Every finding on record at Bigfork Valley Communities

Based on observation, interview and document review, the facility failed to protect the residents' right to be free from mental and physical abuse from a resident (R4) for 5 of 6 residents (R5, R6, R7, R8, R9). This resulted in psychosocial harm for R5, R6, R7, R8, R9 who displayed and or/verbalized fear which included avoiding R4 and using garbage cans to barricade doors to prevent R4 from entering their rooms. Findings include: R4 R4's admission Record indicated she was admitted to the facility 5/21/26. R4's diagnoses included Alzheimer's disease, dementia with behavioral disturbance and aphasia (a communication disorder affecting speech, understanding, reading, and writing due to brain injury). R4's Comprehensive Behavioral assessment dated [DATE], indicated R4 had daily behaviors directed toward staff. R4's behaviors included screaming in the dining room and attempts to argue with other residents, taking other's belongings and food. The assessment indicated R4's behaviors were a safety concern. R4 had advanced dementia and was unable to communicate needs, had aphasia, jumbled words and phrases that did not make sense. R4 admitted from home where she displayed behaviors. Safety concerns related to impulsiveness and was not redirectable. R4's admission Minimum Data Set (MDS) dated [DATE], identified severe cognitive impairment and indicated she displayed physical, verbal and other behaviors directed toward others. R4's MDS indicated she was able to transfer and ambulate independently. Care Area Assessment (CAA) dated 6/1/26, indicated R4 yelled out at meals, approached other residents with the intention to take their food and would get angry and scream at other residents. It was unclear whether behaviors were provoked or not. R4's behaviors occurred in large crowds and during cares which could signal fear in a new environment. Family reported that R4 displayed the same behaviors in her previous living situation. R4's care plan identified severe dementia with behaviors. Care planned interventions with date initiated indicated: 5/29/26- Leave R4 in a safe place and return with new staff if agitated and/or aggressive. 5/29/26- Started on Seroquel for aggression, physical behaviors of hitting, punching, taking other's belongings and behaviors toward other residents. 5/29/26- Family reported R4 had increased agitation from 11:00 a.m. to 12:00 p.m. She may be getting hungry. Give R4 small snack. 6/12/26- Approach in a calm manner, R4 did not like large groups of people and became agitated during mealtime. 6/12/26- R4 got anxious between 2:00 p.m. and 4:00 p.m., and family suggested having her fold towels. 6/12/26- R4 got anxious eating in common areas and did not like large groups of people, if upset move her to activity area for meal. 6/15/26 Allow R4 to wander or walk to help get rid of energy. Keep her safe and know her whereabouts. R4's Progress Notes identified the following: 5/21/26- R4 entered another resident's room and screamed when staff attempted to assist her out of the room. 5/22/26- R4 entered other resident rooms. Stop signs were placed across resident room doors and R4 would go under the banner. 5/23/26- During report, staff heard a door slam. R4 was in another resident's room, standing against the door. R4 was pushing on the door trying to prevent staff from entering the room. The other resident was telling R4 to get out but denied any physical altercation. 5/25/26- R4 hit staff, kicked doors and ducked in and out of rooms under the stop sign. 5/27/26- R4 was yelling, aggressive and hit at staff and residents in dining area. 6/7/26- R4's aggressive, violent behaviors had increased over the weekend. Behaviors included R4 entering other resident rooms with terrorizing behaviors. 6/22/26- R4 started pushing another resident (R5) in her wheelchair and ran R5 into a post. After residents went into the dining room, R4 suddenly stood up and struck R5 on the arm. 6/22/26- R9 sat next to R4. R4 became angry and hit the other resident in the leg and chest. 6/25/26- R4 entered other residents' rooms all evening. Took bedding from a sleeping resident, threw another resident's belongings on the floor. R4 had altercation with R6, wandered into R6's room, became aggressive, grabbed R6's arm and broke R6's bracelets. 6/28/26- R4 was observed walking past R7 who was in the doorway of R7's room. R4 hit R7 in the face with an open hand. 7/2/26- R4 emerged from her room and unprovoked, walked over and hit R5 who was seated in the common area. 7/5/26- R4 was in R7's room and threw an object which hit R7. 7/6/26- R4 was hitting, kicking, spitting and yelling at other residents and visiting family. 7/7/26- R4 was hitting, kicking, spitting and yelling at other residents. 7/9/26/26- R4 was uncooperative and easily enraged with attempt at toileting or cares. Removed own incontinent brief and pants in common area. Another resident told R4 to stop screaming and be nice to staff. R4 later attempted to push another resident in their wheelchair which was unwanted by the other resident who pushed R4's hands away. R4 became upset, yelled loudly and tried to hit the other resident. R4 had socks in her hands and mostly hit the other resident with the socks. Staff had to stand between the two residents. Initial Incident Report dated 6/22/26, indicated R4 approached R9, appeared angry and struck R9 in the leg and chest. Facility investigation dated 6/23/26, indicated R4 was unable to be interviewed and more information from staff was requested. No redness, pain or discomfort noted for R9. E-mail from staff member to the administrator, licensed social worker (LSW) and interim director of nursing (DON) dated 6/22/26, indicated R4 hit R9 in the chest and the face. R5 R5's admission Record indicated she was admitted to the facility 9/5/23. R5's diagnoses included dementia without behaviors, anxiety and depression. R5's quarterly MDS dated [DATE], identified severe cognitive impairment and indicated she did not display behaviors. R5's MDS indicated she ambulated independently up to 50 feet and required assistance from staff for longer distances. R5's care plan dated 8/15/25, identified behaviors that included crying, wanting to call family and isolating herself in her room. The care plan identified