9:30 a.m. due to a lump and bruise on head, along with vomiting. Review of a Progress Notes dated 1/31- 2/2/16 showed the resident was sleeping most of the day, was lethargic, found it difficult to speak, and her pupils were sluggish. Review of a Progress note dated 1/30/16 at 1:48 p.m., showed the resident had an unwitnessed fall in her room. Hit her head. The resident was sent to the ER where she received 2-3 staples for a cut on her head. Review of a Progress Note dated 2/15/16 showed the resident had a change in condition. Very lethargic, unable to hold head up. Holding L hand in R slumped to L when in sitting position. Is able to grip with both hands. Legs equally weak. 2 person assist Br. Began either coughing weakly or retching with breakfast, spit out food and meds in mouth. Review of a Resident Progress Note dated 2/18/16, showed the resident had another fall. The resident was found on the floor in another resident's room sitting on her bottom. During an interview on 4/27/16 at 10:10 a.m., staff member C stated the facility Safety Committee Meeting on 4/7/16 had addressed falls. The committee did identify 51 falls from January through April 7. Fall circumstances were listed. Interventions were Skid Strips, gripper socks, wheelchair next to bed, and grips for toilet bar. Staff member C said they had not evaluated these interventions for effectiveness because things take time. Resident #5's intervention to prevent falls was Skid Strips by bed. 4. Resident #4 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of a Resident Progress Note dated 10/31/15 at 1:49 a.m., showed resident #4 was found sitting on the floor, up against her bedroom door. An assessment was done and bruising was found to the right pinky and ring fingers. Review of the Resident Progress Note dated 10/31/15 at 4:23 p.m., showed the resident had a bruise and slight swelling to the right ring and little fingers and knuckle. C/O slight pain. Review of the Progress Note dated 11/1/15 at 11:39 a.m., showed the resident has swelling, slight bruising, and tenderness to three knuckles and base of the fingers on her right hand. She was able to grasp without wincing. The ER was called and stated the facility should observe it for the next day or two, and observe how the the injury progressed. The family and Dr. were updated. Review of the Progress Note dated 11/2/15 at 1:49 p.m., showed Resident has swelling slight bruising and tenderness to three knuckles and base of fingers. Able to grasp without wincing. Resident does states when moving 'it's kinda tender'. Review of the Progress Note dated 11/2/15 at 6:38 p.m., showed the resident's right hand continued to have edema and bruising, and she stated it hurt more. Dr's office notified, n/o received to send resident to hospital for x-ray. Review of the Progress Note dated 11/4/15 at 3:10 p.m., showed the facility phoned MD to figure out results of wrist x-ray. Resident continues to have bruising and inflammation of the right wrist and finger. Exhibiting mild S/SX of pain at this time, appears controlled with Tylenol. Review of the Progress Note dated 11/4/15 at 6:12 p.m., showed the MD came to the facility with a verbal report that resident's right wrist was fractured. MD placed splint this evening. During an interview on 4/28/16 at 12:05 p.m., staff members C and D stated the ER was called during non business hours instead of the MD. They did not know why the staff member called the ER at 11:39 a.m., during the day, for the resident's fractured wrist. Review of the Event Report for resident #5's fall showed the fall location, pain observation, body observation, neurological check, and possible contributing factors were not completed. It showed the MD and family were not notified and the care plan was not reviewed. The MD was notified on 11/1/16 at 11:39 a.m. Review of the All Falls for Facility log, showed resident #4 continued to fall 10 more times through 3/2016.

On 4/28/16 at 12:15 p.m., the facility administrator was notified that an immediate jeopardy situation existed for 4 of the 15 sampled residents. After the immediacy was removed, the severity and scope remained at a H. Based on observation, interview, and record review, the facility failed to: adequately and accurately assess the risk factors and causes for a pressure ulcer which developed on the resident's coccyx; failed to identify and implement timely interventions, to include utilizing or not utilizing equipment, for the prevention of the deterioration of the pressure ulcer; failed to adequately educate staff on the care needs of the resident with the pressure ulcer, and update the resident's plan of care relating to the pressure ulcer; and failed to provide treatment for [REDACTED].#6); failed to accurately complete the MDS assessment and skin assessments, for a pressure ulcer to the heel in an attempt to determine the type of skin breakdown, and document the information accurately throughout the duration of the pressure ulcer; failed to obtain a physician's orders [REDACTED].#5); and failed to provide the correct treatment for [REDACTED].