Every finding on record at Whitefish Care and Rehabilitation

Based on observations, interviews, and record review, the facility failed to maintain a sanitary kitchen environment and failed to remove expired food in the dry storage area and walk-in fridge. The deficient practices increased the risk of food contamination and foodborne illnesses for residents who dine on facility-prepared meals. Findings include:During the initial kitchen tour on 8/24/26 at 3:33 p.m., the following was observed:The vent on the ceiling of the main kitchen area above the microwave and near the kitchen office was covered in black dirt and dust debris.Two containers of Butter Cream Frosting in the dry storage had a use-by date of 15 July 2026.A reusable container with powdered sugar in the dry storage was dated 2025.There was an uncleanable surface (cardboard and duct tape) on the floor just outside the dry storage room next to the bread cart.There were open containers of cleaning supplies in a box near a cart of bread.During an interview on 8/24/26 at 3:43 p.m., staff member N stated that the most recent kitchen manager had recently quit, and the kitchen did not have enough staff to remove the expired food and keep up with food services.During an observation on 8/26/26 at 1:18 p.m., the following was observed:The same vent on the ceiling of the main kitchen area above the microwave and near the kitchen office was covered in black dirt and dust.A moldy lemon was found in a half-full box of lemons inside the walk-in cooler.The floor in the walk-in cooler, under a storage rack at the back and along the door on the inside of the cooler, was soiled/stained. Colored cutting boards were stained with deep grooves, allowing for food/dust particles to gather.Three emergency water supply sprinklers that were over the stovetop were covered in dust.During an interview on 8/26/26 at 3:44 p.m., staff member O stated she was aware of the dusty vent in the main kitchen area. Staff member O said she submitted a maintenance request earlier on this day to have the vent repaired/cleaned.A review of the facility's Kitchen Cleaning and Sanitation Policy, dated 6/1/26, reflected: [Facility] will maintain the kitchen, food preparation areas, food storage areas, equipment, utensils, and associated dietary service areas in a clean and sanitary condition at all times. Cleaning and sanitizing will be performed at frequencies sufficient to prevent contamination of food, accumulation of grease, food debris, dust or other soil, pest attraction, and transmission of foodborne illness.9. Refrigerators, Freezers and Food Storage Areas. Dispose of expired, spoiled, contaminated, or otherwise unsafe food.11. Cleaning Chemicals. Be stored separately from food and food contact items .

Based on observations, interviews, and record reviews, the facility failed to ensure staff maintained a clean environment for a resident who used a urinal, for 1 (#80) of 1 resident observed for urinal use; failed to ensure staff adhered to enhanced barrier precautions (EBP) for 3 (#s 30, 33, and 56) of 3 residents observed; failed to ensure a clean environment, for 1 (#49) of 1 resident observed; failed to ensure staff maintained a clean environment in the laundry facilities; and failed to ensure proper handling of medications due to non-compliance with PPE protocols for 1 (#40) of 33 sampled and supplemental residents. These deficient practices increased the risk of cross-contamination and the spread of infections for residents and staff. Findings include: 1. Urinal: During an interview and observation on 8/24/26 at 3:17 p.m., resident #80 lay in bed with a bedside table on the left and right sides of the bed. The bedside table on the left held a used urinal with 350 cc of dark yellow to orange urine. Next to the used urinal sat the resident's drinking cup with a lid and straw, and a package of disposable wipes. On the same bedside table, approximately a foot (in distance) from the used urinal, sat a used fork, coffee mug, and an uncovered emesis pan that housed a toothbrush, toothpaste, and a small bottle of mouthwash. Resident #80 stated that he struggled to move the bedside table because the wheels were locked, and he could not reach the urinal caddy that is on the base of the bedside table. During an observation on 8/27/26 at 8:20 a.m., resident #80 lay in his bed sleeping. His left bedside table was within reach; an empty urinal sat on the bedside table next to an uncovered coffee cup, his drinking cup with a lid and straw, and a facility's weekly dining menu. During an interview on 8/27/26 at 8:26 a.m., staff member E, who was assigned to the hall resident #80 resided on, stated that urinals placed on bedside tables were disgusting. Staff member E stated they remove the urinals from the bedside tables whenever they see them. Staff member E could not give an estimated number of times they have removed urinals from the bedside tables. Record review of resident #80's progress note dated 8/24/26 showed resident #80 reported to the wound care nurse that he kept his urinal on the bedside table so he could reach it. Record review of resident #80's Care Plan Report, revised on 5/1/26, showed resident #80 had limited mobility, limited range of motion, and musculoskeletal impairment. The same document did not show interventions or provisions for urinal placement so he could access it himself. Record review of the facility's policy titled, Disinfection of Bedpans and Urinals, dated 6/1/26, showed: .2. Store bedpans and urinals in the resident's bedside cabinet or drawer after placing in a plastic bag or as per facility policy . 3. If the resident uses the bedpan and urinal at will, do not allow placement on the floor or on the bedside table that is used for eating or drinking . 2. EBP: During an interview and observation on 8/24/26 at 3:58 p.m., staff member G, without performing hand hygiene, entered resident #33 and #56's room (room [ROOM NUMBER] with an EBP sign posted on the doorway). While staff member G entered the room, staff member G ate an Easy-Mac cup of macaroni and cheese. Staff member G walked across the room with their cup of macaroni and cheese in hand and turned the call light off for resident #33. Staff member G spoke briefly to resident #33 and exited the room while they ate their cup of macaroni and cheese. Staff member G did not perform hand hygiene after they exited the room. During an interview on 8/24/26 at 4:10 p.m., staff member G stated they did not know what the policy was in regard to staff members eating food while assisting residents or when in the resident rooms, but they knew they should not have done it. Staff member G stated they know they are not allowed to have food or water on the medication carts. During an interview on 8/27/26 at 8:28 a.m., staff member E stated that staff food and drink were not allowed on the floor (while staff was working), medication cart, or the nurse's station. A request was made on 8/27/26 at 10:23 a.m. for the facility's policy in regard to staff food and drink while working on the floor. The requested information was not provided by the end of the survey. During an observation and interview on 8/25/26 at 9:00 a.m., staff member G was going to administer 5 ml of the medication, heparin, to resident #31 but was stopped by the surveyor. Staff member G left the room and came back with a new heparin syringe. In both instances, staff member G wore gloves but failed to follow EBP precautions as shown on the door by not wearing an isolation gown. Staff member G stated she would forget to wear PPE at times. Review of resident #31's physician orders, dated 8/25/26, showed: enhanced barrier precautions in place related to indwelling urinary catheter, nephrostomy tube, and PICC. During an interview on 8/25/26 at 9:31 a.m., staff member V stated EBP were to be worn anytime there was an indwelling device or wound, and there was close contact. Staff member V also stated there should have been signs showing to wear the correct PPE. 3. Clean Environment: During an interview and observation on 8/24/26 at 4:24 p.m., resident #49 stated his bathroom had no toilet paper and is always messy. Resident #49 stated he had told someone about the messiness but did not remember who he told. Resident #49's shared bathroom in room [ROOM NUMBER] presented with a pungent urine odor. The bathroom floor was sticky, with the outline of dried liquid spots on the floor; dark yellow to orange-brown stains were present around the base of the toilet and surrounding floor. A seat riser sat on the toilet bowl and was stained with dark yellow to orange-brown stains. The sink in the bathroom had brown stains scattered in it, and pieces of garbage were scattered on the floor. During an interview on 8/24/26 at 4:40 p.m, staff member S stated they would notify housekeeping in regards to the unclean bathroom. During an observation on 8/25/26 at 8:28 a.m., resident #49's shared bathroom floor remained sticky and stained. The seat riser remained stained with dark yellow to orange-brown stains and had streaks of brown fecal matter on the inner left side. During an interview on 8/26/26 at 9:46 a.m., staff member P stated that ideally the residents' rooms are cleaned daily; however, because they were short-staffed, that did not always happen. Staff member P stated items such as toilet risers were cleaned when the bathroom is cleaned. Staff member P stated if the toilet riser got too bad (when they become stained and can no longer be cleaned) an order is placed with maintenance to replace the toilet riser. 4. Laundry Facilities: During an interview and observation on 8/26/26 at 9:46 a.m., on the dirty side of the laundry facilities, a large quantity (over twenty) lift-slings hung on hooks with the mop bucket side of the housekeeping carts pressed against them. Over ten of those slings had the ends of them lying on the floor. Staff member P stated the facility did a mock survey about a month ago and identified the clean lift-slings being stored on the dirty side of the laundry as an issue. Staff member P stated they were working on a solution but did not have an immediate solution, as there is no room on the clean side to store the clean lift slings. On the clean side of the laundry, the air vent that provided air-conditioning and heat was placed high on the wall, close to the ceiling, above the clean laundry carts and clean folded laundry. The vent had clumps of dust and lint present. Staff member P stated they do sweep, mop, and tidy up both sides of the laundry area daily, but did not have a schedule for cleaning the vents. Staff member P stated they should probably have one. Record review of the facility's policy titled Infection Prevention and Control Program, dated 1/1/26 showed: . 12. Linens: Laundry and direct care staff shall handle, store, process, and transport linens to prevent spread of infection. Clean linen shall be separated from soiled linen at all times . . 16. Staff Education: . b. All staff shall demonstrate competence in relevant infection control practices. Direct care staff shall demonstrate competence in resident care procedures established by our facility 5. Hand Hygiene during Medication Pass: During an interview and observation on 8/25/26 at 9:22 a.m., staff member U had been preparing medications quickly, as he stated the pharmacy order had not been delivered last night due to a flat tire on the delivery truck. Staff member U had dropped a vitamin D pill and touched the medication with his bare hands to place the pill back into the medication cup. Staff member U later administered the medication to resident #40. Staff member U stated he knew he should not be touching medications with his bare hands, as this was an infection control issue, and also stated he knew there was a risk the medication could affect staff member U through absorption on his skin. Review of a facility policy, titled Medication Administration, dated 6/1/26, showed: . 14. Remove medication from source, taking care not to touch medication with bare hands .

Based on observation, interview, and record review, the facility failed to ensure it provided a clean, safe, and homelike environment for the facility residents for 5 residents (#s 3, 31, 40, 49, and 85). Resident #40 voiced concerns about the odor in/around his room and wanted to move due to the odor; #49's bathroom was unclean, and #3, 31, and 85, did not have equipment repaired, replaced, or provided as needed, out of 33 sampled and supplemental residents. Findings include:A. OdorDuring an observation of the facility on 8/25/26 at 9:52 a.m., the hallways smelled strongly of feces and urine.During an observation and interview on 8/25/26 at 9:54 a.m., NF2 and resident #40 were sitting in the hallway eating snacks. NF2 stated they were in the hallway even though it smelled bad because resident #40's room smelled even worse. NF2 stated it smelled, like your face is in the toilet. NF2 stated resident #40 could not stand to be in the room because of the odor from the shared bathroom of room [ROOM NUMBER]. Resident #40 and NF2 were in agreement that #40 wanted to move rooms due to the continued smell in the resident room. B. Odor and Unclean bathroom environmentDuring an observation on 8/24/26 at 4:24 p.m., resident #49's shared bathroom in room [ROOM NUMBER] had a strong odor of urine. The bathroom floor was sticky with the outline of dried liquid spots on the floor; dark yellow to orange-brown stains were present around the base of the toilet and surrounding floor. The toilet's seat riser was stained with dark yellow and orange-brown stains. The bathroom sink had brown stains, and pieces of garbage were scattered on the floor.During an interview on 8/26/26 at 9:46 a.m., staff member P stated resident rooms/bathrooms should be cleaned daily; however, with a shortage of staff, that did not always happen. Staff member P said if the toilet riser was stained and could no longer be cleaned, then an order would be placed with maintenance for a replacement.C. Broken Equipment - Bariatric and Toilet SeatDuring an interview and observation on 8/24/26 at 4:36 p.m., resident #85 and #31's shared bathroom (room [ROOM NUMBER]) had a cracked toilet seat. The crack closer to the front of the seat on the right side.During an interview on 8/24/26 at 4:40 p.m., staff member S stated they would notify maintenance regarding the cracked toilet seat.During an interview on 8/27/26 at 9:23 a.m., staff member A stated the facility had ordered a new replacement bariatric shower chair and a shower gurney. Staff member A stated they should have been delivered already, but the date was pushed back, and the items had still not arrived. Staff member A stated that for resident #3, and others needing the bariatric shower chair, they should have been offered alternative bathing options. Review of resident #3's August 2026 shower documentation sheet, Skin Monitoring: Comprehensive CNA Shower Review, showed resident #3 did not receive a shower on 8/2/26, 8/5/26, 8/12/26, 8/16/26, and 8/19/26 due to not having a shower chair for him to use safely.Review of the facility policy titled Resident Showers, dated 1/1/26, showed, . 5. Help the resident sit on the shower chair. Use safety straps if necessary and available. Utilize appropriate chair/lift if entering bath tub.Record review of the facility's policy titled, Resident Environmental Quality, reviewed on 6/1/26, showed: Policy:This facility is designed, constructed, equipped, and maintained to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public .11. All facility personnel are responsible for reporting broken, defective or malfunctioning equipment or furnishings immediately upon identification of the issue .

Based on observations, interviews, and record review, the facility failed to ensure safe smoking practices were in place and followed, and the location for smoking was safe with hazards mitigated; and failed to ensure the monitor for the smoking sessions had the knowledge to uphold a safe environment during smoking sessions. This failure would affect any resident who smoked in the smoking area, including 3 (#s 49, 51, and 91) of the residents sampled who smoked. The failures increased the risk of injuries, hazards, and the spread of pathogens. Findings include: During an observation on 8/25/26 at 8:34 a.m., seven residents were in the courtyard when the supervised smoking session started. Multiple safety hazards were identified, and some smokers at the facility included #s 49, 51, and 91. The following events occurred: - Staff member C was bringing out a locked cart and handing out cigarette packs with lighters to each resident. Staff member C was wearing gloves.- Staff member C attempted to get a resident to open the clear plastic package to grab the black cigarette tip. The resident was unable to assist with the plastic wrapping. Staff member C opened the package, removed her gloves, and set them on top of the cart so she could grab the lighter and cigarette, and then light the resident's cigarette placed in the cigarette tip. The resident placed the tip in her mouth to smoke the cigarette.- Staff member C did not sanitize her hands before donning a new set of gloves and handed out large tin cans (empty food cans) to the residents to use as ashtrays. Staff member C also passed cigarettes to other residents who joined the group that was smoking.- One resident was not using a tin can or ashtray and was flicking the ashes to the ground, and the ashes landed between the feet of other residents.- A resident had finished smoking, and as she was leaving the area where she was sitting, she was getting her four-wheel walker caught up in the tin cans as she attempted to back over the tin can being used as an ashtray. - At 8:48 a.m., a resident had nearly finished a cigarette before staff member C placed a smoking apron on the resident.- Some residents had finished their cigarettes and returned to the building. Staff member C was dumping the tin cans into the red metal can with a lid as residents finished. She then brought in the locked cart and helped other residents into the building.- Surveyors then looked in the red metal bin and saw a pile of old compacted ash with piles of gloves, tissues, and empty cigarette cartons with the recent cigarette butts and ashes on top of the pile. One of the cigarette butts was still lit and had a red burning ember on the end that had started to smoke and melt the gloves and tissues in the bin. During an interview on 8/25/26 at 8:57 a.m., staff member C stated she would go around and clean up by placing the contents of the tin cans into the red metal can. After getting residents back into the building, she was to take the red metal can and dispose of the contents into the big yellow plastic barrel on wheels with no lid. Staff member C was informed that one of the cigarette butts was still lit and in the red metal bin, to prevent it from being placed in the yellow plastic barrel. Staff member C, with gloved hands, reached into the red metal bin and grabbed the pile of recent cigarette butts and gloves to look for the burning cigarette. Staff member C stated she was not going to put the red metal bin ashes into the yellow plastic barrel because when she went to get it, she noticed someone had placed dried leaves into the barrel, and they were not supposed to be there.During an observation and interview on 8/25/26 at 10:29 a.m., staff member C was touching multiple drawers with the same gloved hands and passing out cigarettes to three different residents. Staff member C did not change gloves between residents or their respective cigarette boxes, did not complete the appropriate hand hygiene, and did not change gloves when taking off a dirty apron when giving a new cigarette to another resident. Staff member C stated she was never taught infection control practices regarding smoking and stated she did not have any clinical background or experience in infection control. Staff member C stated the gloves were improperly placed in the red bin purely because she had no idea what to do with them. She stated she now had a black bucket on top of the smoking cart for the rubber gloves that had not been there this morning. She also showed the surveyor the gloves in the red bin and stated those should not be there.Review of the facility policy titled Smoking and Tobacco/Nicotine Policy, dated 8/7/26, showed, The smoking area must remain clean, well maintained, and free from cigarette butts. All cigarette butts must be placed in the designated fire safe container. The policy did not have information for infection control practices or safe disposal of the smoking rubbish and supplies.

Based on observation, interview, and record review, the facility failed to ensure medications were administered safely without a medication error rate over 5% for 3 (#s 31, 33, and 66) of 5 sampled residents observed during medication pass. The medication error rate was 22.22%. Findings include:During an interview and observation on 8/25/26 at 7:43 a.m., the following medication errors were observed for resident #66:-The MAR showed: protein 30 ml. Staff member T stated that the MAR and the medications/supplements given should match exactly. Staff member T stated a traveler (contracted staff member) may not know what protein meant due to the ambiguity on the MAR. Staff member T prepared the supplement Active Critical Care liquid protein, which was not reflected on the MAR.-The MAR showed: MagOx 400 Oral Tablet (Magnesium Oxide (Mg Supplement) . Give 1 tablet . MagOx 400 Oral Tablet . The MAR failed to show a unit of measurement. The medication bottle showed 400 mg on the front of the bottle but showed 480 mg of Magnesium Oxide was contained in the medication bottle, which was shown on the back of the bottle.-The MAR showed: Torsemide Oral Tablet 10 mg . Give 4 tablet . The medication card (back) showed: take 1 1/2 tabs by mouth once daily, and that each tab was 20 mg. The medication card (front) showed the instructions written in Sharpie: Torsemide Tab 20 mg 2 tabs.-The MAR showed: Symbicort inhalation . 1 inhalation .Staff member T handed resident #66 the inhaler with no instructions on the amount of inhalations. Resident #66 inhaled with the inhaler once, gave the inhaler back to staff member T. Staff member T then handed the inhaler back to resident #66 a second time who then self-administered two inhalations from the inhaler. Staff member T stated in frustration, He always does this (takes too many inhalations). Staff member T stated resident #66 should have taken two inhalations per the physician's order, and stated she should probably notify the provider that resident #66 consistently takes too many inhalations.Review of resident #66's physician order, dated 6/9/26, showed: Symbicort . 1 inhalation .During an interview and observation on 8/25/26 at 8:44 a.m., staff member G prepared the medications for resident #33. Staff member G squeezed 15 mls of Voltaren gel into a medication cup for resident #33. The medication was not measured by the dosage card. Also, resident #33 had one medication, Aspirin/dipyridamole 25-200 mg, which showed ER (extended release) on the MAR, but failed to show this on the medication card. Staff member G stated matching MARs and medications would make it (her job) easier.During an observation and interview on 8/25/26 at 9:00 a.m., staff member G prepared the medication heparin for resident #31. Staff member G was going to administer 5 ml (dose 50u/5ml) of the medication but was stopped by the surveyor. When asked how staff member G knew the dosage and the amount to administer, staff member G stated they had been giving the whole syringe (5 mls) the entire time during their contract thus far. Refer to more details on the high-risk medication administration in F760.During an interview on 8/25/26 at 9:31 a.m., staff member V stated Voltaren gel needed to be measured; otherwise, there was no way to know if a resident got enough of the medication. Staff member V also stated that heparin was a high-risk medication and stated that following the physician's order was important, as it was within the scope of practice of a nurse.Review of a facility policy, titled Medication Administration, dated 6/1/26, showed: . 10. Ensure that the six rights of medication administration are followed .

Based on observation, interviews, and record reviews, the facility's licensed staff responsible for medication administration failed to display the necessary competencies and follow the rights of medication administration processes, which affected 2 (#s 31 and 40) of 33 supplemental and sampled residents. The medication error rate was high due to the lack of staff competencies. During one observation, which included the administration of a high-risk medication, Heparin, the medication was about to be administered to the resident incorrectly, and the staff member was stopped before the medication was given because of the significance of the error that was about to occur. Findings include:During an observation and interview on 8/25/26 at 9:00 a.m., staff member G prepared the medication heparin for resident #31. Staff member G was going to administer the medication but was stopped by this surveyor due to an error. When staff member G was shown the medication error. Staff member G stated she was embarrassed. She said she knew to administer medications as ordered by the physician but had been giving the entire syringe of Heparin (5 mL) to the resident throughout her whole contract period (three months).During an interview and observation on 8/25/26 at 9:22 a.m., staff member U had been preparing medications quickly for resident #40 and dropped a vitamin D pill. Staff member U then touched the medication with his bare hands and placed the pill back into the medication cup. Staff member U later administered the medication to resident #40. Staff member U stated he knew he should not be touching medications with his bare hands, as this was an infection control issue, and also stated he knew there was a risk the medication could affect staff member U through absorption on his skin.During an interview on 8/26/26 at 9:23 a.m. with staff members B and J, staff member J stated the facility had been working on medication administration as they knew there were some areas of improvement. Staff member J stated a PIP was created for this due to medication issues found on a mock survey a few months ago, and education was given to all of the staff. Staff member B stated medication administration audits were being completed but not being done consistently.A request was made on 8/26/26 at 3:01 p.m. for documentation showing staff were audited on the five rights of medication administration. Competency audits were completed the week of 7/26/26 and 8/5/26, with one competency on 8/18/26. Two competencies showed a concern for staff touching medications with bare hands (one of those was staff member G during a subcutaneous injection). Also, staff member G had medication administration competencies on 7/14/26 and 7/30/26, and a Medication Administration Competency Post-Test on 8/5/26, which showed the question: . 10. Which statement best describes safe medication administration? Staff member G answered correctly: . every medication pass requires following facility policy, using clinical judgment.Review of a facility document, dated 6/28/26, showed staff member G had at least a two-day orientation which included medication administration protocols.Review of a facility document, dated 12/19/25, showed the Skills Checklist from a [travel nursing company name] for staff member G. Staff member G was proficient in medication administration.Review of a facility training, Mock Survey Training, dated 7/21/26, showed: Quality Assurance Process Improvement: Performance Improvement Project . Medication safety ., and staff member G and staff member T were on this list for the education provided.Four of the five total staff members followed for medication observations had observed errors. Refer to F759 and F760 for more detail on the medication errors.

Based on observation, interview, and record review, the facility's licensed staff failed to ensure they were safely administering medications using the five rights of medication administration for 1 (#31) of 33 sampled and supplemental residents. This resulted in a nurse being stopped for the risk of administering a high-risk medication, and then the same nurse double-checking the medication, only to later give the incorrect concentration of the medication. This also resulted in a 22.22% medication error rate identified during the survey. Findings include:During an observation and interview on 8/25/26 at 9:00 a.m., staff member G prepared the medication heparin for resident #31. Staff member G was going to administer 5 ml (concentration 50 units/5 ml) of the medication but was stopped by this surveyor. When asked how staff member G knew the dosage and the amount to administer, staff member G stated they had been giving the whole syringe (5 mls) the entire time they had been contracted with the facility, and the contract would be up in September. Staff member G was shocked to see the physician's order specified for 3 ml of heparin and stated she was embarrassed. Staff member G reviewed the MAR with a new heparin flush in hand and then administered the heparin flush with a concentration of 50 units/5 ml (10 unit/ml). Refer to F880 for details on infection control concerns with staff member G. Review of resident #31's physician order showed: Heparin Lock Flush Solution 100 unit/ml, use 3 ml intravenously .During an interview on 8/25/26 at 12:10 p.m., NF3 stated heparin was a blood thinner and could be very harmful if not administered carefully. NF3 stated the concentration of the heparin lock (100 u/ml) was very low and stated the adverse effects would have been seen at 60 to 90 minutes. NF3 stated that if any concentration was given lower than this, it would have less of an effect.During an interview on 8/26/26 at 9:23 a.m. with staff members B, H, and J, staff member B stated heparin was a high-risk medication. Staff member B also stated if the nurse followed the five rights of medication administration, the error should not have happened. Staff member B stated she completed a resident assessment that showed no concerns for bleeding or negative outcomes due to the medication error. Staff member J stated the facility had been working on medication administration, as they knew there were some areas of improvement needed. Staff member J stated a PIP was created for this due to medication issues found on a mock survey, and education was given to all of the nursing staff. Staff member H stated it was addressed with staff member G, and steps were being taken to ensure this error did not happen again. Staff member H also stated that staff member G stated the entire syringe (5 ml) had only been given once before, and that contradicted what staff member G had told the surveyor. Review of the facility medication error investigation, dated 9/25/26 at 9:00 a.m., showed: . Immediate Action Taken: . Noted to be administered was 5ml of 50u/5ml - 250 units less than the prescribed dosage. Additional concern arising is if this nurse had previously administered medication to resident 9 times since start of order. Amounts calculated and discussed with Provider following initial investigation. Provider deemed inconsequential amount . and the additional amount would likely not have any adverse effect on the resident. Discussed results of initial lab testing - Provider did agree to additional testing of added PTT and H&H and performed additional assessment the day following the indicated situation. Injuries Report Post Incident: Privileged and Confidential - Not part of the Medical Record . The investigation also showed: Results of the investigation: Medication was not available in facility and had not been appropriately reordered as a patient-specific medication.During an interview on 8/26/26 at 1:52 p.m., staff member X stated the facility could run out of medications because the night shift nurses did not reorder the medications correctly. Staff member X stated this was a known problem for the facility. During an interview on 8/26/26 at 3:17 p.m., staff member A stated there were no concerns of medications being delivered or ordered to the facility on time that he was aware of. During an observation on 8/26/26 at 2:02 p.m., three syringes of the heparin medication were still located in the medication room where staff member G retrieved the heparin from initially.During an interview on 8/26/26 at 2:05 p.m., staff member H stated he was unaware of the incorrect concentration and that there were remaining heparin medication syringes that had the incorrect concentration. Staff member H was confused and stated, These came from the pharmacy that way. Staff member H stated the administrative staff would take these out of the medication room at this time and look into the concentration as to why it is different coming from the pharmacy.Review of a facility policy, titled Medication Administration, dated 6/1/26, showed: . 12. Compare medication source (bubble pack, vial, etc.) with MAR to verify resident name, medication name, form, dose, route, and time.