R5 as a vulnerable adult and directed staff to allow her to make choices related to meals, activities and clothing. R6 R6's admission Record indicated she was admitted to the facility 7/24/24. R6's diagnoses included dementia, anxiety and depression. R6's quarterly MDS dated [DATE], identified moderate cognitive impairment and indicated she displayed verbal behaviors directed toward others. The MDS indicated R6 ambulated independently with the use of a walker. R6's care plan dated 6/2/25, identified short term memory loss and indicated she displayed verbal aggression toward other residents by making rude comments to them. Behaviors included crying, isolating herself in room and irritability. The care plan further identified R6 as a vulnerable adult due to placement in the facility. R7 R7's admission Record indicated she was admitted to the facility 2/6/25. R7's diagnoses included Alzheimer's disease, bipolar disorder and dementia without behaviors. R7's quarterly MDS dated [DATE], identified severe cognitive impairment and indicated she did not display behaviors. R7 ambulated independently with the use of a walker. R7's care plan dated 4/22/26, identified behaviors that included crying, feelings of loneliness, persistent worry and fear. The care plan identified impaired cognitive function and identified her as a vulnerable adult due to medical diagnosis. R8 R8's admission Record indicated she was admitted to the facility 9/18/23. R8's diagnoses included Multiple Sclerosis and contractures. R8's quarterly MDS dated [DATE], identified intact cognition and indicated she did not display behaviors. R8 was dependent on staff for transfers, did not ambulate and was dependent on staff for wheelchair mobility. R8's care plan dated 4/22/26, identified her as a vulnerable adult related to placement in the facility. R9 R9's admission Record indicated she was admitted to the facility 7/2/25. R9's diagnosis included Alzheimer's disease. R9's quarterly MDS dated [DATE], identified severe cognitive impairment and indicated she displayed physical behaviors directed toward others. R9 was independent with transfers and ambulation. During Interview on 7/9/26 at 2:02 p.m., R8 stated, It's been hell because of R4. R8 stated residents had to be locked in their rooms because R4 went on rampages and stated, The last one lasted a long time. R8 denied being hurt by R4 but stated, [R4] would crouch down and look at me under the stop sign banner. She's a sneaky old bird. Everyone is terrified of her. R8 confirmed she was also afraid of R4, Oh yes, very much so. I can't move or get out of bed without someone else helping me. [R4] has gone into other rooms and hit people while they were sleeping. Earlier this morning she [R4] was on a rampage again. During interview on 7/9/26 at 3:39 p.m., registered nurse (RN)-A stated a past weekend she worked R4 was on a rampage, screaming, hitting out, scratching, biting and kicking. You never know when it will happen. Staff tried to keep eyes on [R4] but they couldn't catch her every time or always get there in time. When R4 hit other residents, staff tried to step in between the residents. RN-A stated she had seen R4 hit R5, just the other day, R4 hit R5 in the chest with a baby doll. That same weekend, R4 had thrown an object at R7 and hit her but was unsure what was thrown or where it hit R7. RN-A stated R4 entered other resident rooms, and it upset the other residents. RN-A stated R7 was afraid of R4 and would go out of her way to ensure she did not cross paths with R4. R7 is not able to communicate her fear of R4. R6 gets upset about R4 and would get, worked up, R5 had been hit by R4 but RN-A did not think R5 would remember it. R5 was not able to verbalize her fear of R4. R8 was afraid of R4 and would not go within an inch of her. RN-A said R9 also would not remember it but had been close to fighting with R4. During interview on 7/9/26 at 3:59 p.m., with the licensed social worker (LSW) and interim director of nursing (DON), the LSW stated resident-to-resident altercations were documented in the progress notes and an incident report was completed. The LSW said staff were looking at variables to R4's behaviors and had tried different interventions which included a baby doll, one-to-one, music and folding towels. Neither the DON nor the LSW knew what had occurred earlier in the day when R4 was yelling at and became physically aggressive towards other residents. The LSW said staff had been doing a great job of keeping eyes on R4 and attempting to intervene when she was agitated. The LSW stated she had reached out to a behavioral unit to assist with R4's behaviors. During interview on 7/9/26 at 4:12 p.m., nursing assistant (NA)-A stated almost every time she worked, R4 got agitated, yelled, kicked, screamed and hit. Sometimes, [R4] would be walking and would go into a resident room and hit them. [R4] has hit [R5], [R7] and [R9]. [R4] has probably yelled at just about everyone on the unit. NA-A said she could tell other residents including R5, R6, R8 and R9 were afraid of R4. If these residents crossed paths with R4 they would turn around. During interview on 7/9/26 at 4:18 p.m., R6 stated, [R4] is a psycho. [R4] came into my room one time and grabbed my arm. I had to pull her hand off me. She knows I don't like her. She [R4] throws fits and gets wild. I told the nurses, if she [R4] gets after me, I'll smack her. R6 said she would shut her door and put her garbage can in front of it so it will make noise and wake her up if R4 tried to come into the room. During interview on 7/10/26 at 9:04 a.m., licensed practical nurse (LPN)-A stated when R4 did not take her medications she got out of hand and went into other resident rooms. The other day [R4] was sitting by the bird cage and was unprovoked, she hit [R5] on the leg. LPN-A said R4 has also been aggressive toward R6 and R7. LPN-A said stops signs were used on other residents' doors and LPN-A has needed to shut doors, Its like putting them on lockdown when [R4] is out of control, until she calms down. LPN-A said it bothered the other residents to be stuck in their rooms. If [R4] went into other residents' rooms, staff tried to intervene and remove her. During interview on 7/10/26 at 9:14 a.m., NA-B stated R4 had hit R6 and said when R4 wandered into R6's room, R6 