#16) out of 21 sampled and supplemental residents. Findings include: 1. Resident #6 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the resident's Annual MDS, with an ARD of 10/7/15, showed the resident had no documented resistance to care. The resident was total assistance of 2+ persons for activities of daily living, and required one person to help with eating. The resident had impaired range of motion on both the left and right side. The resident was coded as being incontinent for bowel and bladder. The resident was not coded as having a pressure ulcer. For the Quarterly MDS, with an ARD of 4/6/16, the resident was coded as having a pressure ulcer. During an observation on 4/27/16 at 8:30 a.m., staff member L and staff member M were transferring the resident from the bed to the wheelchair. The resident repeatedly stated, No throughout the process. Staff member M stated the resident, .does not like care drawn out, so faster is better. When the resident's blankets were removed, she was not wearing protective boots on her feet. The resident did not have compression hose (Teds) on her legs, and these were not put on prior to her being dressed. The resident had a dime size, dark brownish/black scab on the right ankle. Staff member L and M stated they had not seen the skin area prior, but were aware of a wound on the resident's coccyx. The resident was placed in the sling. The lift, a Vanderlift II, was used to assist the resident up off the bed, and into the wheelchair. The sling completely covered the backside of the resident, and cradled around the resident's buttocks as she was transferred. When the resident was placed in the wheelchair a ROHO cushion was in the chair. The lift sling was left between the cushion and the resident. Both staff L and M stated the sling was usually left in the chair. They stated it was difficult to tell if the resident had pain due to her communication deficit. The resident would say words that were inappropriate for the situation, so they watch her facial expression and body language. For wound prevention, both staff members stated they would ensure the resident's brief was dry, that she was turned and positioned in bed, was not laying on her coccyx, and that she was eating protein. The resident was reportedly only out of bed for meals. Both staff members stated they would let the nurse know of any changes or concerns with the resident that were abnormal. A review of the resident's Progress Notes and Pressure Ulcer Documentation forms showed the following: - On 12/2/15 at 3:58 p.m., a skin assessment was completed. The nurse documented that a wound on the lower coccyx was identified, and measured as 0.3 x .01 cm(sic). The area was, .beefy red, no drainage or odor, peri-wound pink intact, n/o for Duoderm (sic), change q 3 days and PRN, reassess in 2 weeks. The Pressure Ulcer form showed it was a stage II pressure ulcer. The documentation lacked evidence for potential causes, or interventions implemented to prevent future skin breakdown. Documentation did not show if the physician or responsible party was notified of the new pressure ulcer. - On 12/17/15 the Pressure Ulcer form showed the pressure ulcer was Unstageable and had increased in size. The resident was being repositioned. - On 12/18/15 a new order was received for a treatment to the pressure ulcer, and the daughter was notified. - On 12/28/15, the pressure ulcer was 1.7 x 1.3 x 0.5 cm in size. There was Moderate amount of [MEDICAL CONDITION] drainage. The records lacked evidence to show how the facility addressed pressure ulcer prevention regarding the equipment the resident used during care. - On 1/1/16 the pressure ulcer had slough, and scant exudate. The nurse documented 25% of the pressure ulcer wound bed was visible, that the pressure ulcer was intact, and was Unstageable. - On 1/21/16 the pressure ulcer was improving; on 2/4/16 it was documented as a stage II pressure ulcer, and was 4 cm intact. - On 2/18/16 the Pressure Ulcer form showed the pressure ulcer was again Unstageable, and had increased in size. It was documented as 2 x 1.5 x .2 cm. The area also had shearing on the edges due to tape. The progress notes showed the resident intermittently would refuse skin care treatment, but lacked evidence to show if the care to the pressure ulcer caused pain for the resident. - On 2/29/16 a therapist documented, At request of wound care nurse, this resident assessed for and provided a ROHO dry flotation seat cushion to help assist in healing. This was almost 3 months after the wound was first identified. A review of the ROHO Dry Flotation wheelchair cushion specification information showed, The cushion and the cover must be compatible and must be used as directed in this manual. IF THEY ARE NOT: 1) The benefits provided by the cushion may be reduced or eliminated, increasing the risk to skin or other soft tissue ., and under the Obstruction section it showed nothing should be placed between the user and the cushion as that would reduce the product's effectiveness. - On 3/9/16 the pressure ulcer wound bed was fully visible. It was documented as a Stage 3. The area was measured as 2 x .5 cms in size. - On 3/23/16 the Pressure Ulcer form showed the nurse was going to check with therapy to .see about getting pressure relieving mattress, and the resident's protein with meals was going to be increased. The documentation included an entry where the pressure ulcer looked much deeper with a wound bed that was .gray/black, and was 1 cm in depth. The resident was uncomfortable with care to the area. - On 3/25/16 at 11:32 a.m., the family voiced concerns with the resident's weight, and that