Based on observation, interview, and record review, the facility failed to ensure there was a clinical indication for a resident's long-term use of a Foley catheter; failed to follow up timely on a physician's PRN order for changing the catheter for over four months1 in an attempt to prevent infections or complications; failed to establish a voiding pattern; and failed to ensure a comprehensive individualized care plan was developed for the resident's long term catheter use, to include goals and interventions for the monitoring and care of the catheter, for 1 (#37) of 3 residents sampled for catheter use and care. Findings include:During an observation and interview on 3/10/26 at 9:51 a.m., resident #37 had a Foley catheter bag attached to the underside of his wheelchair. He stated he had the Foley for a while.Review of resident #37's urology notes, dated 2/10/25, showed the resident had BPH with obs/LUTS (obstructive/lower urinary tract symptoms). During this visit, the resident did not have a Foley catheter. Urodynamic testing showed that his post-void residual was 12 ml. Surgery for a bladder neck contracture was recommended should he go forth with orthopedic surgery to prevent post op retention. There were no further urology notes and no follow-up after his catheterization for acute urinary retention in the hospital in October 2025. Review of resident #37's medical record showed he was admitted to the facility on [DATE]. He did not have a Foley catheter present on admission. A review of resident #37's care plan, printed on 3/11/26, showed he had a Fall care plan, initiated on 9/19/25 and revised on 12/22/25, which included information showing the resident had a Foley catheter. There were no contributing factors related to the use of the catheter or diagnosis for the use, and there were no goals or interventions for the monitoring and or care of the catheter or risk of infections related to the catheter. The resident also had an Incontinence care plan that did not include any information related to the catheter use or risks associated with it. The interventions showed the facility would establish voiding patterns. The resident's ADL care plan showed he needed partial to moderate assistance with toileting, but there was no information related to catheter use. Review of resident #37's 5-day MDS assessment, with an ARD of 10/25/25, showed he had a new indwelling catheter.Review of resident #37's diagnosis list on 3/11/26 did not show a diagnosis supporting the use of a long-term Foley catheter.Review of resident #37's hospital history and physical, dated 2/19/26, showed, . reports a chronic indwelling Foley that was placed a number of months ago (September as reported), however has not been changed and perhaps in so many months . and UA s/p Foley exchange is positive for blood, nitrites, WBCs and 4+ bacteria, flu a PCR is positive, as is MRSA PCR. BCx have been obtained and are pending, empiric IV antibiotic therapy with vancomycin and Zosyn has been started; the hospitalist service has been consulted for admission. Under the Plan it showed the resident had purulent discharge noted at urethral meatus.A review of documentation of resident #37's Foley catheter changes and a void trial revealed there had not been a void trial or catheter change while he had resided at the facility, although the voiding pattern was identified on the care plan. Review of resident #37's historical and current physician orders, from his admission to the date of the survey, showed the following catheter-related directives: -Indwelling Urinary Catheter: change PRN if pulled out, leaking, or clogged as needed. The discontinuation date was 2/24/25.-Foley catheter 16Fr with 10 cc balloon. Change monthly and PRN for obstruction. The start date was 3/11/26.During an interview on 3/11/26 at 3:02 p.m., staff member B stated that foley catheters were changed on a PRN policy unless specified otherwise by the doctor.1 Staff member B stated that for a long-term catheter, they would usually see obstructive uropathy or neurogenic bladder as diagnoses. Staff member B stated, We have a much better process of reviewing hospital documentation since resident #37's last admission, and our coder reached out to the physician to see if obstructive uropathy was the appropriate diagnosis for him. Staff member B stated they would have to check on the policy to see when void trials were indicated. Staff member B stated they would check for urology notes to support resident #37's newly documented diagnosis of obstructive uropathy. A request was made for resident #37's catheter change documentation, and a document was received that showed, No attempt has been made to remove [Resident Name] catheter while in the facility. Review of the facility policy, Post Void Protocol, no implementation date, 2025 The Compliance Store, showed: To safely assess a resident's ability to void spontaneously after indwelling urinary catheter removal . and support the highest practicable level of continence per CMS requirements. Scope applies to all residents in the facility who have had an indwelling urinary catheter removed, particularly those with recent short-term catheterization (e.g. post hospitalization, acute retention, or transient issues) . Indications for a voiding trial . resident was previously continent or voiding independently .Reference: 1SUNA ( Society of Urologic Nurses and Association) Clinical Practice Procedure, Insertion of an Indwelling Urethral Catheter in the Adult Male. Urologic Nursing March-April 2021 Volume 41, Number 2; The optimal interval for changing IUCs is not well defined. According to the Centers for Disease Control and Prevention's Guideline for Prevention of Catheter-Associated Urinary Tract Infections, changing an IUC should be based on clinical indications, such as infection, obstruction, or when the closed system is compromised. However, clinical practice has been to change/replace chronic IUCs every four weeks to minimize stone formation and biofilm development.

Based on observation, interview and record review, the facility failed to ensure expired medications and supplies were removed from active stock for one medication room, one medication cart, and two central supply rooms. This deficient practice had the potential to affect all residents receiving medications and requiring supplies for care. Findings include:During an observation and interview on 3/10/26 at 11:34 a.m., with staff member B, the following items were found:- In the medication room on 200-hall:Prevnar 20 x 37 doses expired [DATE]% dextrose 1000mL IV bag x 2 expired 2/2026- In the CNA Back supply room:19 cases of sterile gloves on floor15 cases of cleaning cloths on floor4 cases of Jevity 1.5 on floor3 cases of urinals on the floor6 cases of chucks on the floortrash/debris on floor- Nurse's back supply room:9 - 22Fr catheters expired 1/15/262 -14Fr catheters expired 6/28/251 -20Fr catheter expired 3/4/251 -16Fr catheter expired 6/22/2538 red rubber catheters expired 5/20/252 suction swab kits expired 10/2023- Medication cart on 400-hall:Blood sugar control Assure dose expired 2/28/26Staff member B stated the medication and supply rooms were checked monthly. Staff member B stated she did not know how the expired items were missed during the monthly checks. Staff member B stated the facility was in the middle of changing the functionality of the medication and supply rooms, moving things, and suspected this was the cause of the items being missed.Review of the facility policy, Storage of Medication requiring Refrigeration, no date, reflected:- . c. Remove any expired medications from active stock and discard medication according to facility policy.Review of the facility policy, Medication Storage, no date, reflected:- . 8. Unused Medications: The pharmacy and all medication rooms are routinely inspected by the consultant pharmacist for discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing labels. These medications are destroyed in accordance with our Destruction of Unused Drugs Policy.

Based on interview and record review, the facility failed to ensure the discharge planning process addressed goals, needs and referrals necessary to support a resident's request for discharge to another location closer to family for 1 (#81) of 25 sampled residents, and this was upsetting to the resident as it was an ongoing issue over the last year, although the resident had requested assistance with looking into other facilities multiple times. Findings include:During an interview on 3/10/26 at 8:45 a.m., resident #81 reported he was from North Dakota and desired to be discharged back to North Dakota because his family lived there and he had no support system in Montana.During an interview on 3/11/26 at 1:51 p.m., NF8 stated it had been resident #81's goal to return to North Dakota. NF8 stated, The facility kept telling us they were working on it. NF8 reported he had visited his brother on his birthday the previous year, and he had spoken with [Staff member A] about resident #81's desire to discharge to North Dakota. NF8 further stated, We would really love to have him back in North Dakota.During an interview on 3/11/26 at 2:12 p.m., staff member E stated referrals related to resident #81's request for placement in North Dakota were sent earlier in the day after the State Survey Agency asked about the discharge planning efforts. Staff member E reported she did not know what actions, if any, had been taken previously to address the resident's request to discharge to North Dakota.During an interview on 3/11/26 at 3:29 p.m., resident #81 stated he requested the facility to investigate placement in North Dakota since he was admitted . Resident #81 stated the staff reported they are looking into discharge options, and it's been brought up at every quarterly meeting, but he had not heard any updates.Review of resident #81's comprehensive care plan with an admission date of 7/24/24 showed,Focus: discharge: [Resident #81] would like to discharge to another LTC closer to family in North Dakota, however it has been discussed that this is not feasible at this time. Date Initiated: 5/6/24 Revision on 10/28/24Goals: [Resident #81] will learn to cope with his new home environment through the review date. [Resident #81] will communicate an understanding of the discharge plan through the review date.Revision on: 3/3/26Interventions: Continue to check in with [Resident #81] on a potential return to North Dakota and his desire to do so. Date Initiated: 12/2/25Evaluate [Resident #81's] desire to return to the community. Date Initiated: 10/29/24 Help [Resident #81] decorate his room to remind him of home. Encourage [Resident #81] to hang up pictures of family. Date Initiated: 10/29/24The care plan interventions focused on assisting the resident with adjustment to the facility rather than discharge planning actions such as identifying potential facilities, coordinating with out of state providers, or initiating placement referrals.Review of resident #81's Occupational Therapy Evaluation and Plan of Treatment for Certification the Period 11/25/25 - 1/19/26 showed, .Patient Referral and History .Transition/DC: Transition/Discharge Plan = Patient to reside in this LTC facility. (pt states he would like to go home to N. (North) Dakota but is aware that he doesn't have anywhere to live). [sic]Despite the resident expressing a desire to discharge closer to family in North Dakota, the facility failed to implement and reassess discharge planning interventions to pursue potential placement options.

Based on observation, interview, and record review, the facility failed to develop a comprehensive, person-centered care plan that included enhanced barrier precautions for a resident with an indwelling urinary catheter for 1 (#81); and failed to include PTSD triggers and interventions on a resident's comprehensive care plan for 2 (#s 53 and 57) of 25 sampled residents. The deficient practice increased the risk for transmission of multidrug-resistant organisms for resident #81 and made it difficult for staff to assist in managing the residents' environment and identify what residents suffered from PTSD and their triggers for residents #53 and #57. Findings include: 1. During an observation on 3/10/26 at 12:10 p.m., resident #81 was observed lying in bed in his room with an indwelling urinary catheter in place. Review of resident #81's comprehensive care plan with an admission date of 7/24/24 showed: Focus: CATHETER: [Resident #81] has Indwelling Catheter r/t Neurogenic bladder and this was initiated: 12/9/24. The Goal showed, [Resident #81] will show no s/sx of Urinary infection through review date, which was initiated 12/9/24. Further review of the care plan showed it did not include enhanced barrier precautions as an intervention to address infection prevention associated with the resident's indwelling urinary catheter. During an interview on 3/12/26 at 9:22 a.m., staff member B stated enhanced barrier precautions should be reflected on the individual care plans for residents currently on enhanced barrier precautions. Review of the facility's policy titled, Comprehensive Care Plan, not dated, showed: Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standard of quality. 3. The Comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. [sic] 2. During an interview on 3/10/26 at 8:41 a.m., resident #57 stated, I was started on Prozac for my anxiety, but no one from the facility has talked to me about my diagnosis of PTSD. I would say my anxiety is part of my PTSD, especially when I feel like I can't move due to being paralyzed three years ago. During an interview on 3/10/26 at 9:06 a.m., resident #53 stated, No one ever listens to the fact that I have severe PTSD, I'm claustrophobic, and it gives me high anxiety. Resident #53 stated he would go to the woods to manage his anxiety when he lived on his own. Resident #53 stated that staff had never talked to him about his PTSD and any associated triggers, such as confinement. During an interview on 3/11/26 at 1:36 p.m., staff member E stated, We [facility staff] care plan a diagnosis of PTSD (for the resident with it) and any identified triggers associated with it. It's all based on getting to know the resident. I plan on doing a deep dive into the care plans. I noticed they aren't very comprehensive, and that is due to the previous staff. During an interview on 3/11/26 at 2:54 p.m., staff member N stated she was only aware of two people who had PTSD. Staff member N stated this was resident #53 and another resident who had a military history. Staff member N stated she did not know resident #57 had a history of PTSD. Staff member N stated she would look in the Kardex in Point Click Care (electronic health record system) to see if someone had PTSD and what their triggers were. Staff member N stated she knew resident #53's triggers included any surprise moments, such as knocking on the door loudly, or quietly approaching the resident. Staff member N stated she did not know resident #53 was claustrophobic, but thought that might be the reason he was moved to a private room. Resident #53's comprehensive care plan, with a revision date of 12/12/25, failed to show identified triggers associated with behaviors or interventions specific to assisting staff in mitigating or preventing behaviors, anxiety, or stress associated with his diagnosis of PTSD. Resident #57's comprehensive care plan, with a revision date of 3/9/26, failed to show identified triggers associated with behaviors and interventions specific to assisting staff in mitigating the behaviors associated with her diagnosis of PTSD. Review of a facility document titled Trauma Informed Care, undated, showed: Policy: . and address the needs of trauma survivors by minimizing triggers and/or re-traumatization.4. The facility will collaborate with resident trauma survivors, and as appropriate, the resident's family, friends, the primary care physician, and any other health care professionals (such as psychologists and mental health professionals) to develop and implement individualized care plan interventions.6. The facility will identify triggers which may re-traumatize residents with a history of trauma. Trigger-specific interventions will identify ways to decrease the resident's exposure to triggers which re-traumatize the resident, as well as identify ways to mitigate or decrease the effect of the trigger on the resident and will be added to the residents care plan.7. Trauma-specific care plan interventions will recognize the interrelation between trauma and symptoms of trauma such as. depression, and anxiety. These interventions will also recognize the survivor's need to be respected, informed, connected, and hopeful regarding their own recovery.8. The facility will evaluate whether the interventions have been able to mitigate (or reduce) the impact of identified triggers on the resident that may cause re-traumatization. [sic]

Based on observation, interview, and record review, the facility failed to update care plan interventions for 2 (#s 4 & 37) residents with new foley catheters; and failed to ensure a resident's family members were involved in the care planning process for 1 (#81) of 25 sampled residents. This failure limited the resident's representative involvement in resident #81's care and treatment decisions. Findings include:1. During an observation and interview on 3/11/26 at 3:07 p.m., resident #4 pointed to her catheter drainage bag hanging from the side of her bed and stated she had a catheter put in after her most recent surgery. Review of resident #4's urology note, dated 2/18/26, showed she was seen for acute urinary retention post hospitalization. Review of resident #4's care plan, revision date 4/30/25, showed, Urinary incontinence: [Resident #4] has urge/stress bladder incontinence . Interventions included ensuring the resident had an unobstructed path to the bathroom and an established voiding pattern. There were no care plan updates acknowledging resident #4's new urinary catheter. During an interview on 3/12/26 at 10:00 a.m., staff member B stated there had been a new division of workload, implemented not long ago, where staff would get an assigned hallway, and for those residents on the halls, they would address the resident care plans and updates. 2. During an observation and interview on 3/10/26 at 9:51 a.m., resident #37 had a Foley catheter bag attached to the underside of his wheelchair. He stated he had the Foley for a while. Review of resident #37's 5-day MDS, with an ARD of 10/25/25, showed he had an indwelling catheter. Review of resident #37's historical and current care plans, dated October 2025 through March 2026, failed to show the resident had a urinary catheter or that urinary catheter interventions were in place, until 3/3/26, which was approximately five months after the MDS showed the resident had a catheter. 3. During an interview on 3/11/26 at 1:06 p.m., NF3 stated the first time the facility reached out to him directly for anything was for a care plan meeting for his brother scheduled on 2/26/26. NF3 stated the facility was going to call him for the meeting. NF3 stated that he and his brother waited for the call, but the facility never called. During an interview on 3/11/26 at 2:12 p.m., staff member E stated she called and invited family to attend care conferences by phone. When asked why resident #81's family had not been involved in the care planning process, she reported that family invitations were based on the resident's cognitive level, and stated that resident #81 did not want his family involved. During an interview on 3/11/26 at 3:29 p.m., resident #81 stated he wanted his family involved in his care. Resident #81 said staff had not asked him if he wanted family to be involved, and resident #81 assumed his family was involved. Review of resident #81's electronic health record showed he was admitted to the facility on [DATE]. Review of resident #81's Comprehensive MDS, with an assessment reference date of 2/13/26, showed the resident had a Brief Interview Mental Status (BIMS) score of 15, cognitively intact. Review of resident #81's social service progress note, dated 2/3/26 at 3:28 p.m., showed Resident and family was notified of care conference of 2/26/26 at 2 p.m. [sic] Review of resident #81's care conference summary, dated 2/26/26, showed the meeting date and time were 2/26/26 at 1:00 p.m. There were no family members listed as participants in the meeting. Review of the facility's policy titled, Comprehensive Care Plans, not dated, showed, .Policy Explanation and Compliance Guidelines: . 4. The comprehensive care plan will be prepared by an interdisciplinary team, that includes, but is not limited to: . e. The resident and the resident's representative, to the extent practicable. f. Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident. Examples include, but are not limited to: . v. Family members, surrogate, or others desired by the resident.

Based on observation, interview, and record review, the facility failed to identify and address the needs of residents with PTSD, to include their psychosocial well being related to past traumatic events, for residents' who displayed and or voiced concerns related to trauma, and or who had a diagnosis of PTSD, in an attempt to assist the residents' and staff in being able to meet the needs of the residents (refer to F656 Comprehensive Care Plan), for 3 (#s 53, 57, and 102) of 25 sampled residents. Resident #53 voiced being upset that no one listened to him about his trauma. Resident #57 stated his behavior was stemming from past trauma related to a significant injury, and resident #102 was often angry. Findings include: 1. During an interview on 3/10/26 at 8:41 a.m., resident #57 stated, No one from the facility has spoken to me about my PTSD or any triggers I have. I have had trauma in my life and became paralyzed three years ago. I would say that my screaming behavior was in response to my anxiety of past trauma and not being able to do things for myself since I'm paralyzed. I was just put on more medicine. During an observation and interview on 3/10/26 at 9:06 a.m., resident #53 was sitting on his bed and appeared upset and short of breath. Resident #53 stated, I have COPD, and it is hard to breathe. I have issues, that's why I'm here. No one listens to the fact that I have severe PTSD. I'm claustrophobic, and it gives me high anxiety. Resident #53 said when living alone, he would handle his symptoms by going into the woods. Resident #53 also mentioned he had other triggers the staff had addressed, such as being startled. Resident #53's room was noted to be clean and organized with bare walls and not homelike. During an interview on 3/10/26 at 9:11 a.m., staff member O stated resident #53 was a tough case. Staff member O stated, We try to accommodate his needs, but he gets angry a lot. During an interview on 3/11/26 at 1:36 p.m., staff member E stated the process for Trauma Informed Care is to evaluate the resident, complete a PASARR screening, trauma-informed assessment, care plan for PTSD, and We now have the option for psych visits. Staff member E stated if a resident had a diagnosis of PTSD, she would talk to the resident and get to know them. Staff member E stated, Our [the facility] trauma evaluations suck, that's why it's important to get to know the residents. Staff member E stated PTSD triggers should be identified and care planned. Staff member E stated to meet the resident's needs, she would go and sit with them, and it would depend on the resident and what would help them. Staff member E stated she would assist residents with arranging counseling services if they chose to utilize them. Staff member E stated, PTSD interventions are monitored by behavior charting, and I watch the nurses charting; I also check in with our more problematic residents daily. If I identify a change in the resident's behaviors, I would report that to the Director of Nursing. The only training I've had at the facility is the normal mandated in-service training. Staff member E stated having no additional behavior training provided besides their own formal education, and staff member E was not aware resident #53 was claustrophobic, so that was not addressed for the resident. Staff member E stated that resident #53 will utilize psych services when he allows it, and staff member E would go and talk to resident #57 but did not identify any triggers for her PTSD. She stated #57's major issues were that she thought she was magic. During an interview on 3/11/26 at 2:54 p.m., staff member N stated she had behavioral health training during staff in-services. Staff member N stated she only knew of two people with PTSD on the 300 hall. Staff member N stated resident #53 and another resident. Staff member N stated she did not know resident #57 had PTSD. Staff member N stated she would look in the Kardex in Point Click Care for a resident's triggers if they have PTSD. Staff member N stated she knew resident #53 did not like to be startled but did not know he was claustrophobic. Staff member N stated, I did not know resident #53 was claustrophobic, but that would make sense as to why he was moved into a room by himself. Review of resident #53's Trauma Informed Care Evaluation, with a date of 12/17/25, failed to show any triggers for resident #53's PTSD. Review of resident #57's Trauma Informed Care Evaluation, with a date of 2/23/26, failed to show any triggers for resident #57's PTSD. Review of social service progress notes failed to show identification of any triggers for residents #53 and #57. A request was made on 3/12/26 for Psychology progress notes for resident #53, and the facility stated they did not have any due to him declining services. 2. During an observation and interview on 3/9/26 at 3:28 p.m., resident #102 was in his room with NF4 and was yelling loudly. Multiple staff members entered the room and attempted to calm resident #102 but were unable to understand what he wanted or was saying. NF4 stated she thought he was angry because he wanted to go home. NF4 stated she attempted to explain to him that he could not safely go home yet and he became angrier. NF4 stated resident #102 needed speech therapy because he could not be understood since his stroke. NF4 stated his wife had dropped him off at the emergency room and left, not returning since. NF4 stated resident #102 was abandoned, and he was angry and hurt. NF4 stated that resident #102 did not understand why he could not go home. NF4 stated she was working with staff member E to figure out what to do next. During an interview on 3/11/26 at 3:20 p.m., staff member E stated resident #102 had a Trauma score of 30 and a PHQ9 (tool used to assess presence and severity of depression) score of 24 (very high), and she was not sure what to do. Staff member E stated she was going to notify the Director of Nursing and figure out a plan but had not notified her yet. Staff member E stated the Director of Nursing usually notifies the physician. Review of resident #102's Trauma-Informed Care Evaluation, dated 3/6/26, reflected a score of 30. The instructions showed, .A positive screen is a total score of >/- 14. Notify the resident's primary care physician and interested party of a positive screen. Review of resident #102's PHQ9 assessment, dated 3/6/26, reflected a score of 24. The PHQ9 Total Severity Score scale for a score of 20-27 was equal to severe depression. Review of resident #102's baseline care plan did not reflect a trauma care plan or trauma interventions to prevent re-traumatization. Review of resident #102's Comprehensive care plan, dated 3/11/26, did not reflect a trauma care plan or trauma interventions to prevent re-traumatization. Review of a facility document titled Trauma Informed Care, undated, showed: It is the policy of this facility to provide care and services which, in addition to meeting professional standards, are delivered using approaches which are culturally-competent, account for experiences and preferences, and address the needs of trauma survivors by minimizing triggers and/or re-traumatization.2. The facility will use a multi-pronged approach to identifying a resident's history of trauma, as well as his or her cultural preferences. This will include asking the resident about triggers that may be stressors or may prompt recall of a previous traumatic event, as well as screening and assessment tools such as the Resident Assessment Instrument (RAI), admission Assessment, the history and physical, the social history/assessment, and others. 6. The facility will identify triggers which may re-traumatize residents with a history of trauma. Trigger-specific interventions will identify ways to mitigate or decrease the effect of the trigger on the resident and will be added to the resident's care plan. While most triggers are highly individualized, some common triggers may include, but are not limited to: a. Experiencing a lack of privacy or confinement in a crowded or small space. 7. [NAME]-specific care plan interventions will recognize the interrelation between trauma and symptoms of trauma such as substance abuse, eating disorders, depression, and anxiety. 8. The facility will evaluate whether the interventions have been able to mitigate (or reduce) the impact of identified triggers on the resident that may cause re-traumatization.10. In a situation where a trauma survivor is reluctant to share their history, the facility will still try to identify triggers which may re-traumatize the resident and develop care plan interventions which minimize or eliminate the effect of the trigger on the resident. [sic]

Based on interview and record review, the facility failed to ensure a physician signature was obtained for a POLST (Montana Provider Orders for Life-Sustaining Treatment) directive prior to activating the order on the resident's EHR for 1 (#102) of 25 sampled residents. This deficient practice had the potential to result in a POLST being implemented during an emergency without a physician's order. Findings include: Review of resident #102's EHR screen reflected that resident #102 had a code status of Do Not Resuscitate: Comfort-focused. Review of resident #102's POLST, dated 3/5/26, reflected that staff member F had prepared a POLST for Do Not Resuscitate: Comfort-focused Treatment but had not been signed by the physician. The section labeled Physician / APRN / PA Signature showed that the section was mandatory. During an interview on 3/10/26 at 4:07 p.m., staff member B stated she was not aware that a POLST should be signed by the physician. Staff member B stated that the state she practiced in prior did not require a physician's signature to be valid. Review of the facility policy, Residents' Rights Regarding Treatment and Advance Directives, no date, did not reflect instructions for completing the POLST form with mandatory sections.

Based on interview and record review, the facility failed to ensure a resident who was being discharged from Part A Medicare services and continued living in the facility was fully informed of which services would and would not be covered for 1 (#86) of 3 residents sampled for beneficiary notices. Findings include: Review of resident #86's medical record showed her Medicare A services ended on 1/20/26. Resident #86 received and signed CMS form 10123 but did not receive CMS form 10055. Resident #86 is a current resident at the facility. During an interview on 3/12/26 at 9:05 a.m., staff member L stated resident #86 had not been given the form (CMS 10123 ABN) because her initial plan had been to go home. After some discussion with family it was decided that she would be staying in the facility long term. Staff member L stated, We had the conversation yesterday should we have given her the ABN after her discharge plan changed and decided yes. Going forward that is our process.