would scream and tell R4 to get out. NA-B had not heard other residents say they were afraid of R4 but a lot of residents made comments about R4. NA-B said R6 and R8 made comments about R4 and stated, I wouldn't be shocked if some of the residents are scared but haven't said anything. NA-B said they have not received training on how to deal with a violent resident, staff tried to remove R4 or give her space when she was agitated. During interview on 7/10/26 at 12:04 p.m., R7's family member (FM)-A stated he was not aware R7 had been hit by R4. FM-A said he did not think R7 would remember the incident other than immediately after. FM-A felt R7 would probably be more nervous than scared. During interview on 7/10/26 at approximately 1:00 p.m., RN-B stated she saw R4 strike R5 on more than one occasion. R5 was very even tempered and could not put two and two together. When R4 went into R7's room, R7 would scream and yell. RN-B said R7 told RN-B she was, scared to death, of R4. R7 closed her door and put a trash can in front of it at night because she was afraid of R4. During interview on 7/10/26 at 1:49 p.m., the LSW stated that after a resident-to-resident incident occurred, staff should put interventions in place to prevent it from happening again and to protect other residents. Facility policy Senior Services Abuse Prevention Plan dated 12/2024, indicated each individual had the right to be free from verbal, sexual, physical and mental abuse including mistreatment, neglect and involuntary seclusion. The policy indicated in the event of suspected mistreatment; the needs of the resident will be immediately addressed. Immediate steps should be taken to ensure that no resident remains in danger of mistreatment.

Based on interview and document review the facility failed to report to the state agency (SA) resident-to-resident abuse that resulted in mental anguish for 4 of 6 residents (R5, R6, R7, R8) reviewed for abuse.Findings include:R4R4's admission Record indicated she was admitted to the facility 5/21/26. R4's diagnoses included Alzheimer's disease, dementia with behavioral disturbance and aphasia (a communication disorder affecting speech, understanding, reading, and writing due to brain injury).R4's Comprehensive Behavioral assessment dated [DATE], indicated R4 had daily behaviors directed toward staff. R4's behaviors included screaming in the dining room and attempts to argue with other residents, taking other's belongings and food. The assessment indicated R4's behaviors were a safety concern. R4 had advanced dementia and was unable to communicate needs, had aphasia, jumbled words and phrases that did not make sense. R4 admitted from home where she displayed behaviors. Safety concerns related to impulsiveness and was not redirectable.R4's care plan dated 5/29/26, identified dementia, severe with behaviors.R4's Progress Notes identified the following:5/21/26- R4 entered another resident's room and screamed when staff attempted to assist her out of the room.5/22/26- R4 entered other resident rooms. Stop signs were placed across resident room doors and R4 would go under the banner.5/23/26- During report, staff heard a door slam. R4 was in another resident's room, standing against the door. R4 was pushing on the door trying to prevent staff from entering the room. The other resident was telling R4 to get out but denied any physical altercation.5/25/26- R4 hit staff, kicked doors and ducked in and out of rooms under the stop sign.5/27/26- R4 was yelling, aggressive and hit at staff and residents in dining area.6/7/26- R4's aggressive, violent behaviors had increased over the weekend. Behaviors included R4 entering other resident rooms with terrorizing behaviors.6/22/26- R4 started pushing another resident (R5) in her wheelchair and ran R5 into a post. After residents went into the dining room, R4 suddenly stood up and struck R5 on the arm.6/22/26- R9 sat next to R4. R4 became angry and hit the other resident in the leg and chest.6/25/26- R4 entered other residents' rooms all evening. Took bedding from a sleeping resident, threw another resident's belongings on the floor. R4 had altercation with R6, wandered into R6's room, became aggressive, grabbed R6's arm and broke R6's bracelets.6/28/26- R4 was observed walking past R7 who was in the doorway of R7's room. R4 hit R7 in the face with an open hand.7/2/26- R4 emerged from her room and unprovoked, walked over and hit R5 who was seated in the common area.7/5/26- R4 was in R7's room and threw an object which hit R7.7/6/26- R4 was hitting, kicking, spitting and yelling at other residents and visiting family.7/7/26- R4 was hitting, kicking, spitting and yelling at other residents.7/9/26/26- R4 was uncooperative and easily enraged with attempt at toileting or cares. Removed own incontinent brief and pants in common area. Another resident told R4 to stop screaming and be nice to staff. R4 later attempted to push another resident in their wheelchair which was unwanted by the other resident who pushed R4's hands away. R4 became upset, yelled loudly and tried to hit the other resident. R4 had socks in her hands and mostly hit the other resident with the socks. Staff had to stand between the two residents.R5R5's admission Record indicated she was admitted to the facility 9/5/23. R5's diagnoses included dementia without behaviors, anxiety and depression.R5's quarterly MDS dated [DATE], identified severe cognitive impairment and indicated she did not display behaviors. R5's MDS indicated she ambulated independently up to 50 feet and required assistance from staff for longer distances.R5's care plan dated 8/15/25, identified behaviors that included crying, wanting to call family and isolating herself in her room. The care plan identified R5 as a vulnerable adult and directed staff to allow her to make choices related to meals, activities and clothing.R6R6's admission Record indicated she was admitted to the facility 7/24/24. R6's diagnoses included dementia, anxiety and depression.R6's quarterly MDS dated [DATE], identified moderate cognitive impairment and indicated she displayed verbal behaviors directed toward others. The MDS indicated R6 ambulated independently with the use of a walker.R6's care plan dated 6/2/25, identified short term memory loss and indicated she displayed verbal aggression