she may have had a urinary tract infection. They expressed concern regarding the pressure sore. - On 4/5/16 the pressure ulcer was 2.5 x 1.5 x 1.5 cm in size. It was documented to have Necrotic tissue, and was undermining. The nurse documented the resident was to be seen by the physician on rounds in the morning. A review of the resident's Provider Progress Note's, showed the resident's weight had dropped from 159.9 pounds on 9/9/15, to 131 pounds on 11/4/15. The resident was to be wearing Ted hose, and on 11/4/15 had no skin problems. On 1/6/16 the primary physician documented, Seen for 60 day exam and only recent change has been decubitus that is slowly improving. The provider's documentation from 2/24/16 and 3/9/16 lacked evidence relating to the coccyx pressure ulcer or deterioration. On 4/6/16 the provider documented the resident was seen for the progression of a decubitus ulcer that had began over two months prior. He documented the wound, .has waxed and waned. She continued up in her chair until just the last week. The physician referred the resident to a surgeon for a consultation. - On 4/11/16 the nurse documented on the Pressure Ulcer form that the resident's wound edges were macerated, that protein and a supplement were added to the resident's diet, and the resident was going to be seen by a surgeon the next day for a possible debridement of the pressure ulcer. During an observation on 4/26/16 at 10:05 a.m. the following occurred: -Staff member D completed a dressing change for resident #6. The resident had a pressure ulcer located near the coccyx. -Staff member D stated the pressure ulcer was identified in December 2015. -When the old dressing was removed from the pressure ulcer, there was a significant odor, and moderate amounts of drainage. Staff member D stated the ulcer was a stage IV, and approximately 5-6 cm across. The exact measurements were not completed during the observation. Staff member D stated the dressing was ordered to be changed twice daily, and nursing would measure it with the next dressing change. -The resident was stating, No, no throughout the dressing change. Staff member D checked with the resident to ensure she was ok, and stated the nurse practitioner would see the resident the following day. In addition, staff member D had talked with the physician prior to the dressing change, with no changes ordered for the treatment of [REDACTED]. -Staff member D washed/sanitized her hands, and applied gloves after setting up her supplies. New gauze packing with sterile saline was inserted into the wound, and a gauze dressing was applied over the opening to the wound, and taped lightly on the outside. During an interview on 4/28/16 at 4:10 p.m., staff member I stated the resident was receiving wound care from staff member C (date unknown). Staff member C was using scissors, and attempting to remove gauze from the wound bed. The scissors were not sterile, and had been utilized for office tasks. Staff member I commented on the scissors, and staff member C stated it was ok because the resident was on antibiotics. Staff member I left the room, and retrieved different scissors. Prior to handing the scissors to staff member C, staff member I had sterilized the scissors with alcohol. A review of the resident's Braden Skin Assessment date 4/5/16 showed a score of 10, and was at high risk for pressure ulcers. During an interview on 4/26/16 at 5:00 p.m., staff member D stated she believed the sling was left in the resident's wheelchair when the resident was sitting in it, and the sling had a split in it. The split would then go around the resident's coccyx wound, rather than over it. The facility had not considered leaving the sling in the wheelchair as a concern relating to the wound. A request was made for the ROHO cushion's specifications. A review of the manufacturers Diagram and Features showed the sling as one piece, with four ties extending out. There were no splits in the sling. Under the section, Leaving Slings Positioned Under Patients in Wheelchair it showed that leaving the sling in the chair, when the resident was still in it, would require the resident's posture to be evaluated by a nurse or professional rehabilitation department staff member. Staff member D was notified that the sling did not have a split in it, therefore it did cover the coccyx wound when the resident was in the wheelchair. During an observation on 4/27/16 at 6:20 p.m., and on 4/28/16 at 8:40 a.m., the resident was sitting in the wheelchair and the lift sling was placed between the resident and the ROHO cushion. During an interview on 4/26/16 at 10:05 a.m., Staff member J stated she did not remove the sling from the resident's chair when she was assisted out of bed and into the wheelchair. Staff member J stated she had been leaving the sling in the chair for a long time. During an interview and observation on 4/26/16 at 6:10 p.m., staff member K inspected the lift sling, and showed how the sling was one piece. Staff member K stated the sling was always left in the resident's chair. During an interview on 4/27/16 at 9:10 a.m., staff member V stated she was not aware of a problem relating to the resident's pressure ulcer until March 2016, which is when she found out about the pressure ulcer. A review of the resident's Pressure Ulcer care plan, initiated on 12/5/15, and last revised on 4/26/16, lacked evidence relating to the use of the lift sling, or that leaving the sling in the wheelchair would reduce the effectiveness of the ROHO cushion. 