Based on interview and record review, the facility failed to ensure the staff and residents were aware of the process for filling out and filing grievance forms, failed to promptly investigate grievances, and failed to follow up with resident representative grievances for 2 (#s 40 and 53) of 25 sampled residents. This practice had the potential to affect anyone wanting to file a grievance or who had filed a grievance. Findings include:During an interview on 3/10/26 at 9:06 a.m., resident #53 stated he was missing multiple items of clothing, and he had spoken to facility staff about it. Resident #53 stated the facility never provided him with a form to fill out, and the facility did not offer to replace the missing clothes. Resident #53 stated, The laundry department is terrible, and I never get my clothes back after they take them to wash them.During an interview on 3/11/26 at 11:27 a.m., NF6 stated he had called staff member E about six months prior and spoke to her about some missing items of his dad's. NF6 stated he had been trying to coordinate a meeting with staff member E for quite some time and was not getting a response. NF6 stated he wanted to meet with staff member E to assist in creating a new inventory list for his dad so they could keep better track of his belongings. NF6 stated his dad was missing a gold cross necklace, a winter coat, and a couple of other items. NF6 stated he was sad these items were missing, and he now felt like he couldn't leave personal belongings at the facility. NF6 stated, It bothers me that I can't leave things there [the facility] to make him feel at home. During an interview on 3/11/26 at 1:36 p.m., staff member E stated she would initiate the grievance process when a family member verbalized a concern. Staff member E stated she does follow up with residents after they have filed a grievance, but she could be better at following up with families on the results of the grievances. Staff member E stated she did not fill out a grievance form for resident #53 when he told her of his concerns about missing clothing. Staff member E stated she did speak with laundry on his behalf, and they were trying to find his missing clothing. Staff member E stated the process for residents missing items would be to fill out a grievance form, find out details of the missing item, relay information to specific departments, contact the family, and start the process to replace or reimburse the resident/resident representative for the item. During an interview on 3/12/26 at 9:05 a.m., staff member K stated he would tell the nurse right away if a resident reported they were missing something, and then he would call the administrator. Staff member K could not identify who the grievance official was. Staff member K stated if a resident was missing something, staff should fill out a lost and found form, which is kept at the nursing station. Review of the facility's grievance logs for the past 12 months showed residents #40 and #53 were not listed on the grievance logs for their missing items. Review of a facility document titled [Facility Name] Grievance Form with a date of 1/26/26, showed resident #40's representative filed a concern about missing items with the facility. The form was not signed by the grievance official, and the section for resolution showed the resolved line was blank, so it was incomplete.Review of a facility document titled Resident and Family Grievances, undated, showed: Policy: It is the policy of this facility to support each resident's and family member's right to voice grievances without discrimination, reprisal, or fear of discrimination or reprisal.1. Social Services Director has been designated as the Grievance Official.2. The Grievance Official is responsible for overseeing the grievance process; receiving and tracking grievances through to their conclusion; leading any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances; issuing written grievance decisions to the resident; and coordinating with state and federal agencies as necessary in light of specific allegations.8. Grievances may be voiced in the following forums:a. Verbal complaint to a staff member or Grievance Official.b. Written complaint to a staff member or Grievance Official.c. Written complaint to an outside party.d. Verbal complaint during resident or family council meetings. 9. A grievance may be filed anonymously. 10. Procedure: .d. ii. Prompt efforts include acknowledgment of complaint/grievances and actively working toward a resolution of that complaint/grievance.e. The Grievance Official, or designee, will keep the resident appropriately apprised of progress towards resolution of the grievances. i. Missing/Lost items will be reported as a grievance. [sic]

Based on interview and record review, the facility failed to ensure documentation of the need for an antipsychotic was reflected in the medical record and to complete attempted gradual dose reductions for a resident receiving an antipsychotic for a diagnosis of dementia for 1 (#60) of 25 sampled residents. This deficient practice had the potential to result in resident #60 remaining on an antipsychotic unnecessarily. Findings include: Review of resident #60's physician order for quetiapine fumarate (antipsychotic), dated 2/19/26, reflected resident #60 was receiving quetiapine 25 mg at bedtime, related to dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, mood disturbance, and anxiety. Review of resident #60's History and Physical, dated 1/20/26, reflected that resident #60 had been started on quetiapine during a hospital admission from 1/7/26-1/13/26, prior to his admission to the facility on 1/26/26. Review of resident #60's Informed Consent for Psychoactive Medications, dated 2/18/26, reflected resident #60's representative had given verbal consent for quetiapine at bedtime on 2/23/26. During an interview on 3/11/26 at 11:45 a.m., staff member B stated resident #60 should not be on an antipsychotic for a dementia diagnosis. Staff member B stated the facility did not have any supporting documentation for resident #60's need for an antipsychotic, any gradual dose reductions, and the monthly medication review, dated 2/22/26, did not include the concern with the quetiapine. Review of the facility's policy, Use of Psychotropic Medications, no date, reflected:- .For psychotropic medications, without documentation in the record explaining that the practitioner has determined that other treatments have been deemed clinically contraindicated, the indication for use is inadequate. - . 12. Residents who use psychotropic drugs shall receive gradual dose reductions, unless clinically contraindicated, in an effort to discontinue these drugs.

Based on interview and record review, the facility failed to ensure the Ombudsman was notified of a resident discharge for a resident who left against medical advice for 1 (#98) of 25 sampled residents. This failure increased the risk that the resident would not have access to independent advocacy and oversight during the discharge process. Findings include:During an interview on 3/10/26 at 2:41 p.m., resident #98 reported it was his choice to leave the facility against medical advice. Resident #98 stated it was cold outside, he was eating poorly and he feared his safety when he discharged .During an interview on 3/10/26 at 3:13 p.m., NF1 stated she was not notified of resident #98's discharge from the facility.During an interview on 3/11/26 at 8:26 a.m., staff member A stated resident #98 left the facility against medical advice. Staff member A stated, The Ombudsman was not notified in this case.Review of resident #98's progress notes showed the following nursing notes:-12/9/25 at 7:00 p.m., Note text: Resident left facility previous shift did not sign out and has not returned. ADON (assistant director of nursing) and Administrator notified. Awaiting resident return at this time. Admin attempting to contact resident a this time [sic] -12/10/25 at 12:00 a.m., Note text: Resident did not return to facility. [Staff member A] states resident is AAO x4 and is independent with decision making. [Staff member A] state resident is now considered AMA.[sic]Review of a facility's document titled, Discharge Against Medical Advice Form, dated 12/10/25 at 12:00 a.m., showed the resident was advised to contact a personal representative or emergency services for further medical care and acknowledged leaving the facility against medical advice. The document stated the resident assumed the risks and consequences associated with leaving the facility. The form also suggested the resident was informed that if he did not return by midnight, the departure would be considered an AMA discharge. The resident signature line on the form was left blank.A request was made for Ombudsman notification for resident #98's discharge. The facility reported they were unable to find a record of Ombudsman notification for resident #98.Review of the facility's policy titled, Transfer and Discharge (including AMA), not dated, showed, . 5. The facility will maintain evidence that the notice was sent to the Ombudsman.

Based on observations, interviews, and record review, the facility failed to complete a baseline care plan within 48 hours for 1 (#102) of 25 sampled residents. This deficient practice resulted in staff difficulty communicating with resident #102, causing frustration and anger for resident #102. Findings include:During an observation and interview on 3/9/26 at 3:28 p.m., resident #102 was in his room with NF4, and he was yelling loudly. Multiple staff members entered the room and attempted to calm resident #102 but were unable to understand what he wanted or was saying. NF4 stated she thought he was angry because he wanted to go home. NF4 stated she attempted to explain to him that he could not safely go home yet, and he became angrier. NF4 stated resident #102 needed speech therapy because he could not be understood since his stroke. During an interview and review of resident #102's CNA Kiosk information on 3/11/26 at 10:25 a.m., staff member H showed this surveyor that resident #102 did not have a baseline care plan for communication needs available. Staff member H stated that the use of the kiosk and the pocket sheet (paper sheets CNAs use showing each resident's needs) was how the CNAs knew what care the resident needed. Staff member H stated he tried to have resident #102 point to things when communicating, but it was often difficult to figure out what he needed when he was angry or frustrated.During an interview on 3/11/26 at 10:28 a.m., staff member J stated resident #102 was not interested in a writing board, so the facility was working on making a picture board for him to point to things he might want. Staff J stated that resident #102 was difficult to understand when he became frustrated and would get angry when the staff could not understand what he was saying. Staff member J stated the resident's inability to manage his anger was related to his brain cancer diagnosis.Review of resident #102's Nursing Note, dated 3/5/26, reflected resident #102 was admitted to the facility on [DATE] with confusion, verbal aggression, and speech aphagia (inability to swallow).Review of resident #102's Speech Therapy Evaluation and Plan of Care, dated 3/6/26, reflected that resident #102 had a communication level of 4, meaning unintelligible most of the time, even to known listeners.Review of the facility policy, Baseline Care Plan, with no date, reflected:1. The baseline care plan will:a. Be developed within 48 hours of a resident's admission.,2. The admitting nurse, or supervising nurse on duty, shall gather information from the admission physical assessment, hospital transfer information, physician orders, and discussion with the resident and resident representative, if applicable. Once gathered, initial goals shall be established that reflect the resident's stated goals and objectives. Interventions shall be initiated that address the resident's current needs, including any health and safety concerns.Any identified needs for supervision, behavioral interventions, and assistance with activities of daily living.

Based on observations, interviews, and record review, the facility failed to consistently implement fall prevention interventions for a resident with previous fall(s) and poor safety awareness for 1 (#77) of 25 sampled residents. This deficient practice placed resident #77 at risk of additional falls. Findings include: During an observation and interview on 3/9/26 at 2:43 p.m., resident #77 was in bed lying flat on his back with his call light clipped to the foot of the bed, resting. Resident #77 stated there were a couple of people who shouldn't work at the facility. He stated, They would leave you sitting in a pile of shit. Yesterday, they (CNAs) kept saying they would come back to change me from 10:00 a.m. in the morning until 8:00 p.m. at night and never changed me. They ignore call lights because you rang it too many times. I saw it happen to another resident across the hall, too. Resident #77 stated he did not know how to work the bed remote and could not reach his call light. Resident #77 stated he had a couple of falls since he had been in the facility but did not remember what he was trying to do when he fell. There was no floor mat observed in the resident's room related to fall safety. During an observation on 3/10/26 at 3:09 p.m., resident #77 was in bed resting. The call light was attached to the foot of the bed, out of reach for resident #77. There was no fall mat on the floor or observed in the room. The resident's bed was not in a low position but was at the height of the surveyor's hip. During an observation on 3/11/26 at 7:40 a.m., resident #77 was in bed sleeping. The call light was clipped to the mattress, at the foot of the bed, hanging between the mattress and the footboard. The call light was not within reach of resident #77. There was no floor mat observed or present in the resident's room.During an interview on 3/11/26 at 7:50 a.m., staff member F stated the call light for resident #77 should not be attached to the foot of the bed. Staff member F stated, I don't know why someone did that; that should never happen. Staff member F then moved the call light and clipped it to resident #77's shirt. Staff member F stated he was not aware of a fall mat being used for resident #77, for the floor, and had not seen one in the resident's room. During an observation on 3/11/26 at 11:28 a.m., resident #77's call light was attached to the end of the mattress again, at the foot of the bed, and resident #77 was in the shower.During an observation on 3/11/26 at 3:14 p.m., resident #77's call light was clipped at the foot of the bed. Resident #77 stated, I just pissed myself now, and can't reach my call button or the urinal. The resident's bed was at the height of the surveyor's hip, not in a low position.During an interview on 3/11/26 at 3:18 p.m., staff member A stated the call light should not be attached to the foot of the bed unless the resident is up in their chair and needed to be able to reach it from the chair. Staff member A stated that the call light needed to be within the resident's reach. Staff member A stated that a request was made for the floor mat to be placed in resident #77's room, which was for fall safety.Review of resident #77's Interdisciplinary Post Event Note, dated 2/12/26, reflected that resident #77 was found on the floor. The root cause was attributed to the resident's poor bed mobility, independent of staff assistance, confusion, and illness. An intervention put into place at the time of the event was to place the call light within reach. Additional interventions added included treatment of current illness, and an additional check by the nurse each night shift.Review of resident #77's Interdisciplinary Post Event Note, dated 2/13/26, reflected that resident #77 was found on the floor next to his bed. Interventions put into place included a larger bed, a floor mat next to his bed, and the bed to be placed in the lowest position.Review of resident #77's Interdisciplinary Post Event Note, dated 2/17/26, reflected that resident #77 was attempting to remove the blankets to cool off, and he became tangled in the blankets, falling on the floor. The fall interventions included placing the bed in a low position, having the fall mat in place, increased checks, and a fan was added to the room.Review of resident #77's fall care plan, initiated 2/16/26, reflected interventions including a call light within reach, prompt response to call the light, to place the bed in a low position, to have the fall mat at bedside, and a fan in his room. Review of the facility policy, Accidents and Supervision, no date, reflected:- 3. Implementation of Interventions-using specific interventions to try to reduce a resident's risk from hazards in the environment. The process includes:- . e. Ensuring interventions are put into action .- . 4. Monitoring and Modifications- . Ensuring that interventions are implemented correctly and consistently.

Based on interview and record review, the facility nursing staff failed to obtain weekly weights and failed to recognize a resident's severe weight loss for 1 (#3) of 4 sampled residents; and failed to ensure residents were monitored and tracked for maintenance of proper hydration status for 3 (#s 1, 3, and 4) of 4 sampled residents. This deficient practice contributed to resident #3's decline in weight and for the development of dehydration, requiring hospitalization for residents #1, 3, and 4. Findings include: 1. Review of resident #3's hospitalist history and physical, for the admission date of 10/3/25, showed: . [Resident #3] is an [AGE] year-old female with a history of CHF (Congestive Heart Failure), CAD (Coronary Artery Disease), CKD (Chronic Kidney Disease) stage III, HTN [Hypertension] and hypothyroidism currently residing at (Facility Name) brought in for decreased responsiveness found to have acute renal failure with severe hyperkalemia .hypotension, lactic acidosis and acute hypoxic respiratory failure. Suspect presentation is from significant volume depletion and infection, most likely bilateral lower lobe pneumonia plus or minus UTI [Urinary Tract Infection].During an interview on 10/21/25 at 3:25 p.m., staff member G said resident #3's fluid intake was monitored and documented and could be found in her medical record. Staff member G was unable to locate the fluid intake information in resident #3's medical record. Staff member G said he was not aware that resident #3 had an abscessed tooth on admission, and he was not concerned with her food or fluid intake. Staff member G did not remember any nausea with vomiting occurring prior to resident #3's hospital transfer. Staff member G said he was not aware resident #3 was taking a diuretic, as a medication aide passes medications in his assigned area.During an interview on 10/21/25 at 4:14 p.m., staff member J said resident #3 was at the facility for a short time before starting to have a medical decline. As resident #3 declined, staff member J was unable to complete weekly weights, as resident #3 had grown weaker, and it was difficult to get the resident out of bed. Staff member J said that when she was finally able to obtain a weight for resident #3, the resident had a 14-pound decline in weight. Resident #3 was not drinking or eating well. She was drinking the high-protein shakes that were ordered. Staff member J said meals and hydration intake were documented by CNA staff, and unfortunately, CNA staff often use NA [Not Applicable] when charting meals and hydration. Staff member J said she was not responsible for the daily monitoring of hydration status for residents; that was a nursing responsibility. Staff member J was responsible for making sure the nutrition was in place and available to meet each resident's needs. Record review of resident #3's Nutritional Services IDT Note, which was a late entry dated 9/25/25, showed resident #3 was admitted post-hospitalization with antibiotic therapy for a urinary tract infection and tooth/jaw infection. The notes showed resident #3 had poor dentition with a dental infection present. Resident #3 was having difficulty with chewing.Review of resident #3's medical record weight documentation showed:9/4/2025; 129.8 pounds9/8/2025; 125.6 pounds9/30/25; 115.8 pounds, a 10.4% weight loss. Resident #3's medical record showed no documentation for her weight for three weeks; and when the weight was taken, there was a severe weight loss of 14-pounds since admission to the facility. Review of resident #3's physician order summary showed an order dated 9/5/2025, which included, Obtain weekly weights; reweigh if >5# difference from previous week in the morning every Mon [Monday].Record review of resident #3's Nutritional Services IDT Note, dated 10/1/25, showed: . WTS: (9/30) 115.8# (9/8) 125.6# (9/4) 129.8#; and,Noted significant wt [weight] loss of -14# (10.8%) x 1mo [month] since admission. Resident has been refusing weekly weights often and therefore have not obtained a weight x 3 wk [weeks]. Resident has had an increase in nausea and loose stools and difficult to get OOB [out of bed] per CNAs. Reported decrease in appetite with intakes averaging 40-60% of meals. Noted dental infection but no plan for surgery as resident cannot afford to pay for out of pocket expenses. [sic]Record review of a physician order for resident #3, dated 9/4/25, showed: Monitor for signs and symptoms of diuretic use such as: Headache; Dizziness; Nausea; Loss of appetite; Upset stomach; Dehydration. Document (Y/N); and notify MD if symptoms persist.Record review of resident #3's Nursing-Skilled Services Note. showed assessments were documented daily from 9/4/25 through 9/16/25, 9/19/25 through 9/23/25, but there were no daily assessments after 9/23/25. 2. Review of resident #1's hospitalist history and physical notes, for the admission date of 1016/25, showed: .Resident #1 is a [AGE] year-old male with morbid obesity with BMI [body mass index] of 73, Type 2 diabetes mellitus, chronic pain who presents from (Facility Name) with altered mental status and associated hyponatremia, UTI, and acute kidney injury. Overall, suspect he has has [sic] a urinary tract infection and associated volume depletion resulting in hyponatremia and acute kidney injury. During an interview on 10/21/25 at 11:42 a.m., staff member F said resident #1 was confused at the change of shift report. Staff member F said when she went to administer his medication and do an evaluation, he was more than confused. Resident #1 was hallucinating and seeing flying cats. Staff member F contacted the physician to report the concerns. Staff member F said resident #1 had been hospitalized for sepsis in August 2025 and had been exhibiting similar symptoms. She said resident #1 was taking a diuretic, and she was not aware of any policies for monitoring the effects of the diuretic, other than monitoring for edema. Staff member F said the hydration status for the residents was not really tracked or monitored unless the resident was showing signs of dehydration. 3. Review of resident #4's Emergency Department Note, for the admission date of 8/07/25, showed: .(Resident #4) is a [AGE] year-old male with recent admission from 7/16 - 8/1 .he was staying at [Facility Name] since his discharge. He reportedly transferred from there to the orthopedic clinic for outpatient follow-up today. He was noted at the clinic to be somnolent altered and hypoxic and was thus transferred here to the ER [Emergency Room] for further evaluation. His wife and daughter .tell me that he has been gradually declining over the last week, but they have noted a big difference in the last few days. He has been more somnolent, confused and weak and his daughter noted some tremors yesterday which is something new for him. They notified staff at his facility of their concerns, and they were told that his symptoms were because of the pain medications that he is taking. [sic]Review of resident #4's Critical Care: H&P, for the admission date of 8/07/25, showed: .Overall clinical picture would suggest that the patient's shock is secondary to simple hypovolemia.Review of resident #4's baseline care plan, with a focus area of nutrition, initiation date 8/1/2025, showed: .(Resident #4) has nutritional problem or potential nutritional problem (SPECIFY) r/t.Provide, serve diet as ordered. Monitor intake and record q [every] meal.During an interview on 10/21/25 at 3:28 p.m., staff member H said the resident meals and hydration documentation were the responsibility of the CNA staff. When a CNA arrives for a shift and is assigned residents, the meals and hydration task will appear on the computer for CNA documentation. Staff member H said nursing staff were responsible for documentation of any nutritional shake intake information and for checking the documentation of the CNA staff. Staff member H said CNA staff were responsible for filling and checking on residents' drinks. The resident's water was changed to fresh water each shift, and the CNA checked on residents when rounding to offer snacks and drinks. Staff member H said she neither remembers any residents having mental status or hydration concerns within the last month, nor notifying nursing staff of any concerns related to hydration or mental status concerns. Staff member H said mental confusion was usually a sign of a UTI, and she would check the urine and report concerns to the nurse. During an interview on 10/22/25 at 8:48 a.m., staff member K said a resident's hydration status was monitored every shift and documented in the medical record. Staff member K said she would supply residents' drinks as needed or requested. Staff member K said during rounds or when providing care, she encouraged residents to drink. Staff member K would not usually report difficulty with a resident's intake unless she had serious concerns or noted a change in a resident's status. During an interview on 10/22/25 at 10:47 a.m., staff member O said that when doing the chart review for the requested surveyor documentation, it was noted that the intake and output for the residents were deleted from the charting system. Staff member O said, Monitoring was not required by the state, but we see now it is important and are in the process of reactivating it. Staff member O said only a few residents within the facility had hydration monitoring, and resident #3 was not one of the residents. During an interview on 10/22/25 at 11:28 a.m., staff member B said the registered dietitian had been removing the hydration tracking for each resident when she placed the order for documentation of a resident's intake. Staff member B stated the facility has not been documenting the fluid intake. Staff member B said, We now have identified hydration as a problem. We need to provide training for the staff on tracking hydration.Review of a facility policy, Hydration, with an implementation date of 7/1/2025, showed: Policy:The facility offers each resident sufficient fluid, including water and other liquids, consistent with resident needs and preferences to maintain proper hydration and health.Sufficient fluid means the amount of fluid needed to prevent dehydration . and maintain health. The amount needed is specific to each resident and fluctuates as the resident's condition fluctuates.1. The facility will utilize a systematic approach to optimize the resident's hydration status:a. Identifying and assessing each resident's hydration status and risk factorsb. Evaluating/analyzing the assessment informationc. Developing and consistently implementing pertinent approaches.2. Identification/assessment:a. Nursing staff shall assess hydration status upon admission and throughout the resident's stay in accordance with assessment protocols.

Based on interview and record review, the facility failed to ensure nursing staff were competent in assessing, monitoring, and recognizing clinical changes for a resident with an ongoing clinical decline for 1 (#3) of 4 sampled residents. This deficient practice resulted in the resident developing an altered mental status, dehydration, and acute renal failure which resulted in a hospitalization. Findings include: Review of resident #3's Emergency Department Note, dated 10/3/25, showed: .XXX[AGE] year-old female from a care facility presented to the ED [Emergency Department] with four days of recurrent vomiting, hypotension (systolic in the 60s-78 mmHg [millimeters of mercury]), and altered mental status. On arrival she was minimally responsive and found to be hypoxic . Final Diagnosis: Aspiration pneumonia, Severe hyperkalemia, Acute renal failure, Sepsis .Review of resident #3's hospitalist history and physical, for the admission date of 10/3/25, showed: . (Resident #3) is an [AGE] year-old . brought in for decreased responsiveness found to have acute renal failure with severe hyperkalemia .hypotension, lactic acidosis and acute hypoxic respiratory failure. Suspect presentation is from significant volume depletion and infection, most likely bilateral lower lobe pneumonia plus or minus UTI [Urinary Tract Infection].1. AssessmentsDuring an interview on 10/21/25 at 3:25 p.m., staff member G said he noticed resident #3 had started falling, had increased confusion, and weakness since her admission. Staff member G said that he had not documented the change of condition for resident #3 in the medical record because It was difficult to identify the reason for the increased falls. Staff member G said a daily skilled nursing assessment should have been completed and documented in the medical record, but there was not always enough time when one nurse was assigned 25 or more residents. Staff member G said, if a resident had a change of mental status, it would be addressed in the daily skilled assessment documentation. For a resident with an altered mental status, he would first check the resident's vital signs, and then check the urine for a UTI. If the vitals were within normal range, and the urine was clear, he would then check their lungs, glucose, and look at their medications for possible side effects. Staff member G was unable to find documentation in the medical record to identify when resident #3 started to have the medical decline, and stated resident #3's decline was not reflected in the medical record. Staff member G said the facility provided an annual education skills checkoff and a monthly staff meeting, which sometimes provides training on specific topics. Staff member G said the assessment skills training was through computer modules. During an interview on 10/21/25 at 3:55 p.m., staff member I said she did the initial social services assessment when resident #3 was admitted to the facility, and said resident #3 was able to answer all questions without difficulty and able to make medical decisions for herself. During an interview on 10/22/25 at 8:53 a.m., staff member C said the facility did not provide clinical pathways for nursing staff to utilize when completing resident assessments. Nurses had to rely on their assessment and critical thinking skills to direct interventions for residents found to be below their baseline medical status. Staff member C said nursing staff needed to do a better job when documenting the alert notes and documentation for the communication between care team members. Staff member C mentioned the documentation for resident #3's medical decline was not clear per the medical record. During an interview on 10/22/25 at 9:32 a.m., staff member L said resident #3's altered mental status was reported to her at change of shift. Staff member L said she checked resident #3's vital signs and she had low blood pressure and was very confused. Staff member L called the physician with a report and received an order to transport resident #3 to the hospital for evaluation. Staff member L said she would have documented the vital signs in the medical record and completed an assessment or progress note stating what had occurred. Staff member L was unable to find the vital signs, assessment, or progress note documented in the medical record for 10/3/25, the day resident #3 was sent to the hospital for evaluation. Staff member L said she could not recall specifically what had occurred with resident #3. Staff member L said resident #3 was a skilled nursing resident and a resident assessment was required to be done daily for skilled residents. Staff member L said she was unable to find the daily skilled assessments for resident #3 for the morning she was transported to the hospital for evaluation. Staff member L said the facility provided verbal instructions on specific assessments or information may be included in the monthly staff meetings. If the facility was busy, the information may be provided through email. Staff member L said the facility had provided training on a resident change of condition. During an interview on 10/22/25 at 11:28 a.m., staff member B said a change in a resident's condition should be reported from nurse to nurse so the resident can be assessed, the causes of the change could be identified, and interventions put in place. Staff member B said that when nursing identified a change in resident #3, an assessment should have been completed, and the provider notified. There was no documentation in the medical record regarding resident #3's change in condition, or a physician's response to the change. Staff member B said for skilled nursing residents, a daily skilled note needed to be documented in the medical record, this was not done for resident #3.Record review of resident #3's Nursing-Skilled Services Note, showed assessments were documented daily from 9/4/25 through 9/16/25, 9/19/25 through 9/23/25, and no daily assessments were documented after 9/23/25. Record review of resident #3's Nursing-Skilled Services Note, dated 9/22/25, showed resident #3 began to have a mental decline and was no longer oriented to the season. The resident no longer knew staff names and faces. Resident #3 was noted to be in her room all day, mostly in bed, which was not her normal routine. Resident #3 had no significant change in the previous 24 hours checked. Record review of resident #3's vital signs, dated 10/2/25 at 1:20 p.m., showed: Called to room [resident #3's] vitals from Hospice nurse reading <70% on resident. Checked vitals, see charting. Shallow breathing at this time. Good waveform on left hand achieved accurate vitals of 94%/78hr/12rr. Breath sounds diminished throughout. Hospice nurse at bedside during this time. She does not appear to be in pain. Eyes closed yet nodded when spoken to. Family at bedside as well. Room Air. Checked Code status prior to entering with Hall nurse and she is per her POLST DNR/DNI.No hospice order was found in resident #3's medical record. Record review of resident #3's EMR showed resident #3 sustained an unwitnessed fall on 10/02/25. The physician was notified at 7:17 p.m. of resident #3's blood pressures reading in the 70's/40's following the fall. On 10/3/25 at 1:47 a.m., the physician was notified of the resident's blood pressure being low, and the MD ordered lisinopril and then to decrease resident #3's diuretic dosage to help increase the blood pressure. Resident #3 was noted to be resting with her eyes closed, and she had even, unlabored breathing noted. While awake, resident #3 was upset and crying to go to the bathroom, even after being assisted to the bathroom and back. Resident #3 was wanting to get out of the hospital and was not easily redirected. Staff were encouraging resident #3 to drink fluids. No documentation was found for the fall that occurred, an assessment following the fall, the sustained low blood pressures, or interventions implented. The only documentation noted was the change in medication ordered by the physician and drinking fluids. Record review of resident #3's nursing note, dated 10/3/25 at 11:22 a.m., showed: .spoke with on call provider. Agreed to send resident out to Ed for AMS [altered mental status]. Resident is responding to painful stimuli, does not know where she is. UA [urine analysis] dip was clear. Resident DNR [Do Not Resuscitate]/selective are measures. Not eating or drinking, decreased mental and physical status. Will not bear weight. 911 called at 1120 . [sic]Record review of resident #3's vital signs showed the last documented vitals were on 10/2/25, the day prior to her hospital transfer on 10/3/25, which included: 1:30 p.m. - Respirations; 12, Blood Pressure; 132/83 11:12 p.m. - Heart rate; 98, regularRecord review of resident #3's Medication Administration Record, dated September 2025, showed the following medication orders with monitoring: -Bupropion HCL 150 mg once daily, for depression. Monitoring for side effects of antidepressant medication; Dry mouth, blurred vision, constipation, urinary retention, hypotension, appetite changes, headache, insomnia, dyspepsia, and weight changes.-Furosemide 40 mg once daily, a diuretic for congestive heart failure.Monitoring for signs and symptoms of diuretic use: headache, dizziness, nausea, loss of appetite, upset stomach, dehydration.Record review of resident #3's Medication Administration Record, dated October 2025, showed the following medication orders with monitoring; -Bupropion HCL 150 mg once daily, for depression. Monitoring for side effects of antidepressant medication; Dry mouth, blurred vision, constipation, urinary retention, hypotension, appetite changes, headache, insomnia, dyspepsia, and weight changes. No documentation was entered for the day shift on 10/1/25 and 10/2/25, and the night shift documented no adverse effects. -Furosemide 40 mg once daily, a diuretic for congestive heart failure.Monitoring for signs and symptoms of diuretic use: headache, dizziness, nausea, loss of appetite, upset stomach, and dehydration. There was no documentation entered for the day shift on 10/1/25 and 10/2/25, and the night shift documented no adverse effects. Review of a facility policy, Documentation in Medical Record, date implemented 7/1/2025, showed: Policy:Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation.1. Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy.b. Documentation shall be accurate, relevant, and complete, containing sufficient details about the resident's care and /or responses to care.2. Nutrition and HydrationDuring an interview on 10/21/25 at 3:25 p.m., staff member G said resident #3's fluid intake was monitored and documented and could be found in her medical record. Staff member G was not able to locate the fluid intake information in resident #3's medical record. Staff member G said he was not aware resident #3 had an abscessed tooth on admission; he was not concerned with her food or fluid intake and did not remember any nausea with vomiting occurring prior to resident #3's hospital transfer. Staff member G said he was not aware that resident #3 was taking a diuretic medication. During the interview, it was identified that staff member G was not fully competently aware of #3's essential health concerns, and staff member G did not complete medical record documentation as needed to reflect #3's status. Review of resident #3's medical records failed to show documentation of nausea, vomiting, or interventions provided by nursing staff before her transfer to the hospital for evaluation. The resident's status and change were not accurately and competently reflected in the EHR by nursing staff. Review of resident #3's care plan, revised on 10/1/2025, showed resident #3 was at risk for weight loss related to chewing difficulties, dental infection, and use of a diuretic. The interventions were to monitor her intake at all meals and alert the dietitian and physician to any decline in her intake. Resident #3's medical record did not show any documentation of a dietitian or physician notification for the decline in her intake.During an interview on 10/21/25 at 4:14 p.m., staff member J said resident #3 was at the facility for a short time before starting to decline. Resident #3 was weaker, and it was more difficult for her to get out of bed. Staff member J said when she was finally able to obtain a weight for resident #3, it was identified that she had a severe 14-pound weight loss. Resident #3 was not drinking or eating well.During an interview on 10/22/25 at 9:32 a.m., staff member L said that at the change of shift, it was reported that resident #3 was not eating or drinking, and there was no report of nausea or vomiting. Staff member L said she was aware that resident #3 was admitted with a tooth infection, and she was on antibiotics and was taking a diuretic for her congestive heart failure. Staff member L said hydration was not documented and recorded in the medical record for each resident. During an interview on 10/22/25 at 10:47 a.m., staff member O said when doing the chart review for the requested documentation, it was noted that the intake and output for most facility residents had been deleted from the charting system. Due to this, the resident's intake and output were not reflected in the EHR. The failure of the staff to competently ensure the resident's intake and or hydration was documented, preventing the facility and staff from identifying concerns or trends timely.During an interview on 10/22/25 at 11:28 a.m., staff member B said the registered dietitian had been disabling the hydration tracking for each resident when she placed the order for meal consumption, although tracking the hydration assists with maintaining a resident's health and is used for identifying concerns or trends related to hydration. Review of resident #3's medical record weight documentation showed resident #3 weighed 129.8 pounds on admission. Resident #3's medical record showed no documentation of a weight for three weeks; and then it was identified that the resident had a 14-pound weight loss, which was a severe loss at 10.4%, and this was 26 days after her admission. Review of resident #3's physician order summary showed an order on 9/5/2025, Obtain weekly weights; reweigh if >5# difference from previous week in the morning every Mon [Monday]. This was not completed as ordered by the nursing staff. Review of a facility policy, Hydration, with an implementation date of 7/1/2025, showed: Policy:The facility offers each resident sufficient fluid, including water and other liquids, consistent with resident needs and preferences to maintain proper hydration and health.Sufficient fluid means the amount of fluid needed to prevent dehydration . and maintain health. The amount needed is specific to each resident and fluctuates as the resident's condition fluctuates.1. The facility will utilize a systematic approach to optimize the resident's hydration status:a. Identifying and assessing each resident's hydration status and risk factorsb. Evaluating/analyzing the assessment informationc. Developing and consistently implementing pertinent approaches.2. Identification/assessment:a. Nursing staff shall assess hydration status upon admission and throughout the resident's stay in accordance with assessment protocols.