toward other residents by making rude comments to them. Behaviors included crying, isolating herself in room and irritability. The care plan further identified R6 as a vulnerable adult due to placement in the facility.R7R7's admission Record indicated she was admitted to the facility 2/6/25. R7's diagnoses included Alzheimer's disease, bipolar disorder and dementia without behaviors.R7's quarterly MDS dated [DATE], identified severe cognitive impairment and indicated she did not display behaviors. R7 ambulated independently with the use of a walker.R7's care plan dated 4/22/26, identified behaviors that included crying, feelings of loneliness, persistent worry and fear. The care plan identified impaired cognitive function and identified her as a vulnerable adult due to medical diagnosis.R8R8's admission Record indicated she was admitted to the facility 9/18/23. R8's diagnoses included Multiple Sclerosis and contractures.R8's quarterly MDS dated [DATE], identified intact cognition and indicated she did not display behaviors. R8 was dependent on staff for transfers, did not ambulate and was dependent on staff for wheelchair mobility.R8's care plan dated 4/22/26, identified her as a vulnerable adult related to placement in the facility.During Interview on 7/9/26 at 2:02 p.m., R8 stated, It's been hell because of R4. R8 stated residents had to be locked in their rooms because R4 went on rampages and stated, The last one lasted a long time. R8 denied being hurt by R4 but stated, [R4] would crouch down and look at me under the stop sign banner. She's a sneaky old bird. Everyone is terrified of her. R8 confirmed she was also afraid of R4, Oh yes, very much so. I can't move or get out of bed without someone else helping me. [R4] has gone into other rooms and hit people while they were sleeping. Earlier this morning she [R4] was on a rampage again.During interview on 7/9/26 at 3:39 p.m., registered nurse (RN)-A stated a past weekend she worked R4 was on a rampage, screaming, hitting out, scratching, biting and kicking. You never know when it will happen. Staff tried to keep eyes on [R4] but they couldn't catch her every time or always get there in time. When R4 hit other residents, staff tried to step in between the residents. RN-A stated she had seen R4 hit R5, just the other day, R4 hit R5 in the chest with a baby doll. That same weekend, R4 had thrown an object at R7 and hit her but was unsure what was thrown or where it hit R7. RN-A stated R4 entered other resident rooms, and it upset the other residents. R7 was afraid of R4 and would go out of her way to ensure she did not cross paths with R4. R6 got upset about R4 and would get, worked up, R5 had been hit by R4 but RN-A did not think R5 would remember it. R8 was afraid of R4 and would not go within an inch of her. During interview on 7/9/26 at 4:12 p.m., Nursing assistant (NA)-A stated almost every time she worked, R4 got agitated, yelled, kicked, screamed and hit. NA-A said sometimes, R4 would be walking and would go into a resident room and hit them. NA-A said R4 had hit R5, R7 and R9 and had probably yelled at just about everyone on the unit. NA-A said she could tell other residents including R5, R6, and R8 were afraid of R4 and said if they crossed paths with R4 they would turn around.During interview on 7/9/26 at 4:18 p.m., R6 stated, [R4] is a psycho. [R4] came into my room one time and grabbed my arm. I had to pull her hand off me. She knows I don't like her. She [R4] throws fits and gets wild. I told the nurses, if she [R4] gets after me, I'll smack her. R6 said she would shut her door and put her garbage can in front of it so it will make noise and wake her up if R4 tried to come into the room.During interview on 7/10/26 at 9:04 a.m., licensed practical nurse (LPN)-A stated when R4 did not take her medications she got out of hand and went into other resident rooms. The other day [R4] was sitting by the bird cage and was unprovoked, she hit [R5] on the leg. LPN-A said R4 has also been aggressive toward R6 and R7. LPN-A said stops signs were used on other residents' doors and LPN-A has needed to shut doors, Its like putting them on lockdown when [R4] is out of control, until she calms down. LPN-A said it bothered the other residents to be stuck in their rooms. If [R4] went into other residents' rooms, staff tried to intervene and remove her.During interview on 7/10/26 at 9:22 a.m., the LSW stated she was only able to locate one incident report related to R4's resident-to-resident altercations dated 6/22/26.During interview on 7/10/26 at 9:14 a.m., NA-B stated R4 had hit R6 and said when R4 wandered into R6's room, R6 would scream and tell R4 to get out. NA-B had not heard other residents say they were afraid of R4 but a lot of residents made comments about R4. NA-B said R6 and R8 made comments about R4 and stated, I wouldn't be shocked if some of the residents are scared but haven't said anything. NA-B said they have not received training on how to deal with a violent resident, staff tried to remove R4 or give her space when she was agitated.During interview on 7/10/26 at 12:04 p.m., R7's family member (FM)-A stated he was not aware R7 had been hit by R4. FM-A said he did not think R7 would remember the incident other than immediately after. FM-A felt R7 would probably be more nervous than scared.During interview on 7/10/26 at approximately 1:00 p.m., RN-B stated she saw R4 strike R5 on more than one occasion. R5 was very even tempered and could not put two and two together. When R4 went into R7's room, R7 would scream and yell. RN-B said R7 told RN-B she was, scared to death, of R4. R7 closed her door and put a trash can in front of it at night because she was afraid of R4.During interview on 7/10/26 at 1:49 p.m., the interim director of nursing stated the resident-to-resident incidents for R4 towards other residents were not reported because R4 had dementia and no physical injuries had occurred.Facility policy Senior Services Abuse Prevention Plan dated 12/2024, indicated each individual had the right to be free from verbal, sexual, physical and mental abuse including mistreatment, neglect and involuntary seclusion. The policy indicated alleged abuse must be reported to the state agency no later than 24 hours if the events did not result in serious bodily injury.