2. Resident #5 was admitted to the facility on [DATE]. Review of the current MDS with the quarterly ARD of 3/9/16, showed resident #5 required extensive assist of 2 people for her bed mobility and transfers. The pressure ulcer was not coded on the MDS. Review of the Braden Scale for Prediction of Pressure Sore Risk form, dated 12/31/15, showed not at risk - no interventions necessary at this time. Review of resident # 5's Resident Progress Notes dated 2/24/16 showed the resident had a 5 cm clear, intact blister to right outer heel, and the left heel was mushy - heels to uploaded and n.o. to apply Skin prep q shift. Review of the Resident Progress Notes dated 2/27/16, showed the right heel blister was intact and left heel was red, and soft. Duoderm was placed over the right heel for additional protection and comfort. Review of the physician progress notes [REDACTED]. The resident's daughter had reported the resident had been pushing hard on that heel anytime she was in severe pain. Review of the Skin - Pressure Ulcer Documentation, dated 3/9/16 showed the pressure ulcer was now unstageable related to being covered with eschar. Review of the Skin - Braden Scale for Prediction of Pressure Sore Risk dated 3/9/16, showed resident #5 was at a Very High Risk for skin breakdown. Review of the Resident Progress Notes dated 3/17/16 showed Left heel wound/blister has resolved, skin pink and CDI, Right heel wound/blister now hardened with darkened scab, CDI, no fluid or draining noted. Cavalon spray applied per MD order. Review of the Progress Notes dated 3/19/16 showed skin prep to R heel blister site. Hard dark scab, no draining, intact. Review of the Progress Notes dated 3/27/16 showed the right heel as eschar and left open to air. A pillow was placed under her feet for comfort. Review of the Physician order [REDACTED].#5's pressure ulcer. A Treatment Order dated 3/12/16 showed May wear heel protectors while in bed. Special instructions: Keep bi-lateral feet offloaded or keep heel protectors on. Review of the Progress Notes dated 3/28/16 showed Patients heels off bed, supported by pillow under lower legs this a.m. Right heel noted to have cushioned dressing place. Dry and intact, and adhering well. Patient stated pain went away once this dressing was placed. Review of the Progress Notes dated 4/8/16 showed readjusted the pillow under resident legs to keep heels off the bed. Wound on right heel is dry and intact and open to air. Review of the Progress Notes dated 4/8/16 showed the resident had a bath and after her bath the wound on her heel was open and weeping onto her sock. Covered wound on her right heel with a [MEDICATION NAME] foam dressing to give it some padding and made sure her heels were floated and off the pillow and bed. Review of the Progress Notes dated 4/14/16 showed, Eschar is completely off heel, area has not depth, surface bed pin, slight maceration around wound, scant clear drainage, n/o received to clean with ns and apply [MEDICATION NAME] qd. Review of the Progress Notes dated 4/29/16 showed, She continues to have 2 small areas on her right heel that has dried skin flakes/layers with the center continuing somewhat discolored but no eschar. During an interview on 4/26/15 at 12:00 p.m., staff member E stated she had been providing treatment for [REDACTED]. She stated she had experienced a decline in February, and stopped eating. She stated the right heel was OK now and the left heel was mushy. During an interview on 4/26/16 at 4:30 p.m., staff member C stated she thought the physician's orders [REDACTED]. Review of resident #5's Standing orders for wound care showed Wound care: per NH Protocol. The facility implemented 5 different treatments during the 6 weeks of care for resident #5's pressure ulcer, without physicians orders. The pressure ulcer progressed to eschar. It reopened after a bath. Two healing areas on the right heel were identified on 4/29/16. A left heel ulcer was documented as healed on 3/17/16 but not identified as a pressure area on the treatment sheets. Review of the Treatments Administration History dated 3/1/16 showed apply Skin Prep to blister on Rt. outer heel and Lt. heel q shift and keep feet off loaded. Review of the Care Plan for resident #5 showed a generic care plan had been initiated on 3/12/16, and not individualized for stage, cause or treatment. 3. Resident #16 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the resident's nursing admission note, dated 3/11/16, showed a skin check was completed and the resident had no skin concerns listed. Review of the facility's form titled Admission -- Clinical Admission Documentation, showed the resident's skin to be dry, warm, no [MEDICAL CONDITION]. Review of a nursing note, dated 3/30/16, showed the resident had a reddened area. Staff did not observe any open areas to his coccyx at that time. Review of a nursing note, dated 4/18/16, showed the resident had a 1 cm open area to the inner left buttock. Review of a nursing note, dated 4/19/16, showed the physician called the facility and ordered the resident to continue with routine wound care including, Duoderm to coccyx, change q 3 days until healed. Keep off coccyx as much as possible. Review of a physician's orders [REDACTED]. Change