Based on observation, interview, and record review, the facility failed to ensure nursing staff had the necessary skills and training for CPR for 2 (#s 1 and 3) of 26 sampled residents. Resident #s 1 and 3 expired in the facility. The facility failed to ensure a process was in place for identifying and tracking staff CPR certifications. The facility failed to obtain the supplies necessary, and ensure they were in stock and on the crash cart, for staff to perform high-quality CPR during emergent situations, which affected 2 (#s 1 and 3). The facility failed to have a process in place to identify and ensure supplies, including respiratory supplies, were on hand and readily available. On [DATE] at 11:09 a.m., an Immediate Jeopardy was announced to the Administrator and the Corporate Clinical Recourse Nurse related to F678 - Cardiopulmonary Resuscitation. The Severity and Scope identified for the Immediate Jeopardy were Identified to be at the level of J, and upon removal of the immediacy, lowered to a G. An acceptable plan for the Removal of Immediacy was approved and verified on [DATE] at 5:00 p.m. Resident #1 coded on [DATE]. A nurse called the code and started chest compressions. The crash cart was located across the facility, in a different hallway. There was no Ambu bag on the crash cart, and no protective barrier present so respirations could be provided safely during CPR. Resident #3, coded on [DATE], and the nurse on shift started CPR. No Ambu bag or protective barrier was on the crash cart to initiate respirations. Findings Include: a. During observation and interview on [DATE] at 11:55 a.m., staff member C showed the crash cart was located in the hallway by the medication room and the nursing station on the 100 and 300 hallway. The crash cart was wedged in between a treatment cart and a wall and was not easily accessible. There was a light blue, tarp-like cloth, covering the crash cart. Staff member C stated a secondary cart was located in a utility room, but it was not used, because staff could not access it easily. The crash cart in the utility room was in a back corner blocked in by intravenous poles and wheelchairs. Staff member C stated she did not know when the crash carts were last stocked or when the equipment was last tested . During an interview on [DATE] at 12:02 p.m., staff member D stated she was on shift when resident #1 coded. Staff member D stated the code was called for resident #1's emergent event, and the staff member had to run across the building to retrieve the crash cart, and the crash cart did not have the supplies needed. Staff member D stated an AED or Ambu bag was unavailable on the crash cart for staff use. Staff member D stated, When I asked about an AED, I was told by staff member K no one knew how to use it, so we don't have one Staff member D stated there had been another code in the facility in [DATE]. Staff member D stated she did not know who was responsible for checking or stocking the crash cart. During an interview on [DATE] at 2:43 p.m., Staff member A stated, Ambu bags were now on the crash carts, and it is corporate policy not to have an AED in the building, it's not required. Review of resident #1's electronic medical record, from [DATE] - [DATE], showed: Resident #1 was hospitalized on [DATE] for acute pneumonia and respiratory failure with hypoxia. Resident #1 was readmitted to the facility on [DATE]. Review of resident #1's POLST, dated [DATE], showed full code with limited interventions. Resident #1 expired in the facility on [DATE]. Review of an emergency services document titled, Prehospital Care Report, dated [DATE], showed: EMS dispatched on [DATE] at 8:27 a.m., arrived on scene at 8:42 a.m., arrived at patient at 8:44 a.m. Depart at 9:11 a.m. Response Delay: Unable to locate. During an interview on [DATE] at 7:08 p.m., an anonymous staff member stated respiratory supplies had been requested back in the middle of [DATE]. The anonymous staff member stated staff members A and K were notified of the need for more respiratory supplies which were not ordered until after [DATE]. The staff member said there had been two residents in the facility who coded and expired in the facility, and there was a delay in care during the first code because a staff member had to leave resident #1's room to go searching for an Ambu bag, one was found, and the staff member returned to resident #1's room and took over the code. The Ambu bag was the last one in the facility, and staff members A and K were notified again. The anonymous staff member stated, About a week later there was another resident who coded in the facility, and there still were no Ambu bags available for use. During an interview on [DATE] at 7:22 p.m., staff member E stated she was involved in the code for resident #1. Staff member E stated resident #1 was found down in his room and staff member H was the nurse on shift, and she started chest compressions. Staff member E stated, When I arrived in resident #1's room there was not an Ambu bag on the crash cart, I had to leave the code to go and find one. Staff member H was just doing compressions. I had to look in multiple areas and then had to run to a storage room located across the building from where resident #1's room was located. I was able to locate an Ambu bag and return to resident #1's room after several minutes. When I returned to resident #1's room it was chaotic, unorganized, no one really knew what they were supposed to do. The communication was very poor. When EMS arrived they took over CPR efforts and attached an AED to resident #1. EMS delivered at least two shocks, under the direction of the AED. If the facility has full code patients, they need to make sure we have the tools to perform our jobs, especially in emergent situations. There also needs to be more than one crash cart available to use. I know that another resident coded in the facility about a week later, but that was in the middle of the night, and I am not sure of the details. During an interview on [DATE] at 9:50 a.m., staff member H stated she was working when resident #1 coded in his room. Staff member H stated, I was passing medications when staff member J yelled for me to come to resident #1's room. I entered resident #1's room and found he was not breathing, and had no pulse, but was still warm to the touch. I immediately started chest compressions and yelled for the crash cart. Staff member I came with the crash cart, but there was no Ambu bags or barriers on the crash cart. I continued with compressions. We called EMS, and they went to the wrong address the first time, and it took them a long time to get here. EMS used the AED and resident #1 was shocked at least twice. The one thing that bothers me is that no one knew where the crash cart was, and there were no Ambu bags or respiratory supplies available on the cart. Staff member H stated, If we would have had all the supplies we needed, and staff had training on emergency situations, it may have helped save his life. Staff member H stated resident #1 had expired. Staff member H stated she was not CPR certified and had not been CPR certified for two years. Staff member H said the facility had never offered any training or certification for CPR, and the employee did not know who was responsible for checking or stocking the crash cart. During an interview on [DATE] at 10:10 a.m., staff member I stated she went to find the crash cart and called 911 with the emergency for resident #1. Staff member I stated, I called 911 at 8:25 a.m., and at 8:37 a.m., 911 called back wanting the address again because they had gone to the wrong building the first time. When I was in resident #1's room during the code, there was no Ambu bag or barriers available on the crash cart. Staff member I stated staff member E had to leave the room to look for an Ambu bag, while staff member H performed compressions. There was a complete delay in care from us and from EMS. If we would have had the needed supplies available, it may have helped save resident #1. Staff member I did not know who was responsible for checking or stocking the crash cart. During an interview on [DATE] at 10:25 a.m., staff member Q stated she was not CPR certified and had never been offered training or certification in CPR. Staff member Q stated, Today was the first time I have been offered a CPR class and this is the first time the facility has offered one as far as I know. During an interview on [DATE] at 10:30 a.m., staff member J stated he was the staff member who found resident #1 in his room not breathing. Staff member J stated he had called for the nurse, and she had run down to the room, assessed resident #1, and started chest compressions. Staff member J stated there was no barrier or Ambu bag available for staff to use, staff had to try and locate one. Staff member J stated he had never been asked about CPR certification or been offered training or certification on CPR. Staff member J said he had kept his certification current on his own. During an interview on [DATE] at 10:55 a.m., staff member A stated that staff member L was responsible for ordering supplies, and, We do not have a designated person who stocked supplies, staff just go to the central supply closet and get what they need, there is no person that is actually responsible for stocking supplies. During an interview on [DATE] at 11:10 a.m., staff member L stated he was responsible for ordering supplies for the facility. Staff member L stated he ordered supplies on Tuesdays and Thursdays. Staff write down what supplies are needed on the paper hanging on the outside of the supply closet. Staff member L stated once he is made aware of needed supplies, he would order them, on the next order date. A review of a facility document titled, SUPPLIES NEEDED, Showed Ambu bags were written down on [DATE], the day after resident #1 coded. A review of a facility document titled, Purchase Order SWCN0000082733, dated [DATE] at 3:29 p.m. showed an order was placed for Ambu bags. Four days after Resident #1 coded. During an interview on [DATE] at 11:40 a.m., staff member A stated she did not have a record of when the supplies arrived but believed it was [DATE]. During an interview on [DATE] at 1:10 a.m., staff member K stated her expectation was all staff should know where to find supplies and where the crash carts are located. Staff member K said, I would expect that night shift (will) be checking the crash cart, but there is no documentation on crash cart checks or supplies. I would expect if a staff member used supplies off the crash cart that they replace what was used and restock the cart. Staff member K said staff member A informed her there was no AED because the staff did not know how to use one. During an interview on [DATE] at 3:00 p.m., staff member B stated, My expectation for supplies is that they are available, and staff know where to find them. All staff should know where to find them at. That should be part of the floor training staff get during orientation. The crash cart should be fully stocked with supplies in case of an emergency, if not, what is the purpose of having a crash cart. Staff member B stated she wasn't sure how the facility ensured staff were trained and certified in CPR. Staff member B stated, That is a building process, I know we do not have an in-house CPR instructor, and I am not sure how they track who needs certifications and who doesn't. During an interview on [DATE] at 3:50 p.m., Staff member A stated, I do not have copies of the CPR cards, I don't track who needs it, and who doesn't. When a person on-boards, they should upload a copy of the certification, but no one has, I just went back and looked. It has been just me. I have not had a full-time Director of Nursing for a long time, I have had interim Directors of Nursing, no one permanent until now, and she just started. B. During an interview on [DATE] at 11:24 p.m., staff member M stated she was the staff member on shift when resident #3 coded. Staff member M stated another staff member brought the crash cart to resident #3's room and called 911. Staff member M stated she had started CPR on resident #3. Staff member M stated resident #3 was a full code. Staff member M stated no Ambu bag or mouth barriers available on the cart. Staff member M stated she had her pocket barrier which she carried with her in her pocket. During an interview on [DATE] at 12:08 p.m., staff member G stated she had witnessed staff member E notify staff members A and K of the need for more respiratory supplies in early [DATE]. Staff member G stated she could not recall the exact date or time but knew it was before resident #1 had coded. Staff member G stated supplies were not received before resident #3 coded, but arrived after. A review of resident #3's electronic medical record showed resident #3 was admitted to the facility on [DATE], from an acute care facility. Resident #3 had a diagnosis of acute chronic respiratory failure, acute and chronic bilateral pulmonary emboli, and obstructive sleep apnea. Resident #3 was a full code per the POLST, dated [DATE], with full interventions, and the resident expired in the facility on [DATE]. A review of a document titled, Prehospital Care Report, dated [DATE] at 3:30 a.m., showed: EMS was dispatched to the facility o [DATE] at 3:30 a.m., At scene at 3:37 a.m., At patient at 3:39 a.m., and departed the facility at 4:19 a.m. [sic] Resident #3 expired in the facility. Review of a facility document titled, Cardiopulmonary Resuscitation (CPR), undated, showed: . 1. The facility will follow current American Heart Association (AHA) guidelines regarding CPR. . 4. Staff will maintain current CPR certification for healthcare providers . A review of a facility document titled, Emergency Crash Cart, undated, showed: It is the policy of this facility to ensure that the facility will maintain at least one emergency crash cart per nursing care floor with additional carts added as deemed necessary in the case of the need for basic life support. The purpose of this policy is to ensure that all supplies critical to basic life support are readily available on the emergency cart. 2. The facility will store the emergency cart in a location that is accessible (Med room near ,d+[DATE] hall) . 4. The emergency crash cart is checked routinely . . 5. Clinical staff will be education on the location and use of the emergency crash cart . [sic] A review of the Facility Assessment, dated [DATE], failed to show any emergency respiratory supplies, such as Ambu bags were identified as needed or addressed. A request was made on [DATE] at 11:00 a.m., for a policy or procedure for ordering and stocking supplies, and CPR certifications for all nursing staff, to include the CPR certifications for staff members H and M. The CPR certifications for staff members H and M were not received before the end of the survey. On [DATE] at 2:10 p.m., Staff member A stated they did not have a policy or procedure for ordering and stocking supplies or for the staff CPR certifications. Staff member A said, I gave you what I could get. A request to speak with staff member AA was made on [DATE] at 2:02 p.m., and on [DATE] at 8:31 a.m. Staff member AA did not call prior to the end of the survey. A review of current CPR standards from the American Heart Association includes: According to the American Heart Association, CPR for healthcare providers include: conventional CPR using chest compressions and mouth-to-mouth breathing at a ratio of 30:2 compressions-to-breaths. In adult victims of cardiac arrest, it is reasonable for rescuers to perform chest compressions at a rate of 100 to 120/min and to a depth of at least 2 inches (5 cm) for an average adult, while avoiding excessive chest compression depths (greater than 2.4 inches [6 cm]). [sic] https://cpr.heart.org/en/resources/what-is-cpr#:~:text=For%20healthcare%20providers%20and%20those,Learn%20About%20Hands%2DOnly%20CPR

Based on observation, interview, and record review, the facility failed to ensure proper respiratory supplies were readily available during emergencies, for 2 (#s 1 and 3) of 26 sampled residents. This deficient practice caused a delay in care during emergent situations, and an Immediate Jeopardy was cited for F678 - Cardio Pulmonary Resuscitation, which included concerns with the lack of supplies and availability. Findings include: During an observation and interview on [DATE] at 11:55 a.m., staff member C showed the crash cart was located in the hallway by the medication room and the nurse's station on the 100 and 300 hallway. The crash cart was wedged in between a treatment cart and the wall and was not easily accessible. There was a light blue, tarp-like cloth covering the crash cart. Staff member C stated a secondary cart was in a utility room but not utilized because they could not access it. The crash cart in the utility room was in a back corner blocked in by intravenous poles and wheelchairs. The crash cart was not covered. Staff member C stated she did not know when the crash carts were stocked or the equipment was tested . a. During an interview on [DATE] at 12:02 p.m., staff member D stated she was on shift when resident #1 had coded. Staff member D stated when the code was called staff had to run across the building to retrieve the crash cart and it did not have the supplies needed. Staff member D stated no AED or Ambu bag was available on the crash cart (for the prior emergent situations). Staff member D said she did not know who was responsible for checking the crash carts. During an interview on [DATE] at 2:43 p.m., Staff member A stated, Ambu bags are now on the crash carts. During an interview on [DATE] at 7:08 p.m., an anonymous staff member stated respiratory supplies had been requested back in the middle of December, and said staff members A and K were notified of the need for more respiratory supplies, and they were not ordered until after [DATE]. The anonymous staff member had to leave resident #1's room to search for an Ambu bag, one was found and the staff member returned to resident #1's room and took over the code . Staff members A and K were notified again about needed respiratory supplies. During an interview on [DATE] at 7:22 p.m., staff member E stated When I arrived in resident #1's room there was not an Ambu bag on the crash cart, I had to leave the code to go and find one. I had to look in multiple areas and had to run to a storage room located across the building from where resident #1's room was located. I was able to locate an Ambu bag and return to resident #1's room. During an interview on [DATE] at 9:50 a.m., staff member H stated I entered resident #1's room and . immediately started chest compressions and yelled for the crash cart. Staff member I came with the crash cart but there was no Ambu bags or barriers, so I could provide manual breathing safely . no one knew where the crash cart was and there were no Ambu bags or respiratory supplies available on the cart. Staff member H stated she didn't know who was responsible for checking or stocking the crash cart. During an interview on [DATE] at 10:10 a.m., staff member I stated she went to find the crash cart and called 911. Staff member I said, I called 911 at 8:25 a.m. When I was in resident #1's room during the code, there was no Ambu bag or barriers available so that manual respirations could be done safely. Staff member E had to leave the room to look for an Ambu bag. There was a complete delay in care from us. If we would have had the needed supplies available, it may have helped save resident #1. Staff member I stated she didn't know who was responsible for checking or stocking the crash cart. During an interview on [DATE] at 10:30 a.m., staff member J stated he was the staff member who found resident #1 in his room not breathing. Staff member J stated he had called for the nurse, and she had run down to the room and had started chest compressions. Staff member J stated there was no barrier or Ambu bag available for staff to use, they had to try and locate one. Resident #1 expired at the facility. b. [DATE] at 11:54 a.m., a call was placed to staff member M. Staff member M was on duty when resident #3 coded. A voice message was left. During an interview on [DATE] at 1:10 a.m., staff member K stated the expectation of the facility was for all staff to know where to find supplies. Staff member K stated, I would expect night shift be checking the crash cart, but there is no documentation of crash cart checks or supplies. I would expect if a staff member used supplies off the crash cart that they replace what was used and restock the cart. During an interview on [DATE] at 3:00 p.m., staff member B stated, My expectation for supplies is that they are available, and staff know where to find them at . That should be part of the floor training staff get during orientation. During an interview on [DATE] at 11:24 a.m., staff member M stated she had been called down to resident #3's room and found resident #3 was not breathing and had no pulse. Staff member M stated she had to use her own respiratory barrier she carried in her pocket because one was not available. Staff member M said there was no Ambu bag available to use. Staff member M stated she had continued to provide CPR until EMS arrived and took over. A review of the Facility Assessment, dated [DATE], failed to show information related to Respiratory Care and Services. The assessment did not include: - The type of care, services, or contracted services, provided to residents for Respiratory Therapy Services and a Pulmonary Program. - Changes in staffing as a result of adding a Pulmonary Program. - Equipment needed for residents who participated in the Pulmonary Program. - No staff training or competencies addressing the Pulmonary Program. - The medical supplies section did not address CPAP, BIPAP, or emergency respiratory supplies, such as Ambu bags. A review of a facility document titled, Emergency Crash Cart, undated, showed: It is the policy of this facility to ensure that the facility will maintain at least one emergency crash cart per nursing care floor with additional carts added as deemed necessary in the case of the need for basic life support. The purpose of this policy is to ensure that all supplies critical to basic life support are readily available on the emergency cart .

Based on interview and record review, the facility failed to provide services which meet professional standards for care necessary to promote healing of wounds for 1 (#9) of 3 sampled residents with wounds. This deficiency had the potential to affect healing for residents with wounds. Findings include: During an interview on 10/23/24 at 12:03 p.m., resident #9 said she was sent to the facility for care of a wound that required a wound vac. The wound vac care she received was not correct, and she only had the wound vac functioning for a week. Resident #9 said the wound vac would alarm and staff would tell her to sit on it to seal the suction. Resident #9 said the wound was getting worse so she signed herself out of the facility against medical advice on 7/31/24. During an interview and record review on 10/23/24 a 7:54 a.m., staff member F said he had been trained on wound care, and the wound documentation. Staff member F said resident #9 was admitted for wound treatments and had a wound vac placed. The wound vac would alarm so the dressing was removed and packed. Staff member F was unable to find documentation on the difficulties on the wound vac management, reinforcement of wound vac dressing, drainage amounts, changing of cannister, or reason for removing the wound vac and placing a wet dressing, or notification of physician for modification of treatment changes. Staff member F said he believed the cannister would be changed when it became full but did not believe the staff documented anything on the drainage description or amounts, or if the staff was having difficulty with maintaining a seal. During an interview on 10/23/24 at 3:42 p.m., staff member B said the wound nurse was out on maternity leave and trained staff member F to care for resident wounds. Staff member F was responsible for documentation of wounds and working with the wound care clinic. Staff member B said the facility had a mock survey and wound care and documentation was an area identified needing improvement. Staff member B said resident #9 had a wound vac and the staff would tire of it alarming and remove the wound vac and pack the wound. Staff member B said staff member F was having difficulty with documentation of wounds and would go to the facility physician to have orders changed from what was ordered by the wound clinic. Staff member B said she expected staff to document any interventions that addressed wound care. Record review of resident #9's electronic record showed she was initially admitted on [DATE] with a readmission of 6/5/24, following a hospital stay for pulmonary embolism and deep vein thrombosis to her right upper extremity. Resident #9 had a diagnosis of chronic pain syndrome, neuromuscular dysfunction of bladder, colostomy, acute osteomyelitis, pressure ulcer of bilateral hips, pulmonary embolism. Resident #9 signed out from the facility against medical advice on 7/31/24. Record review of resident #9's care plan, dated 6/5/24, failed to show a focus areas for wounds, catheter care, colostomy care, activities of daily living and pain management with goals and interventions specific to resident #9. Record review of resident #9's physician orders from the wound clinic showed: - 5/29/24 .2. Replace wound vac dressing & sponge on Mon, Wed, and Fri (with) initials and date on dressing. If wound vac alarms, or looses suction, Do not turn off but replace dressing & if alarm continues, remove dressing & fluff cavity (with) vashe (wound cleaner) dampened kerlix until the next scheduled wound vac changes . [sic] 6/12/24 VAC change to continue MWF Be sure to get Foam to BASE (of wound @ 12'o) . [sic] 6/26/24 Continue VAC & (dressing changes) 3X wk, If vac not working pack right with 4 X4 & ABD & change daily . 7/17/24 .2. R ischium- NPWT device (wound vac) to be started ASAP! Unti then, 1 4X4 gauze into cavity then cover (with) ABD + tape QD -wound vac 125 mmHg continuous suction & change on Mon, Wed, Fri. -Please be sure to start wound vac within 1 wk . Review of resident #9's electronic medical record order review showed: 5/21/24- If wound vac malfunctioning: cleanse R IT wound, pat dry. Loosely pack with moist gauze, cover with abd pad and tape. Discontinued 6/4/24 5/21/24- R ischial tub wound care: Black foam into wound bed, tunneling piece at 12:00. Skin prep and draping to periwound, bridge to hip. Wound vac 125 suction, continuous. Every day shift every Mon, Wed, Fri for wound care and as needed for soiled or detached dressing. Discontinued 6/4/24 5/24/24- Check function of wound vac. If malfunctioning and unable to fix seal, use PRN orders for wound care. Discontinued 6/4/24 6/5/25- Wound Vac: Site: R ischium. Ensure Wound Vac dressing is sealed/intact & setting at 125mn Hg every shift. Discontinued 8/6/24 6/5/24- Wound Vac: if unable to achieve Vac seal, remove Vac dressing, cleanse with NS and apply wet as needed. Discontinued 7/17/24- Notes: Rt no longer has a wound vac. 7/22/24- R ischium- NPWT device (wound vac) to tarted ASAP. Until then 1 4X4 gauze with ABD + tape QD. Wound vac 125mmhg continuous suction & change mon, wed, fri. Please be sure to start wound vac within 1 week. Discontinued 8/6/24. 7/22/24- If wound vac is malfunctioning, pack with moist gauze into tunneling and undermining, cover with Tegaderm adhesive. Discontinued 8/6/24. Review of resident #9's Skin and Wound Evaluation, dated 7/29/24 for the right ischial tuberosity wound showed a pressure wound at Stage 4. The wound had 80% granulation with 20% slough, moderate serosanguineous exudate, normal temperature, and non-attached edges. The assessment showed the dressing was missingm and the resident had negative pressure wound therapy. The progress of the wound was deteriorating. The notes showed the resident has been removing the wound vac as reported by nursing staff, requiring frequent dressing changes and overall being noncompliant with recommended treatment. The wound was noted to have increased depth and surface area. The resident was being followed by the wound clinic. No documentation of resident #9's noncompliance or need for frequent dressing changes was found in the electronic medical record or provided by the facility. Review of a facility policy, Wound Treatment Management [Facility Name], revision date 1/1/24, showed: . 3. Wound assessments are documented at the time of each treatment. If no treatment is due, an indication of the status of the dressing shall be documented each shift (i.e., clean, dry, intact). 4. Additional documentation shall include, but is not limited to: a. Date and time of wound management treatments b. Weekly progress towards healing and effectiveness of current intervention c. Any treatment for pain, if present d. Modifications of treatments or interventions e. Notifications to physician and/or responsible party regarding wound or treatment changes Review of a facility policy, Wound Treatment Management [Facility Name], revised 1/1/24, showed: .1. Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing and frequency of dressing change .