Based on interview and document review the facility failed to thoroughly investigate and failed to implement protection interventions resulting in ongoing incidents of physical abuse for 4 of 6 residents (R4, R5, R6, R7) reviewed for resident-to-resident abuse.Findings include:R4R4's admission Record indicated she was admitted to the facility 5/21/26. R4's diagnoses included Alzheimer's disease, dementia with behavioral disturbance and aphasia (a communication disorder affecting speech, understanding, reading, and writing due to brain injury).R4's Comprehensive Behavioral assessment dated [DATE], indicated R4 had daily behaviors directed toward staff. R4's behaviors included screaming in the dining room and attempts to argue with other residents, taking other's belongings and food. The assessment indicated R4's behaviors were a safety concern. R4 had advanced dementia and was unable to communicate needs, had aphasia, jumbled words and phrases that did not make sense. R4 admitted from home where she displayed behaviors. Safety concerns related to impulsiveness and was not redirectable.R4's admission Minimum Data Set (MDS) dated [DATE], identified severe cognitive impairment and indicated she displayed physical, verbal and other behaviors directed toward others. R4's MDS indicated she was able to transfer and ambulate independently. Care Area Assessment (CAA) dated 6/1/26, indicated R4 yelled out at meals, approached other residents with the intention to take their food and would get angry and scream at other residents. It was unclear whether behaviors were provoked or not. R4's behaviors occurred in large crowds and during cares which could signal fear in a new environment. Family reported that R4 displayed the same behaviors in her previous living situation.R4's care plan identified severe dementia with behaviors. Care planned interventions with date initiated indicated:5/29/26- Leave R4 in a safe place and return with new staff if agitated and/or aggressive. 5/29/26- Started on Seroquel for aggression, physical behaviors of hitting, punching, taking other's belongings and behaviors toward other residents.5/29/26- Family reported R4 had increased agitation from 11:00 a.m. to 12:00 p.m. She may be getting hungry. Give R4 small snack.6/12/26- Approach in a calm manner, R4 did not like large groups of people and became agitated during mealtime. 6/12/26- R4 got anxious between 2:00 p.m. and 4:00 p.m., and family suggested having her fold towels.6/12/26- R4 got anxious eating in common areas and did not like large groups of people, if upset move her to activity area for meal.6/15/26 Allow R4 to wander or walk to help get rid of energy. Keep her safe and know her whereabouts.R4's care plan lacked evidence and/or interventions for abuse toward other residents.R4's Progress Notes identified the following:5/21/26- R4 entered another resident's room and screamed when staff attempted to assist her out of the room.5/22/26- R4 entered other resident rooms. Stop signs were placed across resident room doors and R4 would go under the banner.5/23/26- During report, staff heard a door slam. R4 was in another resident's room, standing against the door. R4 was pushing on the door trying to prevent staff from entering the room. The other resident was telling R4 to get out but denied any physical altercation.5/25/26- R4 hit staff, kicked doors and ducked in and out of rooms under the stop sign.5/27/26- R4 was yelling, aggressive and hit at staff and residents in dining area.6/7/26- R4's aggressive, violent behaviors had increased over the weekend. Behaviors included R4 entering other resident rooms with terrorizing behaviors.6/22/26- R4 started pushing another resident (R5) in her wheelchair and ran R5 into a post. After residents went into the dining room, R4 suddenly stood up and struck R5 on the arm.6/22/26- R9 sat next to R4. R4 became angry and hit the other resident in the leg and chest.6/25/26- R4 entered other residents' rooms all evening. Took bedding from a sleeping resident, threw another resident's belongings on the floor. R4 had altercation with R6, wandered into R6's room, became aggressive, grabbed R6's arm and broke R6's bracelets.6/28/26- R4 was observed walking past R7 who was in the doorway of R7's room. R4 hit R7 in the face with an open hand.7/2/26- R4 emerged from her room and unprovoked, walked over and hit R5 who was seated in the common area.7/5/26- R4 was in R7's room and threw an object which hit R7.7/6/26- R4 was hitting, kicking, spitting and yelling at other residents and visiting family.7/7/26- R4 was hitting, kicking, spitting and yelling at other residents.7/9/26/26- R4 was uncooperative and easily enraged with attempt at toileting or cares. Removed own incontinent brief and pants in common area. Another resident told R4 to stop screaming and be nice to staff. R4 later attempted to push another resident in their wheelchair which was unwanted by the other resident who pushed R4's hands away. R4 became upset, yelled loudly and tried to hit the other resident. R4 had socks in her hands and mostly hit the other resident with the socks. Staff had to stand between the two residents.R5R5's admission Record indicated she was admitted to the facility 9/5/23. R5's diagnoses included dementia without behaviors, anxiety and depression.R5's quarterly MDS dated [DATE], identified severe cognitive impairment and indicated she did not display behaviors. R5's MDS indicated she ambulated independently