q 3 days. Review of a nursing note, dated 4/21/16, showed a stage two pressure ulcer approximately 1.5 cm by 0.5 cm. Area around this is red. Wound is approximately 1 inch above anus. The nursing note also discussed the wound treatment saying, Cleaned with normal saline and [MEDICATION NAME] applied. Nursing also received an order to stop using the K Pad/heat to this area. During an interview on 4/29/16 at 9:30 a.m., staff member N said, I took the order for the pressure ulcer treatment. The physician ordered Duoderm. Duoderm and [MEDICATION NAME] are not the same thing and Duoderm is what should be used. Review of resident #16's care plan contained no updates to reflect the current plan of care and treatment of [REDACTED]. Review of the manufacturer's description shows the Duoderm dressing to be a [MEDICATION NAME] dressing that creates a moist wound environment. The manufacturer's description for the [MEDICATION NAME] dressing showed it is for use with moderately to heavily exuding wounds due to it's foam center island that absorbs exudates.

On [DATE] at 12:15 p.m., the facility administrator was notified that an immediate jeopardy situation existed for 4 of the 15 sampled residents. After the immediacy was removed, the severity and scope remained at a G. Based on observation, record review, and interview, the facility failed to: Identify, analyze, and provide interventions for residents' who had difficulty chewing or swallowing, and staff had awareness of these difficulties. These failures included: Having a system to accurately provide food in a form which the resident could consume; failed to ensure the resident had a physician ordered diet in place; failed to follow and update the resident's individualized care plan for eating/nutrition for the risk factors, interventions and personal preferences; and failed to adequately educate staff on the resident's safety risks for two (#s 6 and 7); and failed to adequately assess, identify, and provide timely intervention for a resident who had a change in condition after a fall and the resident was later admitted to the hospital for dehydration and [MEDICAL CONDITION], for one (#7); failed to adequately assess a resident who had a fall with a significant injury, and provide timely follow up for the resident who had pain and bruising from the injury, which was later identified to be a fracture; failed to update the resident's individualized care plan for the fracture; and failed to adequately educate the staff on the resident's care needs relating to the fracture, for one (#4) out of 15 sampled residents. Findings include: 1. Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident had developed a stage four pressure ulcer at the facility. A review of the resident's Annual MDS, with an ARD of [DATE], and the Quarterly MDS, with an ARD of [DATE], showed the resident had severely impaired cognition. The resident was coded as needing total assistance of one person for eating. The resident was not coded as having any nutritional approaches in place. During an observation on [DATE] at 8:35 a.m., the breakfast meal was observed. The following occurred: - Staff member H was holding up a glass of juice, and the resident was drinking the juice from a straw. The resident was turning her head away pulling the straw from the glass, and had said, No several times. The resident coughed regularly throughout the drinking of the fluid. A liquid gurgle sound could be heard in the resident's throat. The staff member continued to provide the fluids. Staff member H commented to another staff member that maybe the resident was aspirating, and the resident probably needed to have the liquids thickened again. Staff member H stopped assisting the resident at 8:40 a.m., and left the table. No changes were made for the resident. - The resident sat unattended until 9:20 a.m., then she was provided the breakfast meal. The meal was a thin liquid consistency, served in a cup with a straw. Small pieces of food were visible within the liquid mixture. - During an interview and observation at 9:33 a.m., staff member H stated she had told her department head about the concerns with the resident's coughing and drinking. She stated the resident possibly needed to have her liquids thickened again, because she used to have then thickened before. Staff member G was assisting the resident with her meal at the time. The resident was using the straw to consume the breakfast mixture. The resident coughed several times during the meal. Staff member H stated to staff member G, We need to make it thicker (referring to the liquid mixture), she was actually gurgling. Staff member H mentioned telling staff member G about it earlier in the meal session. Staff member G stated, You didn't tell me that. No changes were made to the meal. Shortly after, staff member G stated the resident's meal consisted of eggs, hash browns, and a little bit of milk which had been pureed into a thinner consistency so the resident could drink it. The resident continued to cough randomly throughout the remainder of the meal. A review of the resident's Physician Orders, dated [DATE], lacked evidence for a physician ordered diet. A review of the resident's Telephone Order, dated [DATE], showed the resident was changed to a pureed diet with milk. The order was signed by the nurse only. A review of the resident's Nutritional