Based on observation, interview and record review, the facility failed to thoroughly assess and identify the cause of a resident's pain complaints, which caused a delay in treatment and services provided for a major injury for 1 (#20) of 9 sampled residents. Findings include: During an interview on 5/22/23 at 2:49 p.m., NF1 said resident #20 had three different injuries that involved fractures in the last year. The first fracture was a broken leg, and he was not sure how the injury occurred. NF1 said resident #20 was not taken to the doctor until the following day, and he was notified two days after the injury occurred. NF1 said the second fracture occurred when resident #20 had fallen, and she fractured her ribs. The third fracture was her arm, and he was told it was because resident #20 had brittle bones and was handled improperly, which resulted in a fracture. During an observation and interview on 5/22/23 at 2:57 p.m., resident #20 was observed lying in bed with a sling supporting her right arm. Resident #20 had a bookshelf on the left side of the bed, within reach, covered in books. A bedside table was located over the center of the bed and was covered with personal items. Resident #20's electric wheelchair was located on the resident's right side, right next to the bed. Resident #20 said she had a broken arm but does not remember ever breaking any other bones. Resident #20 said she does not remember how her arm became broken. She did not think anyone in the facility did anything to break her arm but does not remember. Resident #20 said her memory was not good anymore and her roommate keeps track of things for her. Review of a facility reported incident for resident #20, dated 3/28/23, showed: 3/28/23- resident #20 complained of pain to her left rib area. She was evaluated and an x-ray was obtained. The x-ray showed a displaced rib fracture. Resident #20 reported she had bumped in to a bedside table and heard a pop, two days prior to the evaluation. 4/7/23- Resident #20 was complaining of right upper arm pain. The resident had received a pneumonia vaccination on 4/5/23. An order was placed to monitor for signs and symptoms of pain. 4/11/23- Resident #20 was found to have significant bruising to her right upper arm and was having an increase in pain. The provider ordered resident #20 sent for an x-ray. Review of resident #20's x-ray report, dated 4/12/23, showed a right proximal humeral fracture, possibly subacute. Record review of a facility provided document, not labeled, not dated, showed resident received a PrevNar 20 vaccination in her right arm on 4/5/23. No evidence of bruising was noted at that time. Record review of a facility provided document, not labeled, dated 4/7/23, showed staff member K was going to transfer resident #20 from her bed to the shower chair. Staff member K was told resident #20's right arm had been giving her trouble. Staff member K transferred the resident to the shower chair using a gait belt and one person, instead of the usual method of two staff and using the resident's arms. When staff member K lifted resident #20, she began screaming in pain and stopped when she was lowered into the shower chair. Staff member K asked other aides to mention resident #20's pain to the nurse. Staff member K reported what had happened to the nurse when she had finished showering resident #20. Record review of a facility provided document, not labeled, dated 4/7/23, showed staff member L had witnessed the transfer of resident #20 and The resident was screaming about her arm hurting. Record review of a facility provided document, not labeled, not dated, showed staff member N had received report from staff member O, night shift CNA, said resident #20 was complaining of arm pain but resident #20 had received a shot in her arm and that was causing resident #20 pain. Record review of a facility provided document, not labeled, dated 4/8/23, showed staff member M had received report from the night shift that resident #20 had screamed a lot of pain all night and to not get her up. Staff member M used a sheet to turn resident #20 because of her pain. Staff member M was told the pain was from resident #20's flu shot. On 4/12/23, resident #20 screamed when staff member M took her blood pressure with a wrist cuff. Staff member M then noticed bruising on the resident's arm and back when she was rolled. Staff member M went and reported it to nursing staff. Record review of resident #20's EMR (electronic medical record) telehealth visit, dated 4/7/23, showed: . LPN called and reported that 1 1/2 hours after [resident #20's] pain medication given was still rating her pain 7/10.Staff reports that [resident #20] was bathed today and was up in wheelchair more than usual.Ordered to give 1 additional hydrocodone 5-325 tablet now. Reassess in 1 hour. If pain does not lower to 4-10 on pain scale then re-evaluation needed for further causes. Record review of resident #20's EMR Alert note, dated 4/8/23, showed: Resident given on time dose of hydrocodone due to break through pain. Resident reported one hour later she was having pain all over and vomited x1.Resident found to have received pneumonia vaccine yesterday and appears to be having some side effects from injection. A request was made for resident #20's pain evaluation and nursing assessments of resident #20's pain for 4/7/23, none was provided by the end of the survey. A request was made for resident #20's skin assessments. No skin assessments were provided for the week of 4/3/23, the time of the injury. During an interview on 5/23/23 at 1:10 p.m., staff member F said she had not been provided education on any transfering needs for resident #20. Staff member F said if a resident was experiencing pain, greater than would be expected for an immunization, she would immediately assess the resident for other causes. Staff member F said every resident received weekly skin evaluations. During an interview on 5/23/23 at 3:28 p.m., staff member H said she had not been provided training on transferring resident #20. Staff member H said she had only been provided her initial orientation training and relied on previous training at other facilities for abuse and transferring of residents. During an interview on 5/23/23 at 3:50 p.m., staff member D said resident #20 was first evaluated for left rib pain on 3/28/23 by the nurse practitioner. Resident #20 was sent for x-rays and was found to have a rib fracture. The facility was treating resident #20 for pain related to her rib fracture. Staff member D said she became involved in resident #20's care when she was notified of the bruising on resident #20's arm. Staff member D noted the bruising to have yellow around it and the injury had occurred some time prior to 4/12/23. Staff member D interviewed staff and the staff was unable to identify any incident that had occurred with resident #20. Staff member D said she believed the right arm had a hairline fracture that occurred at the same time as the rib fracture, and the arm fractured completely with transfers. Staff member D said resident #20's arm pain had been attributed to her vaccination. Staff member D said she would assume the increased pain of 7/10 would have triggered the nursing staff to have assessed resident #20. Staff member D said the nurse assigned to resident #20's care was a travel nurse, and she assessed resident #20 but did not document. Staff member D said the nurse is no longer working for the facility, her contract was ended early, and she would not be eligible for rehire. Staff member D said all staff had been provided training on how to transfer residents with osteoporosis and osteopenia safely by physical therapy.

Based on interview and record review, the facility failed to implement interventions to identify and prevent a Stage III pressure ulcer from forming for 1 (#72) of 2 sampled residents. Findings include: During an interview on 2/28/23 at 9:00 a.m., resident #72 stated she had a pressure sore on her left ankle that formed while she was at the facility. Resident #72 stated she used to have to wear a boot on her left leg because she broke her leg, and the wound was caused by the boot. Resident #72 could not remember when the sore had formed. Resident #72 stated she did not want a nurse to uncover her wound at the time of the interview, due to some pain, and wanting to rest. During an interview on 2/28/23 at 3:10 p.m., staff member O stated she worked all over the facility, and was not sure whether or not resident #72 was in the facility. Staff member O stated she was not sure if resident #72 had any pressure sores. Staff member O stated skin checks were completed on every resident, and the nurses should have been checking the resident head to toe. Staff member O stated some residents showered themselves, and she would expect those residents to tell her if they had a wound. Staff member O stated if a resident had a boot on, it should come off in the shower, and the skin underneath should have been looked at. Staff member O stated the facility had a wound care nurse. During an interview on 2/28/23 at 3:20 p.m., staff member AA stated she provided wound care to the residents in the facility, and resident #72 had a wound on her left ankle from her brace that she had on, upon admission, on 2/9/23. Staff member AA stated she had not seen the wound at that time. Staff member AA stated if she was doing a skin check, she would take the resident's boot off to look at the skin. Staff member AA stated CNAs report and document abnormal skin issues on the shower sheets after showers. Staff member AA stated resident #72's pressure sore was discovered over the weekend on 2/25/23. Staff member AA did not answer why the wound was not discovered before 2/25/23 during wound checks. During an interview on 3/1/23 at 11:37 a.m., staff member D stated resident #72's Admission MDS was supposed to be completed by 2/16/23, and she had just learned of the resident's leg injury on 2/28/23. Staff member D stated she was supposed to update the care plan with information on the residents left leg injury but did not have the time to complete the MDS, or the care plan, due to needing to work on the floor as a nurse. Review of resident #72's MDS, with an ARD of 2/16/23, showed section M, Skin Conditions, was 'In Progress.' Review of resident #72's EMR Evaluations showed the following incomplete evaluations: -Braden Scale (to show risk of skin breakdown), due 2/16/23, -Weekly Skin Check, due 2/20/23, and -Weekly Pressure Ulcer BWAT Report, due 2/20/23. Review of resident #72's TAR showed an order to, Remove knee immobilizer and check skin integrity. Notify provider with any skin breakdown, dated 2/20/23, 11 days after the resident's admission. Review of resident #72's care plan showed a lack of documentation of interventions to prevent pressure ulcers upon admission. Review of resident #72's shower documentation did not show showers occurred, and did not include information about skin conditions. Review of resident #72's Weekly Skin Checks, dated 2/11/23, 2/13/23, and 2/21/23, did not show documentation of pressure injuries. Review of the Weekly Pressure Ulcer BWAT Report, dated 2/25/23, showed: Site information: Left ankle (outer) Pressure: Width = , - Stage III. Date of initial observation: 02/25/2023. A review of the facility's policy, Pressure Injury Prevention and Management, dated 2022, showed: 2. The facility shall establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment . 3. Assessment of Pressure Injury Risk a. Licensed nurses will conduct a pressure injury risk assessment .on all residents upon admission . 4. Interventions for Prevention and to Promote Healing a. After completing a thorough assessment/evaluation, the interdisciplinary team shall develop a relevant care plan that includes measurable goals for prevention and management of pressure injuries with appropriate interventions.

Based on interview and record review, the facility failed to protect a resident from an elopement for 1 (#26) of 1 sampled resident. This deficient practice resulted in a resident getting hypothermia. Findings include: Review of a Facility Reported Incident, reported to the State Survey Agency, dated 4/23/22, showed resident #26 had left the facility without signing himself out of the facility or notifying staff of his departure. The incident was found substantiated by the facility. Record review of a facility progress note, created 4/23/22 at 11:50 a.m., showed: res. was found to not be facility after breakfast, searched whole facility and outside, 2 staff members drove around for res., [Staff member name] was contacted and was told she was going to call [Staff member name], called police to report elopement gave description to dispatch, police found [Resident #26] @ 11:00 [a.m.] sitting outside a restaurant smoking, officer states he can't force [resident #26] to come back, [Officer name] stated they will keep an eye on him today, [Resident #26] also told police he would walk back to the facility. Record review of a facility progress note, dated 4/23/22 at 11:59 p.m., showed: resident has not returned to facility as of this time. Administrator and on call nurse [Nurses name] contacted. This nurse informed that resident can be gone for 24 hours before any action is to be taken. Record review of a facility progress note, created 4/24/22 at 8:35 a.m., showed: res. Did not come back to facility, received phone call from [Hospital name] ER, res. Is being treated @ hospital for hypothermia . Record review of a facility progress note, created 4/25/22 at 2:52 p.m., showed: The on-call nurse texted this writer at approximately 10:20 pm that resident had not returned to the facility and believed he was at the bars in downtown [City name]. .Prior to resident leaving facility. He was coherent and alert. The resident is responsible for himself and was not assessed to be a wander risk. Record review of resident #26's Unsafe Wandering Risk Evaluation, dated 4/27/22, showed: .A. Risk Factors A2. Is the patient cognitively impaired (e.g. Alzheimer's disease, Dementia)? Answer - Yes . A.4 Does the patient have impaired decision-making skills that decrease his/her awareness of safety? Answer - Yes .Summary/Conclusions and rationale for careplan decision: Resident likes to leave the facility independently, lived on the street in the past and may in the future have desire to do the same as the weather warms up. Record review of a facility document, Elopement and Wandering Residents, revision date 11/14/22, showed: Policy: This facility ensures that residents who exhibit wandering behaviors and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. .3. The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. Record review of resident #26's MDS, OBRA Quarterly Review, dated 12/20/22, showed resident #26 had a BIMS score of 7, meaning the resident was severely cognitively impaired. Record review of resident #26's Care Plan, with the resident's admitted [DATE], showed no focus, goals, or interventions for the risk of elopement. During an interview on 3/1/23 at 2:53 p.m., staff member B said the facility did a full investigation of the incident. Staff member B said an action plan was developed, and a new elopement policy was written. Staff member B said resident #26 was allowed to leave the building. The facility failed to adequately assess resident #26 for elopement risk, and thus, did not implement appropriate interventions to prevent the elopement.

Based on observation, interview, and record review, the facility failed to provide the necessary feeding assistance or cueing to a resident who was in need of assistance during meals, resulting in a severe weight loss, for 1 (#21) of 2 sampled residents. Findings include: During an observation on 2/28/23 at 8:32 a.m., resident #21 was in her room alone and in bed, with her breakfast tray in front of her, on the bedside table. Resident #21 was not eating her food. Resident #21 was speaking very slowly and slurring her words, her eyes were only half open. During an interview on 3/1/23 at 8:17 a.m., staff member F stated resident #21 did not need to be supervised while she was eating, and she did not need to be assisted at all. During an observation on 3/1/23 at 8:34 a.m., staff member I entered resident #21's room. The room was very dark. Staff member I placed the tray on resident #21's bed side table and did not remove anything from the food tray. Staff member I did not assist resident #21 with her food tray, or sit her up in bed. Resident #21 appeared lethargic, and asked what time it was. Staff member I did not turn on any lights in resident #21's room upon exit. During an interview on 3/1/23 at 9:27 a.m., staff member U stated she was aware resident #21 was losing weight, and the resident had interventions implemented to prevent further weight loss. Staff member U stated she did not believe the resident needed assistance, other than set up, for her meals. Staff member U stated the resident would benefit from cueing from staff to eat. Review of resident #21's MDS, with and ARD of 2/10/23, showed, H - Eating . Supervision . 2. One person physical assist. Review of resident #21's nutrition weight review, dated 2/23/23, showed, Noted 3.4# loss x 1 wk and significant loss of -6.6# (6.2%) x 3 wk since admit . Currently receiving health shakes daily, but will increase to all meals d/t decrease in intakes/appetite and noted weight loss. Continue to encourage resident to get up for meals and family brings in snacks as well . Review of resident #21's nutrition weight review, dated 3/1/23, showed, Noted weight loss of -3.6# in past week and significant loss of -10.2# (9.6%) in 1 month since admit. Resident receiving healthshakes w/meals and usually drinks well. Recommending change to [Heath shake name] to increase nutrient density of supplement available and encourage wt maintenance/gain vs continued loss .Resident also benefiting from being OOB for meals and staff providing cueing, encouragement and recommending meals in assisted dining as able. Staff to provide assistance in room if isolation precautions are necessary .

Based on observation, interview, and record review, the facility failed to educate staff on the identification of residents with behavioral health needs, and implementation of non-pharmacological behavioral interventions, for residents with anxiety, for 2 (#s 15 & 71) of 4 sampled residents. This deficient practice caused a resident to experience prolonged levels of anxiety and cause distress, impeding the resident's ability to avoid psychosocial harm. Findings include: 1. During an observation and interview on 2/28/23 at 8:12 a.m., resident #71 was calling and asking for help to a passing staff member, who did not go into the resident's room. Resident #71 spoke to the surveyor, appearing anxious and quick in speech, asking for help, and repeatedly stating she needed help. The surveyor went out of the room and asked a passing staff member about the resident. Staff member O stated, She (resident #71) is so neurotic, she doesn't understand her surroundings. During an interview on 3/1/23 at 11:29 a.m., staff member L stated there was no timeline for when the psychosocial evaluation was completed for residents upon admission. Staff member L stated resident #71 was admitted on [DATE], and she did not complete the psychosocial evaluation for the resident until 2/28/23, after surveyors requested the documentation. Staff member L stated resident #71 was very anxious, and had a phobia of healthcare settings and being away from her significant other. Staff member L stated resident #71 started to become very anxious after about one week of being in the facility. Staff member L stated she needed to update resident #71's care plan with non-pharmacological interventions for the resident's anxiety. During an interview on 3/1/23 at 11:22 a.m., staff member P stated she worked often with resident #71, and noticed the resident used her call light many times a day. Staff member P stated resident #71 would make many requests to use the bathroom, or get situated in bed, and the resident would forget why she put her call light on in the first place, because she was so worked up. Staff member P stated she felt resident #71 was bored and needed attention. Staff member P stated she had never had any special training on behavioral health needs at the facility. Staff member P stated there were a few residents she did not know how to respond to when they were having behaviors, and, Training on what to do would be good to have, in those instances. During an interview on 3/1/23 at 3:54 p.m., staff member Q stated she admitted resident #71 to the facility, and she thought she had a history of anxiety. Staff member Q stated resident #71 had a hard time making decisions upon admission. Staff member Q stated she had not completed any behavioral health training since she had been at the facility. Staff member Q stated there was no orientation checklist to go over behavioral or other nursing items. Staff member Q stated the facility was so short staffed the temporary staff they had went to work on the floor quickly. Staff member Q stated she thought it was strange there was no orientation for new employees. Review of resident #71's EMR showed the following behavioral notes: -2/16/23: Resident is extremely anxious throughout HS shift .Resident extremely anxious, tearful, 'overwhelmed', this morning. Resident cannot speak in complete sentences without hyperventilating .She continues to state 'I'm overwhelmed, I can't concentrate'. [sic] -2/21/23: Resident extremely anxious throughout day .RN went into resident's room in response to call light. Resident shaking, visibly anxious, and states 'I don't know what to do I haven't slept and im so anxious'. This RN gave PRN Ativan, and resident continues anxious behavior throughout morning .later this shift, resident has continued putting call light on .she continues to state 'I'm sorry I'm just worried and I really don't want to be a bother to you' .This RN talked with husband and social services about anxious behavior. Will continue to monitor at this time. [sic] -2/24/23: Resident continues to show extremely anxious behavior. Resident calls out for help and uses call bell consistently throughout shift. Resident continues to state 'Am I okay' .'Can you come see if I'm okay' .Will continue to monitor. [sic] -2/25/23: Resident shakey, anxious, and asking this RN 'Am I okay' .Resident very warm, having anxious sweats so skin is moist .Will continue to monitor. [sic] -2/26/23: Resident continuously using call light and stating 'am I okay?'. CNA and RN has been in throughout day .resident calling out am I ok I'm so anxious'. This RN administered Ativan PRN, and resident continues to hit call light. Will continue to monitor. [sic] Review of resident #71's EMR showed the resident was admitted on [DATE], and the resident's Psychosocial Evaluation was not completed until 2/28/23, when it was requested from surveyors. Review of resident #71's MDS, with an ARD of 2/22/23, showed the Mood and Behavior sections were not completed. Review of resident #71's care plan showed a lack of interventions for the resident's anxiety and psychosocial adjustment to the facility. 40068 2. During an interview on 3/1/23 at 3:30 p.m., staff member EE stated resident #15 had behaviors occasionally. She stated he sometimes had outbursts if he did not get his way. Staff member EE stated she just tried to talk calmly to him and sometimes it worked. During an interview on 3/2/23 at 8:45 a.m., staff member DD stated she was a travel nurse and usually worked in ERs. She stated she had not received any behavioral health training for long-term care, or at the facility. Review of resident #15's nursing progress note, dated 2/10/23, showed, Resident was up in the hallways for most of the morning. He has been very agitated this morning. Yelling and cursing at most of the staff. Review of resident #15's NP progress notes, dated 2/14/23, showed, He is walking around the facility with his walker. He reports he is doing well. He does have a hx of encephalopathy with bouts of behavior changes. He is at his normal mh (mental health) baseline. Review of resident #15's nursing progress notes, dated 2/21/23, showed, Resident had two episodes of yelling at staff this shift. This afternoon resident asked staff sitting at nurse's station for a clipboard. Staff searched for an extra clipboard and were unsuccessful at finding one. Resident became angry and yelled. Again this evening, while nursing staff were doing report, resident interrupted and asked staff to make a phone call for him. Resident was told that after report, assistance would be given to him. He became angry and yelled and cursed at staff. During an interview on 3/1/23 at 2:50 p.m., staff member L stated staff member D and her were in charge of implementing and updating care plans. Staff member L stated if a resident was having behavioral health issues, nursing staff let her know, and she implemented a care plan for behavioral health. Staff member L also attended the residents' care plan meetings. Staff member L stated she was not aware of resident #15 having any behaviors. Review of resident #15's care plan did not show any information regarding his behavioral health needs. During the Quality Assurance interview on 3/2/23 at 9:48 a.m., staff membr A stated the facility did not do behavioral health training with the staff. Staff member A stated the facility would benefit from having behavioral health training. Staff member D stated she was aware some residents who had behavioral health needs, did not have it addressed in their care plans. She stated she was working to update those at that time. Review of the Facility Assessment, dated 2/14/23, showed: Resident support/care needs 2.1 Types of care/services we (or contracted services) provide to the residents: .Mental health and behavior .the IDT will develop and implement interventions in managing resident's behavior and to help support individuals with issues dealing with anxiety . A review of the facility's policy, Behavioral Health Services, revised 11/9/22, showed: 7. The facility utilizes the comprehensive assessment process for identifying and assessing a residents mental and psychosocial status .Staff will: c. Monitor the resident closely for expressions or indications of distress . e. Utilize MDS and care area assessments. f. Assess and develop a person-centered care plan . i. Ensure appropriate follow-up assessment, if needed . k. Evaluate resident and care plan routinely to ensure the approaches are meeting the needs of the resident. 10.Behavioral health training .will include .the competencies and skills necessary to provide the following: b. Interpersonal communication that promotes mental and psychological well-being. e. Individualized, non-pharmacological approaches to care.

Based on interview and record review, the facility failed to protect residents from the transmission of COVID-19 during an outbreak, and 34 residents were found to be positive for COVID-19, to include (#s 3, 4, 5, 7, 8, 9, 12, 17, 21, 22, 23, 27, 28, 37, 38, 39, 42, 45, 47, 48, 50, 51, 52, 56, 61, 62, 63, 65, 72, 75, 77, 177, 228, 229, and 230) of 49 sampled residents; failed to ensure the Infection Prevention and Control policies and procedures were based on current national standards and reviewed at least annually; failed to ensure staff were consistently screened for symptoms of COVID-19 prior to the beginning of each shift worked; and failed to implement a surveillance plan which included ongoing analysis of data and corrective action in response to identified concerns. The deficient practices increased the risk of any resident in the facility contracting COVID-19 and resulted in 34 residents being diagnosed with COVID-19 between 1/22/22 and 2/2/22. Findings include: Transmission of COVID-19 Review of the facility's infection control surveillance line listing, dated 1/19/22 through 2/2/22, showed 34 residents (#s 3, 4, 5, 7, 8, 9, 12, 17, 21, 22, 23, 27, 28, 37, 38, 39, 42, 45, 47, 48, 50, 51, 52, 56, 61, 62, 63, 65, 72, 75, 77, 177, 228, 229, and 230) and 12 staff (C, H, I, J, P, R, S, T, U, V, and W) tested positive for COVID-19. During an interview on 3/30/22 at 8:52 a.m., staff member C stated she had been responsible for infection control until 2/1/22 when staff member O took over the infection control responsibilities. Staff member C stated it was challenging to accomplish the tasks associated with infection control and COVID-19. She stated she was frequently assigned to work the floor and did not have time to monitor screening and testing compliance for the staff. Staff member C stated working the floor made it difficult for her to find the time to analyze surveillance data to identify any concerns or corrective action needed. Staff member C stated she had kept track of Covid-19 positive staff and residents and provided this information to the Public Health Department. Staff member C stated she had missed approximately 10 days of work in January of 2022 due to COVID-19 and no other staff at the facility contacted the Public Health Department during her absence. Staff member C stated she sent the surveillance information as soon as she returned to work on 2/2/22. Annual Review of the Facility Policies and Procedures During an interview on 3/31/22 at 7:34 a.m., staff member C stated she was not sure the last time the Infection Prevention and Control Program had been reviewed. Staff member C stated she would check the QAPI minutes to see when it had been done last. Review of the facility's policy titled, Infection Prevention and Control Program, showed the policy was last revised October 2018. The policy failed to show it had been reviewed at least annually or had been revised based on current national standards, or as necessary. A written request for documentation related to the annual review of the facility's Infection Prevention and Control Program was made on 3/31/22. No documentation was provided prior to the end of the survey. During an interview on 4/13/22 at 3:45 p.m., staff member N stated the facility had become aware of an issue with policies during the first part of the survey from 3/29/22 to 3/31/22. Staff member N stated there were policies provided by [oversight consultant], and the corporate office. Staff member N stated the policies overlapped and sometimes contradicted each other. Staff member N stated the facility was working on eliminating duplicate and contradictory policies. Review of the facility's policy titled, COVID-19 Outbreak Status Procedure, dated 9/18/21, failed to show the current CMS requirements related to visitation and the frequency of COVID-19 testing. The policy showed, When a positive COVID 19 test is produced immediately close the building down to visitors . The policy failed to show CMS revised the visitation restrictions on 11/12/21. The policy showed, Continue to perform weekly testing (every 7 days or more depending on county health recommendations on positivity percentage) . The policy failed to show CMS changed the frequency of COVID-19 testing from the county positivity percentage to the county transmission rate on 9/10/21. Staff Screening During an interview on 3/30/22 at 10:02 a.m., staff member O stated she had become responsible for oversight of infection control in early February of 2022. Staff member O stated some of the staff had been entering the building through a back door and therefore, bypassing the screening area located at the front entrance to the facility. Staff member O stated the front desk receptionist was responsible for screening at the front entrance during office hours, and the facility was working on a system for the off hours. Staff member O stated the facility had been using an electronic kiosk for screening. Staff member O stated the kiosk had not been working recently and they had been using a paper system. During an interview on 4/12/22 at 10:03 a.m., staff member A stated whoever was working the front desk during office hours was responsible for ensuring anyone who entered the building was screened. Staff member A stated this included staff who were entering the facility to work. Staff member A stated staff were on the honor system when it came to screening when there was no one at the front desk. Staff member A stated the facility had advertised for someone who could monitor the screening area when the office was closed but had not had any candidates. Staff member A stated staff member C should have been aware it was her responsibility to ensure staff was screening prior to every shift worked. However, staff member A was not aware if the DON at the time had told staff member C of this responsibility. Review of the facility's staff screening logs for five full-time nurses, dated from 1/1/22 to 3/23/22, showed of 133 shifts worked, there were 63 missed staff screening entries. Surveillance Plan During an interview on 3/29/22 at 10:03 a.m., NF2 stated she should had been in contact with the facility regarding the status of their current outbreak which started in late October of 2021. NF2 stated she was not made aware of the extent of the residents being diagnosed with COVID-19 starting on 1/22/22 until 2/2/22. NF2 stated she received a list of 34 residents who tested positive for COVID-19 between 1/22/22 and 2/2/22. NF2 stated due to the late notification, she was not able to assist the facility with timely management of the outbreak. NF2 stated she was not aware the facility was using crisis staffing strategies by allowing staff who were positive for COVID-19 to care for residents, even those residents who were not positive for COVID-19. During an interview on 3/30/22 at 10:02 a.m., staff member O stated she took over infection control responsibilities from staff member C on 2/1/22. Staff member O stated the facility was on outbreak status when she took over and she was still trying to get a handle on all of the issues related to infection control and COVID-19 management. Staff member O stated she monitored resident infections through reports of antibiotic use generated through the electronic medical record. When asked about surveillance, staff member O stated the facility had not had any infections since she took over. When asked about COVID-19 surveillance, staff member O stated she had not seen any surveillance related to COVID-19 and thought the information was in staff member C's office. During an interview on 3/30/22 at 2:50 p.m., staff member F stated infection surveillance was ongoing and she would provide the log as requested. Review of the infection control line listing since 11/1/21 included a list of residents and staff who tested positive for COVID-19, the date of the positive test, the type of test performed (rapid POC or PCR), and the vaccination status. No other information was found on the line listing which showed any analysis of the data. A request was made on 3/31/22 for the surveillance binder containing surveillance information, analysis, and corrective action related to COVID-19. No binder was provided. After a discussion with staff member C and staff member F, the facility was able to produce case information sheets which had been sent to the Public Health Department in response to positive COVID-19 test results. The facility was not able to produce any documents showing analysis of the information or planned corrective action associated with any identified concerns.