up to 50 feet and required assistance from staff for longer distances.R5's care plan dated 8/15/25, identified behaviors that included crying, wanting to call family and isolating herself in her room. The care plan identified R5 as a vulnerable adult and directed staff to allow her to make choices related to meals, activities and clothing.R6R6's admission Record indicated she was admitted to the facility 7/24/24. R6's diagnoses included dementia, anxiety and depression.R6's quarterly MDS dated [DATE], identified moderate cognitive impairment and indicated she displayed verbal behaviors directed toward others. The MDS indicated R6 ambulated independently with the use of a walker.R6's care plan dated 6/2/25, identified short term memory loss and indicated she displayed verbal aggression toward other residents by making rude comments to them. Behaviors included crying, isolating herself in room and irritability. The care plan further identified R6 as a vulnerable adult due to placement in the facility.R7R7's admission Record indicated she was admitted to the facility 2/6/25. R7's diagnoses included Alzheimer's disease, bipolar disorder and dementia without behaviors.R7's quarterly MDS dated [DATE], identified severe cognitive impairment and indicated she did not display behaviors. R7 ambulated independently with the use of a walker.R7's care plan dated 4/22/26, identified behaviors that included crying, feelings of loneliness, persistent worry and fear. The care plan identified impaired cognitive function and identified her as a vulnerable adult due to medical diagnosis.During interview on 7/9/26 at 3:39 p.m., registered nurse (RN)-A stated a past weekend she worked R4 was on a rampage, screaming, hitting out, scratching, biting and kicking. You never know when it will happen. Staff tried to keep eyes on [R4] but they couldn't catch her every time or always get there in time. When R4 hit other residents, staff tried to step in between the residents. RN-A stated she had seen R4 hit R5, just the other day, R4 hit R5 in the chest with a baby doll. That same weekend, R4 had thrown an object at R7 and hit her but was unsure what was thrown or where it hit R7. RN-A stated when a resident-to-resident incident occurred, a behavior note was placed in the progress note. RN-A said she was not aware if an incident report needed to be completed.During interview on 7/9/26 at 3:59 p.m., with the licensed social worker (LSW) and interim director of nursing (DON), the LSW stated resident-to-resident altercations were documented in the progress notes and an incident report was completed. The LSW said staff were looking at variables to R4's behaviors and had tried different interventions which included a baby doll, one-to-one, music and folding towels. Neither the DON nor the LSW knew what had occurred earlier in the day when R4 was yelling at and became physically aggressive towards other residents. The LSW said staff had been doing a great job of keeping eyes on R4 and attempting to intervene when she was agitated. The LSW stated she had reached out to a behavioral unit to assist with R4's behaviors.During interview on 7/10/26 at 9:04 a.m., licensed practical nurse (LPN)-A stated when R4 did not take her medications she got out of hand and went into other resident rooms. LPN-A said the other day R4 was sitting by the bird cage and unprovoked, hit R5 on the leg. LPN-A said R4 had also been aggressive toward R6 and R7. LPN-A said when R4 was out of control there were stop signs on other residents doors and said she had to shut resident doors, put them on lockdown until R4 calmed down. LPN-A said it bothered the other residents to be stuck in their rooms. LPN-A said if R4 went into other residents rooms, staff tried to intervene and remove R4.During interview on 7/10/26 at 9:22 a.m., the LSW stated she was only able to locate one incident report related to R4's resident-to-resident altercations dated 6/22/26.During interview on 7/10/26 at 12:04 p.m., R7's family member (FM)-A stated he had not been aware R7 had been hit by R4.During interview on 7/10/26 at approximately 1:00 p.m., RN-B stated she saw R4 strike R5 on more than one occasion. R5 was very even tempered and could not put two and two together. When R4 went into R7's room, R7 would scream and yell. RN-B said R7 told RN-B she was, scared to death, of R4. R7 closed her door and put a trash can in front of it at night because she was afraid of R4. RN-B said when a resident-to-resident altercation occurred staff documented in a progress note, no incident report form was completed.During interview on 7/10/26 at 1:49 p.m., the LSW stated after a resident-to-resident incident occurred, staff should have completed an incident report that included which residents were involved, staff who witnessed the incidents and the nature of the incident as well as interventions. The LSW stated staff should have followed-up following the incidents with both skin checks and emotional status of the residents.Facility policy Senior Services Abuse Prevention Plan dated 12/2024, indicated in the event of suspected mistreatment, the needs of the resident will be immediately addressed. Immediate steps should be taken to ensure that no resident remains in danger of mistreatment. Residents responsible party and physician should be notified as soon as possible. Follow up in the form of additional medical and psychological examination and treatment will be documented and implemented.