Care Plan, initiated on [DATE], showed a pureed diet. A review of a second Nutritional Care Plan, last edited on [DATE], showed staff were to wear gloves during meal times when offering the resident food. The care plan included that the resident did not like silverware in her mouth. The care plan lacked evidence to show the resident's meals were to be served in a cup, with a straw, or in a thinner liquid consistency than recommended. A review of the resident's Medical Nutritional Therapy assessment, dated [DATE], showed the resident was to receive a consistent carbohydrate diet. The assessment included documentation that the resident had chewing and swallowing difficulties, and a soft texture diet was in place. The resident had been refusing more foods, and Seems to be more accepting of finger foods, than requiring the use of a utensil. A review of the resident's Medical Nutritional Therapy assessment, dated [DATE], showed the nutritional goals for the prior assessment had not been met, and weight loss has continued down 12.5 pounds in past month. The assessment showed the resident was on a consistent carbohydrate diet. The assessment lacked information relating to any concerns with the resident's swallow or chewing abilities. The resident's clinical record lacked evidence to show any assessments had been completed on the resident's chewing, swallowing, or coughing concerns. A review of the resident's Physician Orders, dated [DATE] through [DATE], lacked evidence to show the medications provided to the resident should be crushed. During an observation on [DATE] at 12:00 p.m., the resident's meal was served in a cup. The staff member assisting with the meal (staff member J), returned the cup to the kitchen because the mixture was too thick and the resident could not drink it. The resident coughed for up to one minute during the remainder of her meal. The CNA checked the resident to ensure she was, Ok but continued to allow the resident to finish the liquid mixture. During an interview and observation on [DATE] at 12:35 p.m., staff member J stated the resident was pretty much given anything (referring to food texture) because she will eat anything you give her. She will eat fruit and vegetables whole, but not always with other staff helping. Staff member J stated she would feed the resident whatever the kitchen provided, and was not aware of the resident's required diet. She stated she would look at the care plan if needed. The resident had a bowl of whole strawberries. Staff member J cut one of the large strawberries in half and gave the resident a bite. The remainder of the meal was a pureed thin liquid consistency. The resident randomly coughed during the meal, but no changes were made to the meal. During an observation on [DATE] at 8:40 a.m., the resident was served a breakfast mixture in a cup which had a straw so she could drink it. Staff member Q stated the food was Mixed with water and she forgot milk was supposed to be used when mixing it together. She stated the resident's meal did not include the toast. The resident's meal was not prepared as recommended, and did not have all of the planned menu food items included. During an observation on [DATE] at 6:15 p.m., staff member I was administering medications to the resident on a plastic spoon. Three pills were on the spoon, the spoon was placed in the resident's mouth, and the resident was then offered a drink of water. The resident started coughing after taking a drink of the water. Staff member I said the resident must have chewed her pills, which she frequently did, and that was probably causing her to choke. Staff member C said to staff member I, What are you doing? I fed her the whole meal and she never coughed once. During an interview on [DATE] at 1:15 p.m., staff member G stated she had not received training on the menu recipes. The recipes would show, and provide directions, for food items to serve to residents with pureed diets. Staff member G stated the dietary staff had not been trained on the recipes. Staff member G stated the interventions documented on the resident's care plan were based on the interventions recommended by the dietitian, and completed during the nutritional assessment. Staff member G stated the resident had been on thickened liquids prior (was unsure of the date), but said this was discontinued. Staff member G stated she would change a resident's diet when she received a communication on the change. She stated she did not question who ordered the change, or why. 2. Resident #7 was admitted to the facility on [DATE], and readmitted on [DATE] with [DIAGNOSES REDACTED]. A review of the resident's Annual MDS, with an ARD of [DATE], showed the resident had moderately impaired cognition. The resident was coded as eating independently with set up help only. The resident was not coded as having problems with swallowing or choking. The resident was independent with most of her activities of daily living, and if assistance was provided it was with set up help only. The review of the Quarterly MDS, with an ARD of [DATE], showed the resident continued to be independent with eating and activities of daily living, and was not coded as having any problem with swallowing or choking. A review of the resident's Physician Orders, dated March/[DATE], showed a lack of evidence for a physician ordered diet. During an observation