Based on interview, and record review, the facility nursing staff failed to ensure an x-ray was performed in a timely manner, using the emergency room at the hospital, and the physician orders [REDACTED].#3) of 11 sampled residents. Findings include: During an interview on 12/8/20 at 12:23 p.m., resident #3 stated she caught her foot in the wheelchair and fell to the floor, while transferring. Only one CNA was assisting. The CNA was unable to stop resident #3 from falling out of her chair to the floor. Resident #3 stated she had terrible pain in her left ankle right after the accident happened. Resident #3 said the facility did not have x-rays taken in a timely manner. Resident #3 said it took five days to get an x-ray taken of her ankle. Through the x-rays, resident #3 found out she broke her left ankle. Review of resident #3's care plan, with a revision date of 5/8/20, showed, Transfers: Provide me with total assist of 2 for transfers using a hoyer lift. Review of a nurse progress note, dated 9/10/20, showed an evaluation was completed on 9/10/20 earlier at 2:27 p.m., that day. The evaluation showed, Scale: Intake: Output: Resident complains of pain. Pain Description: Pain: 8 (hurts whole lot). Reports that pain is constant. Cool compress applied. Relaxation techniques encouraged. Distraction techniques utilized. Resident position changed. Non-medication interventions did not provide relief. PRN medication provided . Review of a Neurologic Focused Evaluation dated 9/10/20 at 5:25 p.m. showed resident #3 complained of pain, at a pain level of an 8 out of 10, with 10 being the worst pain at 4:00 p.m. Resident #3 was medicated for pain. Review of a Pain Evaluation for resident #3, with an effective date of 9/10/20 at 5:25 p.m. showed resident #3 had an onset of sharp pain, radiating from the distal medial tibia, of the left ankle. Resident #3 verbally stated frequent significant pain, rated at 8 (hurts a whole lot), with an acceptable rate at 5. Routine medication and PRN (as needed) were given for the pain. After time elapsed, from implementation of the medication, the writer documented, nothing relieves all pain. Review of the physician's verbal order, dated 9/10/20 at 8:29 p.m., showed resident #3 was to have a foot/ankle x-ray one time only for possible foot trauma for 1 Day. Review of resident #3's progress notes, dated 9/10/2020 at 10:05 p.m. showed: During a wheelchair-to-bed transfer, res attempted to readjust her positioning causing her to slide to the floor. The CNA present was able to help her land gently and placed her in a safe position on the floor. The CNA then reached out for help to properly maneuver the manlift and place her back in bed. After the incident, the resident began to feel a sharp pain in her L ankle. Ice was applied. The ankle was visually inspected. (Resident #3's provider) requested an X-ray to be taken on 9/11/2020 . Review of the physician's verbal order, dated 9/12/20 at 8:51 a.m., showed resident #3 was to have two x-ray views of the left ankle. Review of resident #3's progress note, dated 9/12/2020 at 10:58 a.m. showed resident #3 was complaining of pain to her left ankle. Resident #3 was unable to touch or move the area without yelling in pain. Resident #3 told the writer that her left ankle had hurt since her fall on Thursday (9/10/20). The provider was notified, and an order was obtained for the mobile x-ray to come to the facility and x-ray the left ankle. The mobile imaging was contacted and stated the ability to do the x-ray the next day. Review of the physician progress notes [REDACTED].#3 had a tibia fracture as a result of her fall on 9/10/20. The physician said to the [MEDICAL CONDITION] with immobilization for 6 weeks with a boot and then re-image. During an interview on 12/9/20 at 10:03 a.m., staff member A stated the reason for delay in x-ray services for resident #3 was due to the local critical access hospital would not accept resident #3 because she had Covid-19. The local mobile x-ray company said they wouldn't come into the building due to COVID-19 in the facility. During an interview on 12/9/20 at 10:35 a.m., staff member N stated the mobile x-ray service would not come into the facility when an order was placed 9/10/20. The facility contacted the provider who gave another order. The mobile x-ray company returned, completing the x-ray in the dining room of the facility. Review of all resident #3's records showed no contact physically or verbally with the local critical access hospital, the local mobile x-ray services, or the local hospital in the town located approximately 15 miles away from the facility to get an x-ray completed for a physician order [REDACTED]. Review of resident #3's care plan on falls had been revised on 11/29/20 to include, providing verbal cues for proper pacing and energy conservation techniques during care so resident does not overcorrect during assistance. There were no updates for the broken ankle which occured during the fall on 9/10/20. During an interview on 12/9/20 at 11:32 a.m., staff member B stated the facility now updates all residents' care plans following a fall. There is a risk management interdisciplinary team which now reviews falls. During an interview on 12/10/20 at 11:18 a.m., staff member A agreed there was a delay in receiving an x-ray for resident #3's left ankle, after her fall on 9/10/20.

Based on observation, interview, and record review, the facility and staff failed to: - Ensure COVID-19 negative residents were not roomed with COVID-19 positive residents for 4 (#20, #43, #44, #45) - Failed to ensure housekeeping staff were dedicated to their appropriate assignments within the facility, to not include COVID-19 isolation rooms, and the non isolation unit areas, in one day's shift, putting all residents at risk if the staff member entered their room and failed to use proper precautions. - The facility failed to ensure the housekeeping staff were following proper PPE precautions for infection control for 1 (#22) - Failed to ensure staff were correctly donning and doffing PPE, and applying PPE prior to entering a COVID-19 positive resident's room, for residents 5 (#6, #22, #48, #49, #50) - Failed to ensure staff were using proper PPE, with adequate training, to include N95 masks, when COVID-19 infected residents were present in the facility - Failed to ensure the correct infection control precaution signage was present throughout the facility, based on the residents isolation needs for residents 10 (#15, #19, #22, #24, #27, #28, #34, #36, #39, #48) - Failed to ensure residents and visitors were adhering to proper visitation precautions to prevent the spread of infection for 1 (#6) - Failed to ensure a COVID-19 positive resident was not within six feet of a COVID-19 negative resident for 2 (#21 and #47) - The facility failed to protect residents from infection, and in total, residents #1 through #43 had positive or presumptively positive (tested /Pending with symptoms) COVID-19 test results as of [DATE]. Residents #1, #3, #9, and #10 were deceased , and residents #14, #31, and #38 were hospitalized as of [DATE]. These deficient practices directly contributed to the spread of the COVID-19 infection within the facility, due to unsafe infection control practices utilized by staff, for the 50 sampled and supplemental residents. Immediate Jeopardy Announcement On [DATE] at 5:35 p.m. an Immediate Jeopardy was announced to the Administrator and Director of Nursing. The Immediate Jeopardy situation was related to F880 - Infection Control, for all residents within the facility. The onsite survey investigation discovered infection control concerns related to resident safety and the spread of COVID-19, as shown above in the facility failures. The Immediate Jeopardy was cited at the Severity and Scope of an L, and upon removal of the immediacy of the deficient practice, would be lowered to an I. The facility did not remove the immediacy prior to the end of the survey on [DATE]. As of [DATE] an acceptable plan to remove the immediacy has not been received by the State Survey Agency. Findings include: 1. Rooming COVID-19 Positive Residents with COVID-19 Negative Residents During an interview with staff member I on [DATE] at 3:59 p.m., staff member I stated they had combined COVID-19 positive and COVID-19 negative residents in the same room. Staff member I reviewed her resident listing and stated rooms [ROOM NUMBERS] each had two residents, and the residents were a combination of COVID-19 positive and negative test results. Residents #44 and #45 were in room [ROOM NUMBER], and residents #43 and #20 were in room [ROOM NUMBER]. 2. Housekeeping Staff Assignments and Proper PPE Precautions During an observation and interview with staff member D on [DATE] at 2:15 p.m., staff member D stated she was cleaning more since COVID-19 had started in the facility, using an approved cleaner or bleach on lights, rails, tables, and everything that residents touch. Staff member D stated, We normally have a housekeeper on COVID-19 (unit), but there was a call-in today so I'm doing the whole building. Staff member D was wearing an N95 mask and stated her mask was definitely snug. During an observation on [DATE] at 2:31 p.m., staff member D applied her PPE (gown and gloves) outside resident #22's room. Staff member D rolled up the reusable gown sleeves to her elbows so that her skin was showing and then put gloves on and entered the resident's room. The resident's room had a droplet precaution sign on the door. During an interview on [DATE] at 2:51 p.m., staff member D stated she did not remember the last time she had any PPE training, hand hygiene training, or training related to COVID-19. Staff member D stated, I think maybe I had training on hand hygiene ,[DATE] months ago, I don't know. I am so tired, I can't even think. We are all working off of no energy. 3. Staff Donning and Doffing PPE During an observation on [DATE] at 2:13 p.m., staff member E exited resident room [ROOM NUMBER] and resident #6 was in the room. Staff member E doffed her reusable gown outside of the resident's room and placed it in an unlabeled clear plastic bag. Staff member E stated, I had to come outside the room to put the gown in a bag because there wasn't anywhere to put it in the resident's room. During an observation on [DATE] at 2:15 p.m., staff member G stepped out of resident room [ROOM NUMBER] into the hallway wearing full PPE and then stepped back into the resident's room and doffed her gown and gloves into the Biohazard bag in the resident's room. Staff member G then walked out of the resident's room and left the resident's door open. Resident #6 was in the room. The resident's door had signage showing the resident was on droplet precautions. During an observation on [DATE] at 2:20 p.m., staff member E walked into resident #6's room without a gown or gloves on. The staff member walked out of the resident's room and did not perform hand hygiene, and then grabbed a disposable gown and donned gloves and gown, and then entered resident's room. Resident #6 was in the room. The resident's door had signage showing the resident was on droplet precautions. During an observation on [DATE] at 2:25 p.m., resident #49 was outside his room [ROOM NUMBER] with a protective face covering. Staff member E walked past and did not instruct the resident to go back into his room. During an observation on [DATE] at 2:31 p.m., staff member D applied her PPE (gown and gloves) outside resident #22's room. Staff member D rolled up the reusable gown sleeves to her elbows so that her skin was showing and then put gloves on and entered the resident's room. The resident's room had a droplet precaution sign on the door. During an observation on [DATE] at 2:36 p.m., staff member E doffed PPE inside resident #48's room [ROOM NUMBER], and then left the room and did not perform hand hygiene. Staff E touched her face-shield and mask, grabbed a new isolation gown, put it over her head, and then sanitized her hands. Staff E then entered resident #6's room [ROOM NUMBER]. During an interview on [DATE] at 2:38 p.m., staff member E stated, I have had handwashing training, training on putting on and taking off PPE and how to use a face shield. There was a lady here last week doing the training. During an interview on [DATE] at 3:00 p.m., staff member B stated anyone showing any symptoms of COVID-19 were on droplet precautions, but the whole facility was on isolation precautions. Staff member B stated the expectation for staff was to wear all PPE face shield or eye protection, a mask, a gown and gloves, and for them to doff their PPE inside the resident's room and change PPE between residents. Staff member B stated, It's been taking around ten days for the results of the COVID-19 tests to come back to the facility. During an interview with staff member B on [DATE] at 3:05 p.m., staff member B stated the facility had provided PPE training to the staff and recently held training during the week of [DATE]th. During an observation on [DATE] at 3:44 p.m., staff member J walked into resident room [ROOM NUMBER] wearing a surgical mask and a face shield but no gloves or a gown. The signage on the door showed keep door closed, and there was a Biohazard bag inside the room. Staff member J left the resident's room [ROOM NUMBER] and did not perform hand hygiene. Staff member J then entered into resident #50's room [ROOM NUMBER] and did not don a gown or gloves. Staff member J removed a food tray from the resident's room and left the resident's room. No hand hygiene was performed upon staff member J leaving the resident's room. There was no door signage on room [ROOM NUMBER] showing if the resident was on isolation precautions. During an interview on [DATE] at 3:45 p.m., staff member J stated I don't know who is on precautions honestly. I never wear PPE when I go into a resident's room because I'm not in there for very long. During an interview with staff member F on [DATE] at 3:45 p.m., staff member F stated she had worked at the facility since the end of [DATE]. Staff member F stated there was COVID-19 in all areas of the facility except for the 300 hall. Staff member F stated she had received PPE training and had completed skills checkoffs for donning and doffing PPE when she started in April. During an interview on [DATE] at 4:02 p.m., staff member I stated most of the residents on the 100 and 400 wings have COVID-19 and tested positive and they are not in the COVID-19 wing because they had milder symptoms. Staff member I stated, This information is what I am going off of, I heard it last Thursday. During an interview with staff member J on [DATE] at 4:10 p.m., staff member J stated, I gown up sometimes, but I have a lot to do, and most of the time I don't gown, the DON made us for awhile, changing gowns on and off. Staff member J stated he had been working at the facility for the past three to four weeks and he had read PPE trainings. During an interview with staff member H on [DATE] at 4:11 p.m., staff member H stated, They gave us PPE, donning/doffing and hand washing training last week. During an interview on [DATE] at 4:13 p.m., staff member H stated she was trained last week on donning and doffing PPE. Staff member H stated, I always wear a gown, gloves, face shield or mask. Then I always take it off after I am done in each resident's room. During an interview with staff member B on [DATE] at 4:19 p.m., staff member B stated he had been doing surveillance in the facility with infection control and when they first started surveying staff, No one was complying. Staff member B stated he had not been documenting the infection control auditing of the staff. Staff member B stated, How do I get staff to comply with infection control? My staff is very young and the battle is hard, it's retention vs. compliance. Staff member B stated last week they had infection control training for the staff. During an observation on [DATE] at 4:31 p.m., staff member H was observed going into room [ROOM NUMBER] without a gown or gloves. During an observation on [DATE] at 4:45 p.m., staff member J donned PPE with a face shield, a surgical mask, a gown and gloves. Staff member J entered room [ROOM NUMBER] and then exited the room without doffing his gown or gloves. Staff member J went over to the food cart that was in the hallway and touched two food trays that had not been delivered to residents yet. Staff member J then went back into room [ROOM NUMBER], doffed his gown and gloves and left the resident's room. A review of the facility's COVID Cluster Line List, dated [DATE], showed residents #1 thru #43 had positive or presumptively positive (tested /Pending with symptoms) COVID-19 test results as of [DATE]. Residents #1, #3, #9, and #10 were deceased , and residents #14, #31, and #38 were hospitalized as of [DATE]. For COVID-19 testing, the first staff member tested positive on [DATE]. The first resident began displaying signs of symptom of the COVID-19 infection on [DATE]. 4. Isolation Mask Use During an interview on [DATE] at 2:05 p.m., staff member B stated the staff not working on the COVID-19 wing are to wear the surgical mask, and a face shield or eye protection. Only the staff working on the COVID-19 wing are to wear the N95. During an interview with staff member B on [DATE] at 3:05 p.m., staff member B stated he started working at the facility in [DATE]. Staff member B stated the facility provided masks to the residents, and the facility staff were using surgical masks. During an observation and interview with staff member H on [DATE] at 3:59 p.m., staff member H was wearing a duck bill N95 mask that was gaping open at the nose and sliding down off the staff member's nose, and not being worn properly. Staff member H stated she was just back to work that day after being off work with COVID-19 for the past three weeks. 5. Infection Control Precaution Signage During an observation on [DATE] at 2:25 p.m., resident #19 in room [ROOM NUMBER] was in her room with the door open. The signage on the door showed droplet precautions. During an observation on [DATE] at 2:25 p.m., resident #39 was in room [ROOM NUMBER], and the door was open. Door signage showed droplet precautions. During an observation on [DATE] at 2:26 p.m., resident #22 was in room [ROOM NUMBER] and the door was open. Door signage stated droplet precautions. Resident #48 was in room [ROOM NUMBER] and the door was open. Door signage showed droplet precautions. During an observation and interview on [DATE] at 2:46 p.m., staff member D stated there was COVID-19 in the hall, past the double doors, and past room [ROOM NUMBER]. No infection control or other signage was present on the closed double doors. During an observation on [DATE] at 3:38 p.m., resident #15 was in room [ROOM NUMBER] and the door was open. Door signage showed droplet precautions. During an observation on [DATE] at 3:40 p.m.: - Resident room [ROOM NUMBER], 102, 103, 104, 105, 106, 112, 403, 402, 404, and 410 did not have any signage showing that the residents were on isolation precautions. - Resident room [ROOM NUMBER] had signage on the door which showed Contact Precautions, and the door was left open. - Resident room [ROOM NUMBER] had signage on the door which showed Contact Precautions, and the door was left open. During an observation on [DATE] at 4:07 p.m., staff member H stated residents in rooms 402A/B (residents #36 and #24), 403A/B (residents #34 and #27), 404A/B, 406A/B, 409A, 410A, and 112A all had COVID-19. Staff member I stated residents in rooms 101A/B, 102A, 103B, 104A, 105B, 106A, 109A, and 112B all had COVID-19. Review of the facility's COVID Cluster Line List dated [DATE], showed resident #15, in room [ROOM NUMBER], had tested positive for COVID-19, and resident #28 in room [ROOM NUMBER] was presumptive positive for COVID-19. 6. Window Visitor Precautions During an observation on [DATE] at 2:31 p.m., resident #6 was seated in a wheelchair in her room, and was talking through an open, screened window with a male visitor on the outside of the building. Neither resident #6, nor the male visitor on the outside of the window, were wearing a protective face mask. During an observation on [DATE] at 2:33 p.m., staff member E donned a gown and gloves outside resident #6's room. Staff member E entered resident #6's room and closed the open window, as requested by resident #6, after the male visitor on the outside of the window had walked away. Staff did not provide safety interventions for the visit. 7. COVID-19 Positive Resident Within Six Feet of COVID-10 Negative Resident During an observation on [DATE] at 3:40 p.m., residents #21 and #47 were outside of their rooms by the nurses' station on the 400 wing. They were both in wheelchairs sitting next to each other closer than 6 feet. Staff members H and I were at the nurse's station, within sight of residents and did not intervene. During an observation on [DATE] at 3:42 p.m., resident #21 was wearing her surgical mask below her chin. During an observation and interview on [DATE] at 3:46 p.m., staff member H stated that resident #21 had tested positive for COVID. She stated the resident does not stay in her room, so they allow her to be by the nurses' station. Staff member H stated resident #47 had tested negative for COVID. Residents #47 and #21 were sitting in wheelchairs, closer than 6 feet apart from each other by the nurses' station. During an interview on [DATE] at 4:02 p.m., staff member I stated most of the residents on the 100 and 400 wings have tested positive for COVID. Staff member I stated they are not in the COVID wing because they have milder symptoms. Staff member I stated, This information is what I am going off of, I heard it last Thursday. During an observation on [DATE] at 4:05 p.m., resident #21 was seated in a wheelchair located near the nurses' station in the 400 hall and was wearing a mask that had fallen down off the resident's face. Staff member I told resident #21 to pull her mask up on her face. Staff member I stated they had tried everything to keep resident #21 in her room, but the resident refused to stay in her room and continued to roam through the halls in her wheelchair, not properly wearing her mask. Staff member I stated resident #21 had tested positive for COVID-19. During an observation and interview on [DATE] at 4:13 p.m., resident #47 was wearing a protective face mask, and was seated in a wheelchair near the nurses' station on the 400 hall. Resident #47 stated she was at the facility for rehab on her leg, and had been tested twice for COVID-19, and was negative both times. A record review of Progress Notes for nursing for resident #3 showed on [DATE]: Residents POA called to speak with nursing about residents condition with the SOB (shortness of breath), LOW 02 (low oxygen), Covid-19 positive and contested lungs . Decision made to send resident to ER (emergency room ) for eval and treatment .Resident left facility around 4:15 (p.m.) tonight via ambulange .02 stats low at 80% . A record review of Progress Notes for nursing for resident #9 showed on [DATE]: CNA alerted this nurse that the PT (patient) was not breathing. This nurse assessed Pt (patient) immidiately (sic). Pt not breathing. Apical pulse was absent for 60 seconds. This nurse attempted to contact POA to notify,m POA did not answer. This nurse left a voicemail for POA to contact facility as soon as possible. This nurse contacted MD (medical doctor), verbal order to release body . A record review of Progress Notes for nursing for resident #10 showed on [DATE]: .Resident is COVID positive. Resident 02 stats continued to drop throughout the day and resident wouldn't allow me to keep the oxygen placed on her face. Later when assessing the resident 02 sats were t (sic) 78% .Resident had a spiked temp of 102.2. MD notified Family notified hustand wanted resident sent to ER for eval and treatment . A record review of Progress Notes for nursing for resident #38 showed on [DATE]: Resident had a decrease in LOC (level of care) would open eyes when calling resident's name but would not keep eyes open. O2 SAT (oxygen saturations) at 86% with oxygen on via NC (nasal cannula. Temp of 100.6. MD notified of change in condition. Resident went to the hospital via ambulance .spoke with (responsible party) of change in condition and of resident going to hospital. Review of the facility's COVID-19 Management policy, showed: I. Infection Control - Resident with known or suspected COVID-19 will follow Standard, Contact and Droplet Precautions with an N-95 or higher-level respirator if available. - Visual alerts and signs will be posted at the entrance and throughout the facility to provide residents and healthcare staff about hand hygiene, respiratory hygiene and cough etiquette. V. Immediate identification and Management of potentially affected residents - The facility will make every effort to designate a unit or a wing, with dedicated healthcare staff to house suspected and positive COVID-19 residents. When a resident is identified as having COVID-19 like symptoms, he/she will be moved to a single, isolation room, with the door closed. - If there is a sustained community transmission or case(s) of COVID-19 in the facility, the facility will restrict residents to their room unless there is a medical necessity to leave their room. In such cases, residents will wear face masks, practice hand hygiene, limit movement in the facility and maintain social distancing (6 feet away from others). VII. Education - The facility will provide education to staff on COVID-19, including but not limited to signs and symptoms, transmission, screening criteria, etc. Review of the Whitefish Care and Rehabilitation Emergency Operations Plan, dated [DATE], showed: - Infectious Disease - Initial Actions - Limit exposure between infected and non-infected persons, consider isolation of ill persons.