Based on interview and document review, the facility failed to complete a medication assessment per doctor's orders for 1 of 5 resident (R19) reviewed for unnecessary medication. Findings include:R19's annual Minimum Data Set (MDS) dated [DATE], identified R19 had moderate cognition, and diagnoses included Alzheimer's disease, anxiety, and depression. R19 received antianxiety medication 4 days and antidepressant medication 7 days during the assessment period.R19's nurses communication form to the physician dated 11/5/25, identified R19 continued to tolerate lorazepam 0.5 mg three times daily, had no increased lethargy or sedation and requested to continue as ordered previously and re-assess in 30 days. The communication was signed by medical doctor (MD)-A on 11/6/25.R19's signed medication order dated 11/5/25, identified continue lorazepam 0.5 mg oral tablet give 0.5 mg by mouth three times a day for anxiety, re-assess on 12/6/25.R19's medical record failed to identify R19 was reassessed for continued use of lorazepam on 12/6/25, as ordered. On 12/10/25 at 9:29 a.m., the director of nursing (DON) stated there was a reminder on the treatment administration record (TAR) reminding the nurse on 12/6/25, to reassess the resident and notify the doctor of the results, to ensure the resident still needed lorazepam. On 12/6/25, registered nurse (RN)-B had signed the TAR reminder. DON was unable to find documentation that R19 had been reassessed, or the doctor was notified. RN-B approached and stated she had been working on 12/6/25 and had signed off the TAR reminder. RN-B stated she would have completed a progress note if the reassessment was completed and faxed to the doctor. After review of the medical record, RN-B stated she had failed to reassess the resident according to orders and failed to fax the doctor. Further, RN-B stated the family wouldn't allow the lorazepam to be discontinue but staff still needed to fax the doctor with updates and to get a continued order to ensure R19 still needed the medication. The LTC Physician Order Communication policy approved date 1/25, identified each resident must be under the care of a licensed physician authorized to practice medicine in this state and must be seen by physician at least every sixty (60) days. A current list of orders must be maintained in the clinical record of each resident and physician orders/progress notes must be signed and dated every thirty (30) days. Nurse to provider communications is faxed to the clinic on an as needed basis. Physicians will address areas of concerns or FYI and return the communication forms via fax. Once received the nurse will review/implement/and communicate any new orders.

Based on observation, interview, and document review the facility failed to include the daily census and actual hours worked by nursing staff. This had the potential to affect all 21 residents, staff and visitors who wished to review the information. Findings include:On 12/10/25 at 7:59 a.m., the daily staff postings hanging on a corkboard on the wall next to the Aspen Circle entrance, there was staff postings grouped together dated 12/10/25 through 12/21/25, with 12/10/25 on top of the postings, The postings identified the date, registered nurse (RN) hours, licensed practical nurse (LPN) hours, nursing assistant (NA) hours and additional hours for orientation. The forms failed to identify the resident census as well as the total number of actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift. On 12/10/25 at 12:10 p.m., the director of nursing (DON) stated there was not a place within the facility that showed the resident census or how many and type of staff were working on a particular shift. The daily staff posting was updated every day and included the facility name, date and hours for RN, licensed staff and NA's. The posting did not include the census, and hours were not divided between shifts.The Posting Direct Care Daily Staffing Numbers policy approved 1/25, identified the facility would post on a daily basis for each shift, the number of nursing personnel responsible for providing direct care to residents. The shift staffing information would be recorded on the Nursing Staff Directly Responsible for Residents Care form for each shift and would include: The name of the facility. The date for which the information is posted.The resident census at the beginning of the shift for which the information was posted. Twenty-four (24)-hour shift schedule operated by the facility. Type (RN, LPN, TMA or NA) and category (licensed or non-licensed) of nursing staff working during that shift. The actual time worked during that shift for each category and type of nursing staff. Total number of licensed and non-licensed nursing staff working for the posted shift.