on [DATE] at 9:40 a.m., the resident was eating alone in the solarium. Staff was not present in the room to observe the resident during the meal. A review of the resident's Progress Notes showed the following: - [DATE]-5:17 a.m. - The resident was very weak. She could not put pills into her mouth, or hold her cup without assistance. The resident stated she fell and hit her head before supper. The resident had stated a big man helped her, and a short girl. The resident was assisted to bed. The resident was incontinent, and could barely walk. She required two person assistance. - [DATE]-6:19 p.m. - The resident remained weakened. Staff had reported not assisting her from the floor, or witnessing a fall. The resident was reporting pain and tingling on the left side of her face and temple. The resident refused her evening medication due to difficulty with swallowing. The physician was notified, but the nurse documented, Awaiting response. A response was not documented. A review of the Assessment and Recognition policy showed many falls may be isolated, but then many may be due to a treatable medical disorder, or functional disturbance as the underlying cause. The policy included a thorough assessment process was to be followed to determine potential causes of falls. - [DATE]-6:08 p.m. - The resident continued to exhibit weakness and difficulty with ADLs, and swallowing. The resident did not feel swallowing was strong enough to take all her medication. A urine dip test was competed, and showed it was positive for leukocytes. The physician was contacted. Antibiotics for a urinary tract infection were initiated on [DATE]. - [DATE] - A new order was received to discontinue [MEDICATION NAME](antibiotic), and [MEDICATION NAME] (antibiotic) was initiated for 10 days for the treatment of [REDACTED]. - [DATE] - The resident had a difficult time swallowing her pills during the morning medication pass. - [DATE] - The resident had a difficult time swallowing water, which the staff person documented as not a new event. - [DATE] - The resident had trouble swallowing, denied a sore throat or pain, and fluids were encouraged. The nurse documented she would continue to monitor. - [DATE] - The resident was hunched forward in her chair for part of the shift, and was put into bed. The resident was letting fluids dribble out of her mouth. The nurse documented medications were held due to sleepiness, and the resident was an aspiration risk. The antibiotic was scheduled to end on this day. The medical record lacked evidence to show why the resident was having problems with swallowing, or any follow up regarding the concerns with the swallowing. A review of the Monitoring and Follow-up section of the fall policy showed staff would monitor the resident until stable, and document the individual's response to the interventions intended to reduce the falls. Under the Treatment/Management section of the policy, it showed that if an underlying cause cannot be readily identified or corrected, staff will try various relevant interventions based on the resident's assessment. - [DATE] - The clinic was notified of the resident's decrease in appetite, and the facility requested [MEDICATION NAME] for an appetite stimulant. The swallowing difficulty was not addressed. - [DATE] - The resident continued to sleep a lot and was not eating well. - [DATE] - The resident was seen by a provider, and lab work was ordered. The resident's activity assessment was completed, and found that the resident spent much of her day napping, she would get lost in her thoughts, and was confused. - [DATE] - The resident was admitted to the local hospital for [MEDICAL CONDITION] and dehydration. This was 21 days after the initial fall and change of condition began. - [DATE] - The resident was readmitted to the facility. While at the hospital, the resident received two units of packed red blood cells, and treated for [REDACTED]. During an interview on [DATE] at 9:10 a.m., staff member V stated she was unaware the resident was having problems swallowing. Staff member V stated she was notified of the resident's change on [DATE], which was when the laboratory tests were ordered. Staff member V checked the providers' progress notes, and was unable to locate information on concerns relating to the resident's swallowing concerns from [DATE] to [DATE]. During an interview on [DATE] at 6:10 p.m., staff member O had been working during the time period where the resident had fallen on [DATE], and was having swallowing difficulty documented in the clinical record. He stated he was not aware of the resident having any problems during that time. Staff member O provided care for the resident regularly, and recalled she was frequently tired. Staff member O stated the resident was usually so independent he .did not have to do anything for her. During an interview on [DATE] at 8:00 a.m., staff member P stated she recalled the resident's behavior, from [DATE] until her hospital admission which .was not a change from her normal behavior. Staff member P was aware of the resident holding pills in her mouth, but was not aware of the swallowing problems. Staff member P recalled working with the resident during the time she was being treated for [REDACTED]. During an interview on [DATE] at 8:07 a.m., staff member C stated she recalled discussing the resident's fall and change in status