Based on observation, interview, and record review, the facility failed to ensure residents were free from emotional harm and felt neglected and scared for 1(#8), provided feeding assistance for a dependent resident for 1 (#1), dressing assistance for 1 (#10), and regularly scheduled baths/showers for dependent residents for 12 (#s 1, 2, *3, *4, 5, *6, 7, *8, 9, 10, 11, 12, 13) of 13 sampled and supplemental residents. Findings include: 1. During an observation on 4/7/20 at 7:37 p.m., resident #8 was found to be lying in her bed, she appeared uncomfortable, she was trying to reposition herself. She looked ungroomed, with matted, greasy hair. During an observation and interview on 4/7/20 at 7:37 p.m., resident #8 stated she had not had a bath in three weeks, she stated she, Had not been out of this bed in weeks. She said it took staff too much time because she was a Hoyer lift, so they don't want to get her up. She went on to say she was flaky and dirty and, I can smell my own crotch. She was lying on a dark blue air mattress with no bottom sheet. It was clear to see the skin flakes all over the mattress. She stated she asks every day to get out of bed and get a shower. She stated, I feel neglected, and scared. I could die in here and rigor mortice could set in before they find me. She said she doesn't get her brief changed often. She stated on Sunday night (4/5/20) I was changed at 10:45 p.m., the next morning I put my call light on at 7:00 a.m., the CNA said she was alone and would come back. It was Monday at 1:10 p.m. when I finally got changed. She said she was very wet with urine. Review of bathing records for resident #8, dated 4/8/20, showed her previous bath was 3/4/20, making it 35 days since she had a shower. Before that, she had a bath or shower on February 4, 7, 11, and 18. In the month of January, she had only received two showers, on the 10th and the 18th. 2. During an observation and interview on 4/8/20 at 12:15 p.m., resident #6 was lying in a recliner chair, hair was greasy with diffuse white flakes throughout hair, and the skin on the resident's face was shiny with several long chin hairs visible. During an interview on 4/8/20 at 2:00 p.m., resident #6 stated she had not showered in at least three weeks but would like to have one. Review of resident #6's Weekly Bath Record, 1/1/20 through 4/9/20, showed: -January-resident bathed four times out of nine scheduled days, -February-resident bathed three times out of eight scheduled days, -March-resident bathed on 3/3/20, -April-resident had no documentation of any baths provided. 3. During an interview on 4/7/20 at 6:52 p.m., resident #5 stated she had not been receiving showers and she was sad and stated, the facility used to be a wonderful place. During an interview on 4/8/20 at 11:05 a.m., resident #5 stated she believed her last bath was on 4/2/20 but was unsure. Resident #5 stated she had an [MEDICAL CONDITION], and the sponge needed to be changed every three days, or the skin around the stoma would breakdown. During an observation and interview on 4/8/20 at 11:12 a.m., staff member C and Q came into the room to take resident #5 to the shower. Resident #5 stated the skin surrounding the stoma was clean due to her diligence in taking care of the site, not the facility's care regarding showers. Review of resident #5 bathing record, showed the following: -March 2020, resident #5 did not receive eight out of nine scheduled showers, with one shower on 3/13/20. -April 2020, resident #5 did not receive two out of two scheduled showers, and received a shower on 4/8/20. -Resident #5 went 25 days without a shower from 3/13/20 to 4/8/20. 4. During an observation on 4/7/20 at 6:35 p.m., resident #3 lowered her bed to the low position, transferred from the wheelchair to the bed, independently without staff assistance, and laid down in the bed. Resident #3's hair was greasy and uncombed, and the resident had short, dark hairs which covered her chin area. During an observation on 4/9/20 at 3:10 p.m., resident #3 still had greasy, uncombed hair, and dark whiskers on her chin. During an interview on 4/9/20 at 4:15 p.m., NF1 stated resident #3 emptied her [MEDICAL CONDITION] bag herself and had put herself to bed on different occasions. Review of resident #3's Weekly Bath Record, January through April 2020, showed: -January-resident bathed six times out of nine scheduled days, -February-resident bathed four times out of eight scheduled days, -March-resident bathed two times out of nine scheduled days, -April-resident had no documentation of bathing days. 5. During an observation and interview on 4/7/20 at 6:28 p.m., resident #7 was lying in bed and had greasy hair. Resident #7 stated, I got a bath last Thursday and it had been a month before that. I'm supposed to get two baths a week. Never get one on Saturday. They are always so short on help. During an interview on 4/7/20 at 6:36 p.m., resident #7 stated there is no ADL assistance from staff to help with daily hygiene or baths. Resident #7 stated her roommate with dementia brought her a wet cloth for her face because staff had not been available to help. Review of resident #7's bathing record, dated 3/1/20 to 4/1/20, showed: -March 2020, resident #7 did not receive seven out of eight scheduled showers, with one shower on 3/18/20. -April 2020, resident #7 did not receive three out of three scheduled showers. -Resident #7 went 21 days without a shower from 3/18/20 to 4/8/20. 6. During an observation and interview on 4/7/20 at 6:05 p.m., resident #13 was feeding resident #1. Resident #13 had gloves on her hands and was sitting in her wheelchair assisting resident #1, who was lying in her bed in a hospital gown with her hair slicked back and greasy in appearance. Resident #13 stated she was not supposed to be feeding her roommate, and it was the third time she had done it. Resident #13 stated she was feeding resident #1 because there was no one to help her eat, and the staff just walk right by, even with the call light on. Resident #1 stated she had not had a shower in quite some time which made her feel terrible. During an observation and interview on 4/8/20 at 9:11 a.m., resident #1 was lying in bed, with the head of the bed raised to 45 degrees. Resident #1 stated, I have not been changed recently and on 4/5/20 I sat for two hours, without being changed, after having a bowel movement. Resident #1 stated it had been at least 12 days since she had been bathed. During an interview on 4/8/20 at 1:53 p.m., staff member I stated she had heard that resident #13 had been feeding resident #1. Review of resident #1's ADL charting, dated April 2020 from 4/1/20 to 4/8/20, showed the resident had not been assisted to eat for 12 meals of 21 total meals. Review of resident #1's ADL charting, dated March 2020, showed the resident had not been assisted to eat for 53 meals of 93 total meals. Resident #1's weight remained stable as her roommate had been assisting her to eat. Review of resident #1's bathing record, dated March 2020, showed, resident #1 received showers on 3/14/20 and 3/18/20. No other showers were documented for the month of March 2020. Review of resident #1's bathing record, dated April 2020 from 4/1/20 to 4/8/20, showed no documented showers. Review of resident #1's care plan, dated 1/1/19, showed the following: -Provide resident with total assist for bathing. -Provide resident with total assist of eating. Resident needs to be fed meals. 7. During an observation and interview on 4/7/20 at 7:40 p.m., resident #10 was sitting in a recliner in blue and white polka dot pajamas, she stated she goes three weeks between showers. Resident #10 stated she did not want to stay in her pajamas as she felt better when she gets ready for the day. Resident #10 stated there was not a lot of staff and things do not get done in a timely manner. Resident #10 stated she did not ask staff for help often, but did need it at times. During an observation and interview on 4/8/20 at 11:45 a.m., resident #10 stated she would like to put on some fresh pajamas as she had these on for 3 days, pointing at her blue and white polka dot pajamas. Resident #10 stated staff had not offered her to get dressed or showered for the day. During an interview on 4/8/20 at 9:10 a.m., staff member M stated he expected residents to be up and dressed for the day by breakfast unless the resident prefers to stay in their pajamas. Staff member M stated he had never seen a shower list for the facility and showers have been a challenge to complete and had not been completed all of the time. During an interview on 4/8/20 at 1:53 p.m., staff member I stated resident care has been affected by sparse staffing. Staff member I stated they have been trying to catch up on showers and would expect that residents are not left in their pajamas all day. During an observation on 4/8/20 at 2:20 p.m., resident #10 was sitting in her recliner in her blue and white polka dot pajamas. During an interview on 4/8/20 at 2:40 p.m., staff member O stated certified nursing assistants should be getting residents dressed. Staff member O stated the management team will be checking activity of daily living sheets to ensure cares are being completed. Review of resident #10's care plan, dated 8/16/19, showed the following: -(Name) requires assistance for ADL care in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting . -Provide (Name) with extensive, assist of 1 for bathing. -The residents care plan does not address the level of assistance the resident requires for dressing. Review of resident #10's dressing assistance record, showed the following: -In March 2020, resident #10 was assisted in dressing 21 times out of 62 times. No refusals were documented. Resident #10 self-performed the task three times in March 2020. -From 4/1/20 to 4/9/20, resident #10 received dressing assistance on 4/2/20. No other assistance had been documented. Review of resident #10's bathing record for 3/1/20 to 4/9/20, showed no documented shower assistance provided to resident #10. 8. During an observation and interview, on 4/7/20 at 6:44 p.m., resident #11 was lying in her bed with long whiskers on her chin, she stated she could not recall when she had a shower last. During an interview on 4/9/20 at 8:24 a.m., staff member J stated he was unsure when resident #11 had been showered last. Staff member J stated on his last shift on 4/7/20 he was too busy and unable to complete showers while trying to figure out the facility as it was his first day at the facility. Review of resident #11's bathing record, dated 3/11/20 to 4/9/20, showed no documented showers since her admission on 3/11/20. 9. During an observation on 4/7/20 at 6:25 p.m., resident #9 was in her room, it smelled of body odor in the room. During an interview on 4/7/20 at 6:25 p.m., resident #9 stated it had been a while since she had a bath and it had been about two weeks. Review of resident #9's bathing record, dated March 2020, showed one documented shower on 3/13/20. No other showers had been documented for the month of March 2020. Review of resident #9's bathing record, dated 4/1/20 to 4/9/20, showed no documented shower for resident #9. Review of resident #9's care plan, dated 5/9/19, showed, Provide at least two showers weekly to promote good hygiene. 10. During an observation and interview on 4/8/20 at 12:08 p.m., resident #4 was sitting in the wheelchair, with visibly greasy, uncombed hair. Review of resident #4's Weekly Bath Record, February through April 2020, showed the last time the resident was bathed was 2/8/20. The records showed no documentation for bathing in the months from 3/1/20 to 4/9/20. 11. During an observation on 4/8/20 at 2:00 p.m., resident #2 was lying in bed with visibly greasy, uncombed hair. Review of resident #2's Weekly Bath Record, January through April 2020, showed: -January-resident bathed two times out of four scheduled days, -February-resident bathed six times out of eight scheduled days, -March-resident had no documentation of bathing, -April-resident had no documentation of bathing. 12. During an interview on 4/9/20 at 8:30 a.m., resident #12 stated that she had not received a shower since admission on 3/23/20. She did say she would like a shower. Review of resident #12's shower record from 3/23/20 to 4/9/20, showed no documented showers. During an interview on 4/8/20 at 2:34 p.m., staff member N stated showers had not been getting done due to staffing shortages. Staff member N stated certified nursing assistants are responsible for giving showers and nurses are responsible to oversee to ensure showers are given. During an interview on 4/9/20 at 2:05 p.m., staff member B stated showers had not been completed. Staff member B stated she had just implemented a new shower schedule. Staff member B stated certified nursing assistants are responsible for giving showers. The floor nurses, and the director of nursing, are ultimately responsible to ensure showers are getting completed. During an interview on 4/9/20 at 3:45 p.m., staff member A stated showering had been identified as a concern since last fall. Staff member A stated the facility is trying to find a solution to ensure showers are being completed through education and a catch up shower day during the week for management oversight. Staff member A stated the director of nursing is responsible for monitoring of showers. Staff member A stated the showers for the day are gone over during morning meetings and stand ups. Review of the facility policy titled, Activities of Daily Living, undated, showed: -Assistance is provided to residents who need extensive or total assistance with maintenance of nutrition, grooming, and personal and oral hygiene. Review of facility policy titled Bath, Shower/Tub, revised February 2018, showed: -The purpose of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. (sic)

Based on observation, interview, and record review, the facility failed to ensure residents received the necessary care and services, by performing timely skin assessments to identify and monitor for any altered skin integrity that lead to unidentified skin breakdown for 3 (#s 1, 2, and *4); and failed to identify skin breakdown that lead to pain for 1 (#*6) of 12 sampled residents. This failure had the potential to affect residents at risk for skin breakdown residing in the facility. Findings include: 1. During an observation and interview on 4/8/20 at 12:15 p.m., resident #6 stated while roommate was being interviewed, I have sores. Resident #6 was assisted by staff member D to stand with a walker, which was located against the wall. The resident's wheelchair was observed against the wall without any cushion on the seat. Staff member D removed resident #6's incontinence brief and the resident's bilateral buttocks had an unidentified, open area on each cheek, surrounded by a five inch by three inch dark purple, non-blanchable area. Resident #6 stated her pain was rated at a five on a scale of one to ten. During an observation and interview on 4/8/20 at 2:30 p.m., resident #6 had reddened areas in her groin and wanted to show staff member D the areas under her breasts. Under both breasts the areas were bright red and resident #6 stated they itched bad. During an interview on 4/8/20 at 2:33 p.m., resident #6 stated she had not told anyone about her bottom and it was not being treated by anyone. The resident's last documented day of bathing was 3/3/20. During an interview on 4/8/20 at 2:52 p.m., resident #6 stated, regarding the cushion for the wheelchair, Haven't had in quite a while. Review of resident #6's Annual MDS, with an ARD of 9/11/19, showed: -Section G, Functional Status, one person, physical assist for transfer, dressing, toilet use, and personal hygiene, -Section H, Bladder and Bowel, always incontinent of urine, -Section I, Active Diagnoses, Hearth Failure, Hypertension, Diabetes Mellitus, Arthritis, [MEDICAL CONDITION], Non-Alzheimer's Dementia, [MEDICAL CONDITION] or [MEDICAL CONDITIONS] Disorder or [MEDICAL CONDITION], Depression, [MEDICAL CONDITIONS], -Section M, Skin Conditions, resident is at risk for developing pressure ulcers/injuries, resident does not have any unhealed pressure ulcers/injuries, pressure reducing device for chair. Review of resident #6's Order Summary Report, dated 4/9/20, showed: -[MEDICATION NAME] Powder apply to groin/breast topically as needed for rash ensure areas are dry before apply. Start date of 11/11/18. There were no physician orders for a pressure relieving device to the wheelchair or monitoring. Review of resident #6's Medication Administration Record, [REDACTED] -applied on 1/28/20, -no application in February, -applied on 3/18/20, -no application in April. Review of resident #6's Weekly Skin Check, dated 1/27/20, showed: -Skin condition: redness, -Other Redness to Rt side of face near temple that is pre-existing. Scabbing present to coccyx, barrier cream applied, -Groin Redness, [MEDICATION NAME] powder applied, -Face Redness to Rt side of face near temple that is pre-existing, -Other Redness below bilat breasts and abdominal fold, [MEDICATION NAME] powder applied, -Other Scabbing present to coccyx, barrier cream applied. Review of resident #6's Weekly Skin Check, dated 2/24/20, showed: -Other skin issue: scab to bilateral buttock, -Resident has scabs to bilateral buttock with blanchable purple surrounding the areas. This nurse applied a [MEDICATION NAME] for protection, -Clinical Suggestions: Skin evaluated for signs of breakdown. Review of resident #6's Weekly Skin Check, dated 3/9/20, showed: -Left buttock-Blanchable purple/redness to buttock, -Barrier cream applied and encouraging offloading as often as possible. 2. During an observation and interview on 4/8/20 at 12:08 p.m., resident #4's skin surrounding her eyes was red and swollen. Resident #4 stated, They hurt. During an observation and interview on 4/8/20 at 2:36 p.m., resident #4's skin surrounding the eyes was more swollen than when it was observed at 12:08 p.m. Resident #4 was itching the eyes and stated the right eye hurts. During an observation on 4/8/20 at 2:40 p.m., staff member D transferred resident #4 from the wheelchair to the bed. Resident #4 did not have a cushion on the seat of the wheelchair. After a urine soaked, incontinence brief was removed, it was observed resident #4 had bilateral, bright red areas on her buttocks. Resident #4 had a small open area on the left buttock, approximately one half inch by one half inch. During an observation and interview on 4/8/20 at 2:45 p.m., resident #4 rolled on to her back from a left sided lying position and vigorously began rubbing her vaginal area with both hands and stated It itches. Resident #4 had reddened, excoriated, bilateral, open areas to her upper thighs near the groin. Review of resident #4's Annual MDS, with an ARD of 11/2/19, showed: -Section G, Functional Status, one person, physical assist for bed mobility, transfer, dressing, toilet use, and personal hygiene, -Section H, Bladder and Bowel, always incontinent of urine and bowel, -Section I, Active Diagnoses, Diabetes Mellitus, [MEDICAL CONDITION] Disorder, [MEDICAL CONDITION], Non-Alzheimer's Dementia, [MEDICAL CONDITION] Disorder or [MEDICAL CONDITION], Depression, [MEDICAL CONDITION]. Review of resident #4's Order Summary Report, dated 4/8/20, showed: -No orders were documented for any skin treatment or increased monitoring of skin conditions except the new orders initiated on 4/8/20, for the treatment of [REDACTED]. after cares, -Roho cushion to wheelchair, check for proper inflation and ensure in good repair, every day shift, start date of 11/13/18. Review of resident #4's Treatment Administration Record, 1/1/20 through 4/8/20, check for pressure relieving cushion, showed: -1/1/20-1/31/20 no documentation for nine out of 31 scheduled days, -2/1/20-2/29/20 no documentation for 12 out of 29 scheduled days, -3/1/20-3/31/20 no documentation for 12 out of 31 scheduled days, -4/1/20-4/8/20 no documentation for three out of eight scheduled days. Review of resident #4's Nursing Progress Notes, dated 3/4/20, showed: -Other Skin Issue: redness, -Resident has non-yeast related redness to groin, MBC applied. -Skin is intact with no areas of concern at this time. There were no clinical suggestions listed. Review of resident #4's Nursing Progress Notes, dated 2/19/20, showed: -Other Skin Issue: redness to groin, MBC applied. -Resident has redness to groin, MBC applied. Skin is intact with no other areas of concern at this time. -Clinical Suggestions: Evaluated, addressed the cause of moisture. Review of resident #4's Weekly Skin Check, dated 4/1/20, showed: -No skin conditions or changes, ulcers, or injuries, -Skin is clean, dry, and intact. Review of resident #4's Weekly Skin Check, dated 2/5/20, showed, no skin conditions or changes, ulcers, or injuries. 3. During an observation on 4/8/20 at 10:00 a.m., resident #1 had a small open area on the coccyx, with a six inch by six inch, dark purple, blanchable area surrounding the coccyx that bled when it was wiped with a moistened, disposable wipe. Review of resident #1's Re-entry MDS, with an ARD of 11/8/19, showed: -Section G, Functional Status, two plus persons physical assist for bed mobility, transfer, dressing, toilet use, and personal hygiene, -Section I, Active Diagnoses, [MEDICAL CONDITION], Hypertension, Diabetes Mellitus, [MEDICAL CONDITIONS] Disorder or [MEDICAL CONDITION], Anxiety Disorder, Depression, Dysphagia, Tinea Unguium, Age-Related [MEDICAL CONDITION], and Muscle Weakness. Review of resident #1's Order Summary Report, dated 4/8/20 showed, Is to be up in wheelchair M,W,F x 3 hours. The order was started on 12/18/19. Review of resident #1's Treatment Administration Record, 1/1/20 through 4/8/20, regarding orders for the resident to be up in the wheelchair, showed: -1/1/20-1/31/20 no documentation for five out of 14 scheduled days, -2/1/20-2/29/20 no documentation for two out of 12 scheduled days, -3/1/20-3/31/20 no documentation for six out of 13 scheduled days, -4/1/20-4/8/20 no documentation for two out of four scheduled days. 4. During an observation on 4/8/20 at 2:00 p.m., resident #2 was lying on her back, barefoot, with heels in direct contact with the bed. There were no heel protectors or heel lifts observed. Resident #2's right heel was reddened, boggy, and non-blanchable when staff member D pressed on it. A blister was present with depressed skin in the middle of the reddened area. Resident #2 had an undressed, small, open area on the coccyx, a non-blanchable, reddened area on her left buttock, and a dark purple, non-blanchable, tiny, non-raised rash, in a line pattern, on the left buttock. The facility had not identified the type of the skin injury to the foot or that it was avoidable. During an interview on 4/8/20 at 2:20 p.m., staff member D stated the facility did not have a wound nurse, they did not think they needed one. Review of resident #2's Admission MDS, with an ARD of 1/23/20, showed: -Section G, Functional Status, two plus persons physical assist for bed mobility, transfer, dressing, toilet use, and personal hygiene, -Section H, Bladder and Bowel, always incontinent of urine, -Section I, Active Diagnoses, [MEDICAL CONDITION] Fibrillation or Other [MEDICAL CONDITION], Hypertension, Diabetes Mellitus, [MEDICAL CONDITIONS], [MEDICAL CONDITIONS], Encounter for Other Orthopedic Aftercare. Review of resident #2's Order Summary Report, dated 4/8/20, showed: -Apply [MEDICATION NAME] then place a silicone border dressing. Change Tue, Thur, Sat. one time a day every Tue, Thu, Sat for wound care to coccyx. -Order started on 3/21/20, There were no documented physician orders for any skin checks. Review of resident #2's Treatment Administration Record, for March and April 2020, showed: -March's record from 3/21/20-3/31/20 showed the dressing to the coccyx was changed on two of the five scheduled days, with three days not done, -April's record from 4/1/20-4/8/20 showed the dressing to the coccyx was changed on one of the three scheduled days, with two days not done. Review of resident #2's Braden Scale Observation/Assessment, dated 1/16/20 and 1/23/20, showed the resident was at risk, with a score of 16. Review of resident #2's Braden Scale Observation/Assessment, dated 1/30/20, showed the resident was at risk, with a score of 17. Review of resident #2's Weekly Skin Check, dated 1/23/20, showed: -Right trochanter (hip) surgical wounds, -Right arm bruising from broken arm. Review of resident #2's Weekly Skin Check, dated 1/30/20, showed no new skin conditions since the last documented skin check. No skin checks were documented after 1/30/20. During an interview on 4/9/20 at 8:08 a.m., NF3 stated only residents that have identified wounds are assessed during a visit and only the residents under the care of NF4. NF3 stated there is not a specific wound care nurse, all nurses report wounds. NF3 stated, I feel all wounds are always avoidable. During an interview on 4/9/20 at 8:14 a.m., NF3 stated, I depend on nursing staff to identify the wounds so I can then assess them for treatment. During an interview on 4/9/20 at 2:16 p.m., staff member B stated, She knows there are skin problems. We are getting ready to do a skin sweep to identify problems and do education. Staff member B stated NF3 does wound assessments every Thursday and only looks at the people the nurses have identified. During an interview on 4/9/20 at 2:56 p.m., staff member D stated she was not sure if there was a policy on when and whom to report skin changes to. Staff member D stated Braden Scales help identify risks and allow precautions to be put in place before skin issues happen. Staff member D stated weekly skin assessments help prevent skin issues. Staff member D stated the resident's provider should always be notified of any changes in skin condition. During an interview on 4/9/20 at 3:19 p.m., staff member C stated any changes in skin condition should be reported to the nurse on that hall as soon as possible. During an interview on 4/9/20 at 3:27 p.m., staff member G stated any skin issues are reported to the medical doctor by calling them or writing a note, depending on the severity. Staff member G stated monitoring staff to ensure they are implementing care planned interventions is the responsibility of the nurse on the unit.

Based on observation, interview, and record review, the facility failed to ensure care needs were met, leading to skin excoriation surrounding the [MEDICAL CONDITION], and to include a physician's orders [REDACTED].#3) of 12 sampled residents. Findings include: During an observation on 4/9/20 at 3:10 p.m., staff member D wheeled resident #3 to her room, to evaluate the resident's [MEDICAL CONDITION]. On resident #3's abdomen, on the lower left side of the adhered [MEDICAL CONDITION] bag, was an opened area with reddened and excoriated skin. The reddened area extended two inches beyond the tape holding the [MEDICAL CONDITION] bag to the abdomen. Resident #3's abdomen, on the right side of the [MEDICAL CONDITION] bag, had a speckled rash, that extended out beyond the tape. During an interview on 4/9/20 at 4:15 p.m., NF1 stated resident #3 emptied her [MEDICAL CONDITION] bag herself on different occasions. Review of resident #3's Admission MDS, with an ARD of 8/28/19, showed: -Section C, Cognitive Patterns, BIMS of 9 (moderate impairment), -Section G, Functional Status, one person, physical assist for bed mobility, transfer, dressing, toilet use, and personal hygiene, -Section G, Balance during Transitions and Walking, Surface-to-surface transfer (transfer between bed and chair or wheelchair) not steady, only able to stabilize with staff assistance, -Section H, Bladder and Bowel, frequently incontinent of urine, -Section H, Bladder and Bowel, Appliances, box not checked for Ostomy (including [MEDICATION NAME], [MEDICAL CONDITION], and [MEDICAL CONDITION]), -Section I, Active Diagnoses, Cancer, [MEDICAL CONDITION], Hypertension, [MEDICAL CONDITION] Reflux Disease, [MEDICAL CONDITIONS], Other Fracture, Non-Alzheimer's Dementia, [MEDICAL CONDITION] Status. Review of resident #3's Order Summary Report, dated 4/9/20, showed no orders for any monitoring or changing of the [MEDICAL CONDITION] bag. Review of resident #3's Treatment Administration Records, for the months of January through April 2020 showed no interventions or parameters for changing the [MEDICAL CONDITION] bag. Review of resident #3's Nursing Progress Notes, dated 3/21/20, showed, Resident room mate reports resident [MEDICAL CONDITION] bag has stunk all day and she alerted staff, reports that staff took her away to another bathroom and 'cleaned her up' brought her back and she still stunk. The room was very odoriferous. Resident had pulled the appliance apart and this was not cleaned up causing wafer to become soiled, roommate reports they knew she was not clean and even commented she had a whole in the bag but did nothing about it. This SN had no choice but to replace appliance again the second time in 3 days, resident is very excoriated and some bleeding noted under wafer. SN did use powder and skin barrier to make a shield for her skin last time and it is showing improvement. SN did this technique again to try and prevent further damage. Will continue to monitor and assess (sic). There was no documentation of any continued monitoring or assessment. Review of resident #3's Progress Notes from 1/1/20 through 4/8/20 showed no documentation mentioning any status of the resident's [MEDICAL CONDITION], other than on 3/21/20. Review of resident #3's Weekly Skin check, dated 1/3/20, showed, Redness below and around stoma site has been present since admission. Review of resident #3's Weekly Skin Check, dated 1/24/20, showed, Redness below and around stoma site has been present since admission. Review of resident #3's Weekly Skin Check, dated 1/31/20, showed no skin conditions or changes, ulcers, or injuries. Review of resident #3's Skin Only Evaluation, dated 2/7/20, showed a lower back faint rash.