during the morning meeting. She recalled the resident had chronic [MEDICAL CONDITION], and lab work was completed. She stated the staff at the facility questioned if the resident had a stroke. The resident was put on the list for the FNP provider to see. Staff member C stated the resident Did not have a fall because she was not helped up by anyone, and didn't know what she was talking about, because she didn't fall. Staff member C referenced the resident being confused. A review of the Change in a Resident's Condition or Status policy showed the facility shall promptly notify the resident's attending physician, representative of: - An accident or incident involving the resident. - A reaction to a medication. - A significant change in the resident's physical condition. - Refusal of treatment or Medications. Section five of the policy showed that Except in medical emergencies, notification will be made within 24 hours of a change occurring in the resident's medical/mental condition or status. During an interview on [DATE] at 9:20 a.m., a family member stated: - A notification of the fall on [DATE] had not been received. The family member found out about the fall when visiting the resident almost two days later. - Upon entering the resident's room (late Friday afternoon [DATE]), the family member stated the resident was slumped over in the chair. The family member had a history of [REDACTED]. - The family member approached the staff on [DATE], regarding the resident's change. A CNA questioned if the resident had a urinary tract infection. - The nurse completed a urine dip stick test based on the CNA's question, and the urine dip test had a positive reading for a possible infection. Because of this, the nurse contacted the physician. - The family member recalled the resident could not take her pills because she would start gagging on the pills. The resident had a history of [REDACTED]. - The nurse had to start crushing pills for the resident when the change of status occurred. - Prior to the resident's admission to the hospital, the family member stated the hydration rounds had stopped. She said water had been passed each shift to the residents, but for some reason had stopped. She believed the hydration rounds had recently been reinitiated. - The family member stated the medications the resident was taking at the facility were not beneficial for the resident's [MEDICAL CONDITION]. Because of this, the medications had to be changed when she was admitted to the hospital. The family member stated the physician at the hospital was upset this had not been identified at the facility. The family member stated, She almost died this time, it was upsetting. I'd like to say it was due to staff changing over, because I know the staff was trying, but it wasn't. One time when I came in I found feces all over the chair, bed and pad. The room smelled of feces, and the family member stated the resident just needed more help sometimes. The family member had addressed the concerns with management. 3. Resident #4 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of the Resident Progress notes dated [DATE] at 1:49 a.m., showed resident #4 was found sitting on the floor up against her bedroom door. An assessment was done and bruising was found to the right pinky and ring fingers. Review of the Resident Progress Notes dated [DATE] at 4:23 p.m., showed the resident had bruise and slight swelling to right ring and little fingers and knuckle. C/O slight pain. Review of the Progress Notes dated [DATE] at 11:39 a.m., showed the resident had swelling, slight bruising, and tenderness to three knuckles and the base of her fingers on her right hand. The resident was able to grasp without wincing. The ER was called and stated the facility should observe it for the next day or two and observe how the injury progressed. The Family and Dr. were also updated. Review of the Progress Notes dated [DATE] at 1:49 p.m., showed Resident has swelling slight bruising and tenderness to three knuckles and base of fingers. Able to grasp without wincing. Resident does state when moving it's kinda tender. Review of the Progress Notes dated [DATE] at 6:38 p.m., showed the resident's right hand continued to have [MEDICAL CONDITION] and bruising and stated it hurts more. Dr's office notified, n/o received to send resident to hospital for x-ray. Review of the Progress Notes dated [DATE] at 3:10 p.m., showed the facility phoned MD to figure out results of wrist x-ray. Resident continues to have bruising and inflammation of the right wrist and finger. Exhibiting mild S/SX of pain at this time, appears controlled with Tylenol. Review of the Progress Notes dated [DATE] at 6:12 p.m., showed MD came to facility with verbal report that resident's right wrist was fractured. MD placed splint this evening. During an interview on [DATE] at 12:05 p.m., staff members C and D stated the ER was called during non business hours instead of the MD. They did not know why the staff member called the ER at 11:39 a.m., during the day, for the resident's fractured wrist. Review of the Event Report for resident #5's fall showed the fall location, pain observation, body observation, neurological check, and possible contributing factors were not completed. It showed the MD and family were not notified and the care plan was not reviewed. The MD was notified on [DATE] at 11:39 a.m.