Based on interview and record review, the facility failed to prevent neglect for 2 (#s 43 and 52) of 37 sampled residents, resulting in hip dislocation for resident #52 and incontinence for resident #43. Findings include: 1. During an interview on 6/26/19 at 10:17 a.m., resident #52 explained he was admitted to the facility following surgery on his left hip. Resident #52 confirmed he was hospitalized in (MONTH) of 2019 for a hip dislocation and infection. Resident #52 denied experiencing current issues with pain. Review of the Facility Reported Incident regarding resident #52, dated 2/8/19 at 5:15 p.m., showed, Around 330 pm (sic) facility received a call from ER nurse at (hospital). Resident (#52) was transferred to (hospital) earlier with infection to the left hip. Report received that resident did have infection in left hip and hip was dislocated. Upon transfer to (hospital), nurse stated that resident (#52) reported that the woman involved in his care is rough with him especially when he soils himself. Review of the facility's findings of the above incident, submitted on 2/13/19, indicates, .Upon interviewing resident (#52) he stated that CNA (NF1) had been rough with him while providing care. He stated that he was having pain in his hip and was needing to be helped into his wheelchair. He stated that CNA was rough when turning him and preparing him to be transferred. When asked if he believed CNA did it on purpose, he stated she has done this before, she is a big strong girl and he believes she just lost patience with him. Resident (#52) stated he had a good relationship with the CNA, and confirmed that this occurred with another CNA present. That CNA was interviewed and confirmed that CNA (NF1) was present on the night of Wednesday 2/6/19. CNA confirmed that (NF1) and she were getting him up and while doing so she noticed (NF1) being rough and when resident expressed discomfort during care CNA swore out of frustration. Other residents were interviewed throughout the center and voiced no complaints or concerns of anyone being rough with them during cares. CNA (NF1) was suspended immediately after allegation and was subsequently terminated .Re-education was immediately initiated on Abuse and Neglect and immediate reporting to the Abuse Coordinator. The facility's findings report reflected law enforcement was contacted 2/8/19 at 5:20 p.m. During an interview on 6/27/19 at 9:26 a.m., staff member A stated, upon investigating the incident on 2/8/19, the facility had substantiated the abuse allegation. Staff member A stated resident #52 had just had surgery on his hip, which meant resident #52 was at risk for a dislocation. Staff member A explained when NF1 performed perineal care on resident #52 with another CNA, resident #52 refused to turn over. Staff member A stated when NF1 did turn him over, it was too rough, and that dislocated the hip. Staff member A stated, We believe that is what happened, especially since he was already at risk for that. Staff member A explained management would have considered it abuse regardless of whether resident #52 had had surgery on his hip. Staff member A stated he believed the rough care happened on 2/7/19 during the night shift. Staff member A stated he reported NF1 to the CNA Registry and Whitefish Police on 2/8/19. Review of resident #52's Nursing Note, dated 2/5/2019 at 3:16 p.m., showed, This nurse entered room to do resident's Tx to L hip. Incisions to L hip and lateral thigh are well approximated & healed. D/C dressing change at this time; left OTA. No bruising noted to L hip at this time. Will continue to monitor. Review of resident #52's Nursing Note, dated 2/7/2019 at 9:24 p.m., showed, Resident (#52) was up in w/c for supper but refused to let staff place the foot rests on his w/c. Resident (#52) stated they are uncomfortable. Monitored resident while in chair. Resident (#52) remained in upright position and was not sliding in chair at that time. Resident (#52) was able to wheel himself independently back to his room from the dining room and pressed his call button for assistance to go back to bed. Will continue to monitor. Review of Resident #52's Nursing Note, dated 2/8/19 at 11:44 a.m., showed, Resident (#52) was calling out from his room. Resident (#52) stated he was having increased pain to left hip. RN noted the left surgical hip was slightly distended. No redness noted. Left hip was Warm to touch. Resident unable to roll in bed due to pain. RN checked full set of vitals . Resident (#52) sent to (hospital) for [MEDICAL CONDITION] from left hip. RN called report to (staff member) at (hospital's) ER .Pending report from ER for residents status. (sic) Review of NF1's CNA training checklist indicated the facility had completed a resident rights, abuse, and harassment training with NF1 on 12/17/18. Review of NF1's personnel file, verified NF1's employee disciplinary action, dated 2/13/19. Review of the facility's In-Service Trainings on abuse were offered and completed by staff on 2/9/19, 2/11/19, 2/18/19, and 2/19/19. 2. During an interview on 6/24/19 at 3:00 p.m., resident #43 said that recently, it took staff over an hour and a half to answer her call light. The resident said, I messed myself, because I had to wait. Resident #43 said she needed the assistance of staff for transfers and toileting. Review of resident #43's MDS, with an ARD of 5/6/19, showed resident #43 had a BIMs of 10, moderately impaired decision making, and needed total assist with two or more staff with transfers and extensive assist of one person for toileting.

Based on observation, interview, and record review, the facility failed to provide a transportation vehicle to accommodate an extra-wide manual wheelchair for 1 (#61) of 37 sampled residents, and the resident was transferred in a wheelchair that was too small, causing the resident pain and contributing to skin breakdown. Findings include: During an observation on 6/26/19 at 11:13 a.m., skin breakdown was noted on resident #61's posterior left thigh, close to the gluteal fold. The area was approximately 3-4 inches in diameter and was mostly light pink in color, with some darker pink/light red splotches. The area surrounding the skin breakdown was a faded, dull brown. During an interview on 6/26/19 at 11:20 a.m., staff member G stated she had not noticed signs of skin breakdown on resident #61 prior to her observation at 11:13 a.m. Staff member G stated she would inform resident #61's primary physician about the skin breakdown. Staff member G added that resident #61 was taking an antibiotic to [MEDICAL CONDITION]; every time resident #61's provider attempted to remove the antibiotic, resident #61 would exhibit signs and symptoms [MEDICAL CONDITION]. During an observation on 6/26/19 at 11:32 a.m., staff members G, Q, and R returned to resident #61's room to re-examine the area of skin breakdown prior to using a Hoyer lift to move resident #61 into her wheelchair. Staff member R stated she believed the skin breakdown was caused by resident #61's brief and recommended a barrier cream. Resident #61 then stated it had happened earlier that week because she had to be in her smaller wheelchair for her appointment, and the normal chair does not fit on the van. Resident #61 stated she felt a pinching sensation when she sat in the smaller wheelchair. Staff members G, Q, and R, then transferred resident #61 to her extra-wide wheelchair. During an interview on 6/26/19 at 2:34 p.m., staff member Q stated she transferred resident #61 on the morning of 6/24/19, from her extra-wide wheelchair to her smaller wheelchair, prior to resident #61 getting onto the facility's transport van, via the van's lift platform. Staff member Q stated she had noticed resident #61 in pain when resident #61 has had to transfer to the smaller wheelchair, which occurred for off-site appointments only. Staff member Q stated she had told staff member G that the wheelchair was too small. Staff member Q stated, I do not know what to do or what (the facility) would do (to fix it). It is hard to get anything around here. During an interview on 6/26/19 at 2:45 p.m., staff member T confirmed resident #61 had two wheelchairs: the larger of which was provided by the facility, and the smaller, resident #61 had brought from home. Staff member T stated she was the transporter and driver for resident #61's appointment on 6/24/19. Staff member T explained resident #61 had to transfer from her extra-wide wheelchair to her smaller sized wheelchair when going on transports since the van was not suited for that size of extra-wide wheelchairs. Staff member T stated she had brought this issue to management's attention this week, following resident #61's appointment on 6/24/19. During an interview on 6/26/19 at 3:04 p.m., staff member G stated she last performed perineal care with resident #61 on 6/23/19, in the afternoon. Staff member G did not notice skin breakdown at that time. During an interview on 6/26/19 at 3:34 p.m., staff member B stated she was not aware the facility's transportation van did not accommodate that size of extra-wide wheelchairs. Staff member B stated she was going to collaborate with physical therapy to solve the issue. During an interview on 6/26/19 at 3:38 p.m., staff member U stated she was unfamiliar with the width accommodation of the van the facility used for transports, but (the facility) has not had any issues with that. Staff member U stated adjustments could be made to the smaller chair to ensure comfort, such as replacing the armrests, seat cushions, and other lateral supports. During an observation on 6/26/19 at 3:59 p.m., staff member U measured resident #61's wheelchairs. The larger wheelchair's seat measured 30 in width, while the smaller wheelchair's seat measured 24 in width. Staff member U stated, when including the wheels, the larger wheelchair required 38 for clearance, and the smaller wheelchair required 30-32 for clearance. During an interview on 6/26/19 at 4:58 p.m., staff member Q stated she had just turned resident #61 and observed the skin deterioration. She said It looked differently than when I last saw it. She used to have a purplish scar (in the same place where it is now pink). Staff member Q stated she last observed that area of skin, sometime before this past weekend. Review of resident #61's MDS, with an ARD of 6/14/19, showed resident #61 did not have a pressure ulcer at the time of assessment, and was at risk for developing one. Review of resident #61's current care plan lacked information about her wheelchairs. Resident #61's care plan showed the following in regards to skin breakdown: (Resident #61) will not have actual skin breakdown related to [MEDICAL CONDITION] and urinary incontinence. Has a history of chronic redness to lt. (sic) axillary, treat as ordered. Interventions under this goal included: (Resident #61) will be without skin breakdown this quarter; assist in repositioning PRN; do weekly skin assessments as ordered and report changes to MD; evaluate for localized skin problems; evaluate for skin risk problems per protocol; monitor skin for S/S of skin breakdown; observe skin condition with ADL cares daily and report abnormalities.

Based on observation, interview, and record review, the facility failed to prevent two Unstageable pressure ulcers, both of which were acquiried within the facility: one below the left 5th toe, and another on the left heel, the latter of which resulted in an osteo[DIAGNOSES REDACTED] infection of the left heel for 1 (#48) out of 37 sampled residents. Findings include: During an observation on 6/24/19 at 3:03 p.m., resident #48 was observed in bed, resting, with his left foot pressed up against the footboard. Resident #48 was slouched down in the bed, so that his head was about 14 below the top of the bed. Resident #48's head of bed was raised to approximately 35 degrees. Resident #48 was not wearing a supportive boot on his left foot. During an observation on 6/25/19 at 9:27 a.m., staff members W and X entered resident #48's room to perform wound care on resident #48's pressure ulcers. Upon entering resident #48's room, the resident was observed to have his left foot pressed up against the footboard. Pillows, a cushion, and a boot for pressure relief were not observed to be used on the lower extremities. During an interview on 6/25/19 at 9:32 a.m., staff member W explained resident #48 had two Unstageable pressure ulcers, one on the left heel with measurements of 5.6 x 2.2 x 2.9 cm (area x length x width; depth not applicable), and one on the plantar left foot, with measurements 2.8 x 2.0 x 1.9 cm (area x length x width; depth not applicable), just below the pinky toe. Staff member W stated that the pressure ulcer on the plantar left foot was 21% smaller in diameter; however, she was concerned that the depth had increased, as it was diagnosed as an Unstageable pressure ulcer. Staff member W explained resident #48 was diagnosed with [REDACTED]. Staff member W stated resident #48 was non-compliant with wearing the recommended boot to prevent pressure on his left foot. Staff member W stated that last week, she had suspected an infection of the bone related to resident #48's pressure ulcer on his left heel and prescribed an antibiotic. Staff member W stated resident #48 had an MRI scheduled later this week to gather additional information on the effects of the pressure ulcers. During an observation on 6/25/19 at 9:38 a.m., resident #48's sheets had 11 splotches of light red/brown circular stains varying from 1-3 in diameter on the left side of the bed by the footboard. During an interview and observation on 6/25/19 at 9:40 a.m., staff member W stated a different dressing may be helpful since the wound drainage appeared to have leaked through onto the sheet. Staff member X then propped resident #48's left foot on a pillow, with the top half of his foot pressing onto the footboard, where the pressure ulcer was located. Staff member W stated a boot would protect the foot from additional pressure; however, staff have not strapped the boot because they have been worried resident #48 would fall, since he has not used his call light for assistance in the past. After observing wound care, resident #48 was observed lying down in bed, with his left leg positioned diagonally to the right, with his head sliding down in the bed. Staff member W, upon observing resident #48's position, stated she wondered if removing the footboard would be helpful, but was concerned about removing it because she thought he would slide down and out of bed. During an interview on 6/25/19 at 10:07 a.m., staff member Y stated, (resident #48) is supposed to have (the footboard) off because he's noncompliant with the boot. Staff member Y checked for an order for [REDACTED]. I know (the pressure ulcers) were in-house acquired. During an observation on 6/25/19 at 11:44 a.m., resident #48 was observed lying in bed, with his left foot in a supportive boot, which was pushed up against the footboard. Resident #48's left leg was slightly bent and angled to the right, with no support under the knee. During an interview on 6/25/19 at 3:37 p.m., staff member Z stated she did not know the cause of the pressure ulcers. Staff member Z stated, (Staff) will float (resident #48's) heels, but he is aggressive, or he will kick them off. We do not know the cause; (resident #48) has had ulcers since his arrival. (Staff) try to scoot him up in bed, but he adjusts his bed himself and will often slip back down. Staff member Z was unaware of any potential alterations to resident #48's footboard or bed. During an observation on 6/26/19 at 8:22 a.m., resident #48 was in his wheelchair, moving independently in his room, and using his left foot and right hand to propel himself forward and backward. Resident #48 pulled the bedside table close to his torso to play cards. Resident #48 had socks on his left foot; his left heel was resting on the floor without a boot or other supportive device. During an interview on 6/26/19 at 8:42 a.m., staff member B stated resident #48's pressure ulcer on his left heel was discovered 5/31/19; the pressure ulcer on the plantar side of his left foot was discovered 6/10/19. Staff member B stated, (Staff) have tried to change the bed previously, but he refuses. (Resident #48) is noncompliant. Staff member B stated that staff have not done a root cause analysis for resident #48's pressure ulcer at this point. Staff member B stated, Resident #48 is more agreeable when you use short and 'to-the-point' sentences. In regard to future interventions for resident #48, staff member B explained that the plan was to switch out resident #48's bed while he was off-site for his MRI later in the week. During an observation on 6/27/19 at 9:26 a.m., resident #48 was sitting in his wheelchair on the window side of his bed. Resident #48 was wearing a sock and did not have a boot on his foot. The boot was not observed to be in his bed. Resident #48 stated his foot hurt a little bit today and confirmed he had an appointment for an MRI in the afternoon. Upon record review, resident #48's Quarterly MDS, with an ARD of 5/31/19, under Section M, showed resident #48 did not have a pressure ulcer/injury, a scar over a bony prominence, or a non-removable dressing/device. The facility's policy titled, Prevention of Pressure Ulcers/Injuries, showed, Teach residents who can change positions independently the importance of repositioning. Provide support devices and assistance as needed . Select appropriate support surfaces based on the resident's mobility, continence, skin moisture and perfusion, body size, weight, and overall risk factors . Evaluate, report and document potential changes in the skin; review the interventions and strategies for effectiveness on an ongoing basis.

Based on record review and interview, the facility failed to adequately manage a resident's pain, and assess mood, for a resident who voiced wanting to end [MEDICAL TREATMENT] treatment due to pain, for 1 (#3) of 15 sampled residents. Findings include: 1. Review of the Progress Note for resident #3, dated 9/19/16, showed C/O pain in right elbow, slightly swollen. The documentation did not show steps taken by the RN to address the pain and swelling. Review of the Physical Therapy note for resident #3, dated 9/19/16, showed Patient reporting increased pain right upper extremity and swelling at the elbow. The therapy note showed the resident had declined ambulation, and had pain with movement. The documentation does not show what steps were taken to address the pain. Review of the resident's Progress Note, dated 9/22/16, showed Pain has limited day to day activities intensity using the Numeric Rating Scale: 8. The pt is not experiencing new pain or new signs/symptoms of pain, therefore, a pain evaluation was not indicated. The pt's acceptable level of pain using a 0-10 scale is : 0 (no pain). The resident is satisfied with his/her current level of pain. Although the resident was satisfied with her pain level, the documentation showed it limited the resident's day to day activities. Review of the Physical Therapy note for resident #3, dated 9/23/16, showed Secondary to increased right arm pain yesterday patient was unable to ambulate. Patient had significant increase in right shoulder and arm pain yesterday to the point where patient was unable to transfer out of bed. The documentation does not show steps taken to address the pain. Review of the Progress Note for resident #3, dated 9/25/16, showed Suspected deep tissue injury on right elbow. Somewhat boggy. Intact. Cleansed and bordered gauze dressing applied . experiencing pain. 10/10. At 2:43 a.m., the resident was complaining of pain in the elbow. At 10:16 a.m., the nurse documented the apparent bruise was noted. The area was inflamed, skin taut, and pint. The documentation showed the pain was controlled with [MEDICATION NAME]. Review of the Progress Note for resident #3, dated 9/26/16, showed Resident receiving prn [MEDICATION NAME] q 4h for pain control of elbow pain. Wound RN in to assess elbow dressing and skin. A review of the resident's MAR, TAR, and PRN Pain Flow Sheets for September 2016, showed daily monitoring of the elbow on the left forearm did not start until 9/27/16. The resident had not utilized PRN pain medication until 9/28/16, and this was [MEDICATION NAME], and given for pain in the right arm. Time administered shows, 20 and the pain was rated at a 7, which is severe/horrible pain. The PRN Flow Sheets for the resident did not reflect the [MEDICATION NAME] was provided every four hours as needed, as documented in the nursing note on 9/26/16. Review of the Wound Clinic Notes, dated 9/30/16, showed a pressure ulcer of the right elbow, was unstageable. The pressure ulcer measures 4 cm x 4.5 cm x 0.2 cm. The patient scores the pain as 10 on a scale of 0 to 10. Review of the resident's Progress Note dated 9/30/16, showed for resident #3 tolerating cares well but grimaces in pain if anyone touches elbow. A review of the resident's care card, utilized by the CNA staff who provided ADL care for the resident, did no include information relating to pain, or directives on how to provide care to alleviate pain in the area of the elbow. Review of the [MEDICAL TREATMENT] Clinic note, dated 10/7/16, showed (The resident) has not been completing full [MEDICAL TREATMENT] treatments due to pain/anxiety. This has reached a point that it is becoming life-endangering. Please note the stronger dose of [MEDICATION NAME]. Review of the resident's Progress Note, dated 10/8/16, showed Resident again refused [MEDICAL TREATMENT] this AM. Review of the [MEDICAL TREATMENT] Communication Record, dated 10/8/16, showed Please note fax sent yesterday - we need physician to state quantity for [MEDICATION NAME] 0.5 mg and [MEDICATION NAME] 7.5 - 325 mg before they will release. Without we can not dispense. Review of the physician's orders [REDACTED]. The order was not written and signed by the physician until 10/10/16. Review of the [MEDICAL TREATMENT] Communication Record, dated 10/11/16, showed the [MEDICAL TREATMENT] clinic requested information which showed, Please indicate times given (referring to [MEDICATION NAME] and [MEDICATION NAME]) so the clinic would know when to give the next dose. The resident was complaining of pain, and this was rated at a 7 out of 10 being the worst. The clinic also documented, Pt c/o being accused of 'faking pain' and she was provided encouragement and goals discussed. Review of the 60-day MDS with the ARD of 10/11/16 showed the resident had frequent pain that interfered with daily activities and sleep. Review of the [MEDICAL TREATMENT] Communication Record, dated 10/13/16, showed Pt c/o severe pain during latter half of treatment. Please send pt with pain medication. During an interview on 1/10/17, NF3 stated the resident was in excruciating pain and she had decided to stop her wound care and [MEDICAL TREATMENT] treatments. A review of the resident's Care Plan, showed the resident was at risk for alterations in comfort, and the resident's right elbow pain and open area was on the plan. The plan did not include evidence for what steps staff should take when providing direct care (ADLs) to the area, or what direct care staff should do if the resident was experiencing pain, to ensure the resident's needs were met. 2. Review of resident #3's [DIAGNOSES REDACTED]. Review of the current and past physician orders [REDACTED]. Review of the PT notes dated 10/5/16, showed Patient was also crying at one point of our conversation because she's been thinking about stopping [MEDICAL TREATMENT] and going on hospice. The nurse was made aware of the patient's condition this morning. During an interview on 1/10/17 at 10:25 a.m., staff member M stated she was not aware of the crying episode with the resident. When asked about resident #3's mood, staff member M stated she thought she was doing ok. She said she was doing better. When asked about the resident's [DIAGNOSES REDACTED].#3's sister said she was not compliant with taking medication. Review of the care plan dated 8/17/16 showed depression was not identified as an area of concern for resident #3. During an interview on 1/12/17 at 9:05 a.m., NF4 stated the resident did have chronic pain that was difficult to manage. (The resident) was having a very hard time. She felt comfortable talking to me, and was thinking about stopping her [MEDICAL TREATMENT]. Some days were worse.

Based on observation, interview and record review, the facility failed to adequately identify and thoroughly assess, then implement interventions for a pressure ulcer to the elbow, which caused severe pain and later became infected, for 1 (#3) of 15 sampled residents. Findings include: Review of the facility Progress Note for resident #3, dated 9/19/16, showed C/O pain in right elbow, slightly swollen. Review of the Physical Therapy note for resident #3, dated 9/19/16, showed Patient reporting increased pain right upper extremity and swelling at the elbow. Review of the Physical Therapy note for resident #3, dated 9/23/16, showed Secondary to increased right arm pain yesterday patient was unable to ambulate. Patient had significant increase in right shoulder and arm pain yesterday to the point where patient was unable to transfer out of bed. During an interview on 1/11/16 at 3:15 p.m., non-staff member NF2 stated she did not look at resident #3's elbow, because she thought the pain was from her fistula. Review of the Progress Note for resident #3, dated 9/25/16, showed Suspected deep tissue injury on right elbow. Somewhat boggy. Intact. Cleansed and bordered gauze dressing applied . experiencing pain. 10/10. Review of the Progress Note for resident #3, dated 9/26/16, showed Resident receiving prn [MEDICATION NAME] q 4h for pain control of elbow pain. Wound RN in to assess elbow dressing and skin. During an interview on 1/12/17 at 8:10 a.m., staff member E stated she did look at resident #3's elbow on 9/27/16, but did not document the encounter. She stated she did not know what to call the wound, and was waiting to hear from the physician. She also said she did not think it was a deep tissue injury, because it was open when she saw it. Review of the Progress Note for resident #3, dated 9/27/16, showed [MEDICAL TREATMENT] nurse called facility at 8:30 to state pt not tolerating treatment and due to right arm/elbow pain and drainage, they were transferring her to ER for evaluation. Returned from ER with ABO for suspected infection of right elbow. Review of the ER discharge Notes, dated 9/27/16, showed Right elbow breakdown of the skin. Evaluation wound clinic later this week for care of what could become an ulcer. There is an eschar appearing circular 3-4 cm over the olicranon process. Review of the Wound Clinic Notes, dated 9/30/16, showed a pressure ulcer of the right elbow, unstageable. The pressure ulcer measures 4 cm x 4.5 cm x 0.2 cm. The patient scores the pain as 10 on a scale of 0 to 10. There is a modest amount of serosanguineous exudate draining from the pressure ulcer. The pressure ulcer base is described as containing pink granulation, has slough, and is covered with a necrotic eschar. Review of the physician visit, dated 10/3/16, showed resident #3 stated her elbow had hurt since her original fall on 8/13/16. She stated she frequently pushed herself up in bed with her elbows. Review of a physician order [REDACTED].*Off-load by any means ** possible! VERY IMPORTANT!! Has to keep pressure off elbow!!! The way the order was written showed the writer was attempting to highlight the necessity of the order with the punctuation used. During an interview on 1/10/17 at 9:15 a.m., NF3 stated she came to the facility on e day, and resident #3's elbow was wrapped in gauze. A CNA asked NF3 if she knew (resident #3) had a hole in her elbow. Approximately early October she kept telling them her arm hurt. At no time did they ever change her position or move her around. She laid with her arm flat on the bed for most of the day. She only got up to use commode or go to [MEDICAL TREATMENT]. About a week later she developed a full blown pressure sore. They wrapped it but still just let it lay there. During an interview on 1/11/17 at 10:50 a.m., staff member G stated she remembered resident #3 came in with a bruise on her elbow. She stated she could not remember what the open wound looked like, because she dressed a lot of wounds. During an interview on 1/11/17 at 2:55 p.m., NF1 stated the wound looked pretty bad at the wound clinic on 9/30/16. During an interview on 1/12/17 at 9:25 a.m., staff member K stated she had not known about the open area on resident #3's elbow until a week after the initial identification of the deep tissue injury. She stated the resident had a scab on her elbow at some point, and it had resolved. She also said the doctor thought the open area may have been related to an underlying infection. During an interview on 1/12/17 at 1:55 p.m., staff member J stated the elbow pads used for reducing pressure were too painful for the resident to use. Review of the Care Plan for the open area showed an initiation date of 9/30/16, 5 days after the deep tissue injury was discovered, and pressure reduction interventions were dated 10/5/16. During an interview on 1/12/17 at 10.15 a.m., staff member L stated she did remember something on resident #3's elbow, but it had resolved. She thought the new open area was healing, but could not recall what it looked like. She stated she sent the resident to the hospital on [DATE], and thought she might not make it. Review of the Progress Notes, dated 10/13/16, showed a change in medical condition for resident #3. Her temperature was recorded at 103.4, pulse was 166, and blood pressure was 88/52. Review of the hospital admission note dated 10/13/16, showed the resident had [MEDICAL CONDITION]. Review of the Wound clinic notes showed resident #3 continued with wound care until 10/19/16 and passed away on 10/23/16.

Based on record review and interview, the facility failed to give scheduled pain and anxiety medication and document the presence of pain for 1 (#1) of 5 sampled residents, resulting in increased pain, agitation, and a fall. Findings include: Resident #1 was admitted to the facility on [DATE]. The [DIAGNOSES REDACTED]. The resident passed away on 4/29/16, while on hospice care. Review of resident #1's Medication Administration Record [REDACTED]. She was also prescribed as needed pain medication, [MEDICATION NAME] 10 MG 2 tablets by mouth every 6 hours as needed, with a start date of 2/2/16; and [MEDICATION NAME] sulfate 20 MG/ML, .25 ml by mouth every 1 hour as needed, with a start date of 12/18/15. The resident only received the [MEDICATION NAME] 5 times between 4/8/16 and 4/14/16. She received the [MEDICATION NAME] sulfate one time a day, in the morning, on 4/3, 4/5, 4/6, 4/10, 4/11, 4/13, 4/15 and 4/17. On 4/19 she received two doses, and on 4/9 and 4/18, she received 3 doses. Review of resident #1's pain monitoring section of the MAR, from 4/1/16 to 4/18/16, reflected the day shift failed to mark a yes or a no regarding the resident's pain on 12 of 18 days. The resident responded with a yes on the other six. Review of the night shift showed the resident responded yes to being in pain every shift, except on 4/13/16, the MAR indicated [REDACTED]. However, review of resident #1's PRN Pain Management Flow Sheet reflected the resident received a PRN pain medication only two times in 18 shifts, on the night shift from 4/1/16 to 4/18/16. Review of nursing notes from 4/1/16 to 4/19/16 reflected a skin condition being followed, and IDT notes regarding falls on 3/5/16, 3/11/16 and 3/19/16, and pain related to those falls. There were no other dates in which the nursing notes documented resident #1's internal pain. On 4/19/16, a nursing note described the resident as having increased agitation, yelling out, crying, hitting staff, grabbing at air (sic), spitting medications out, climbing out of bed and trying to stand up out of the wheel chair without assistance. Consequently, on this day the physician discontinued the resident's PRN pain and anxiety medications and started the scheduled medications for pain, agitation, and anxiety. In a confidential interview on 7/7/16 at 8:30 a.m., the interviewee stated the medications were changed to scheduled on 4/19/16 because of resident #1's increased pain, agitation, and anxiety, where PRN medications were not enough. [MEDICATION NAME] was added to the scheduled regimen for agitation. The newly ordered medications were also of a type that could be slipped into the cheek or under the tongue to dissolve, or placed rectally, so doses would not be missed, as the resident was approaching the end of life. Review of the hospice nursing notes for resident #1 reflected an incident note, dated 4/27/16 to the medical director of the hospice service regarding resident #1 not receiving her scheduled medication. The note described a period of eight days where the resident did not receive eight doses of [MEDICATION NAME], five doses of [MEDICATION NAME] sulfate, and three doses of [MEDICATION NAME]. The hospice incident note said the resident had increased anxiety, crying, attempting to get out of bed or the wheelchair, and had one non-injury fall on 4/25/16. Further review of resident #1's MAR indicated [REDACTED]. On 4/26/16, the resident did not receive her first two doses of [MEDICATION NAME] for the day, making it 5 consecutive doses of [MEDICATION NAME] that were missed.