Based on interview and document review the facility failed to follow up on grievances related to call light response times for 2 of 3 residents (R1, R4) reviewed for grievances.Findings include:R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 required substantial to maximal assistance for bed mobility, was dependent on staff for transfers and was always incontinent of bowel. R1's care plan identified limited physical mobility and directed staff to assist with positioning using two staff and indicated he was dependent on staff for transfers using a mechanical lift.R1's undated admission Record identified R1 admitted to the facility on [DATE]. Diagnosis included paraplegia, neuromuscular dysfunction of bladder and a stage IV pressure ulcer (a full-thickness tissue loss where exposed bone, tendon, or muscle is visible or directly palpable in the wound bed). R1's care plan dated 7/11/25, identified bowel incontinence, high risk for pressure injuries and a self-care deficit. The care plan indicated R1 required assistance from two staff for bed mobility, toileting and was dependent on staff for transfer using a mechanical lift.R4's care plan dated 7/11/25, indicated a potential for impaired skin integrity, risk for falls, self-care deficit and bowel and bladder incontinence. The care plan indicated R2 required assistance from two staff for toileting needs and was dependent on staff for transfers using a mechanical lift.R4's undated admission Record indicated R4 admitted to the facility 7/10/25. Diagnosis included multiple sclerosis, paraplegia. dependence on wheelchair and obesity.The facility concern/grievance forms indicated the following:9/29/25, care concern reported related to call light response times. Met with staff to ask about all light wait times. Nursing assistants (NA)'s on day shift stated morning were longer wait times due to answering previous lights and cares for other residents. Afternoon NA's reported they will answer the light but id another NA is not available they have to wait longer. Call light report showed longer wait times but did note other lights on prior to R1 and R2's with residents also requiring two staff assist. Staff to continue to check in with R1 and R2.10/6/25, Concern made by R1 about waiting a long time for call light to be answered. Met with R1 and R2 who reported waiting a long time for staff to answer light. Scheduler and health unit coordinator assisted with cares that day. Staff to continue to monitor call lights.On 11/14/25 at 10:32 a.m., R1 and R4 were interviewed. R1 stated staff had not been answering call lights for up to as long as two hours. R1 said the facility took action and completed audits but said the call lights were still on for a full hour, sometimes. R1 said staff were supposed to answer the light to see if there was an immediate need but indicated that had not been happening. R1 said he felt waiting thirty minutes for call lights to be answered was reasonable. R1 stated the social worker (SW) had spoken to him for the first time earlier in the day. R2 said staff did not come to assist her to get up this morning until after 9:00 a.m. Review of facility call light logs identified the following: 11/4/25, R4 placed the call light on at 7:47 a.m. Staff responded to the light at 9:11 a.m., one hour and 23 minutes later. 11/4/25, R1 placed his call light on at 7:57 a.m. Staff responded to the light at 9:07 a.m., one hour and 10 minutes later.11/4/25, R4 placed the call light on at 12:31 p.m. Staff responded to the light at 2:01 p.m., one hour and thirty minutes later.11/5/25, R1 placed the call light on at 8:05 a.m. Staff responded to the light at 9:07 a.m., one hour and two minutes later.11/5/25, R4 placed the call light on at 12:26 p.m. Staff responded to the light at 1:41 p.m., one hour and 15 minutes later.11/7/25, R4 placed the call light on at 12:35 p.m. Staff responded to the light at 1:39 p.m., one hour and 4 minutes later.11/8/25, R1 and R4 both placed their call lights on at 8:11 a.m., the lights were answered by staff at 9:10 a.m., 58 minutes later.11/11/25, R4 placed the call light on at 8:17 p.m. Staff responded to the call light at 9:20 p.m., one hour and three minutes later.11/11/25, R4 placed the call light on at 12:43 p.m. Staff responded to the light at 1:42 p.m., 59 minutes later.11/12/25, R1 placed the call light on at 5:15 p.m., Staff responded to the call light at 6:54 p.m., one hour and 38 minutes later.11/13/25, R1 placed the call light on at 8:09 a.m. Staff responded to the light at 9:45 a.m., one hour and 35 minutes later.11/13/25, R4 placed the call light on at 8:20 a.m. Staff responded to the light at 9:35 a.m., one hour and fourteen minutes later.11/13/25, R1 placed his call light on at 12:33 p.m., Staff responded to the light at 1:36 p.m., one hour and three minutes later.11/14/25, R4 placed her call light on at 8:06 a.m. The call light was answered by staff at 9:03 a.m., 57 minutes later.On 11/14/25 at 11:33 a.m., NA-A and NA-B were interviewed. NA-B stated they were able to monitor call lights on the unit outside the secured area and carried pagers and a monitor that showed up red when a call light was on. NA-B said because they were on a dementia unit they were told safety on that unit came first. NA-B said staff were not assigned to the three residents outside the secured unit. NA-A said sometimes they got over there on time and some days it took longer. NA-B said cares always got done but lights took longer to answer.During interview on 11/14/25 at 12:49 p.m., licensed social workier (LSW)-A stated the facility had been tracking the call light times and having been trying to bring in more staff. LSW-A said the facility lost a lot of staff when school started. LSW-A said R1 and R4 required to people for cares and had noticed some of the other two person assists also waited for additional staff assistance.A policy related to call light response was requested but not received.

Based on observation, interview and document review, the facility failed to assist with personal hygiene as directed by the care plan for 1 of 3 (R17) residents reviewed for activities of daily living (ADLs). Findings include: R17's quarterly Minimum Data Set (MDS) dated [DATE], identified R17 was cognitively aware with diagnoses that included malignant neoplasm of accessory sinus (sinus cavity cancer), type 2 diabetes, heart failure and hypertension. R17 required set up or clean up assistance with personal hygiene and R17 completed the activity. R17's care plan dated 7/1/24, identified R17 required extensive assist of one staff for personal hygiene. During an observation on 10/21/24 at 6:20 p.m., R17 was lying in bed on his left side. R17 had dried, dark red blood that had oozed from his left nostril to the left corner of his mouth and onto R17's beard. R17 hair was greasy and disheveled. During an observation on 10/22/24 at 9:36 a.m., RN-A administered R17's Lantus injection. R17 was lying in bed and was wearing the same long-sleeved t-shirt and sweatpants as the evening prior. R17's hair continued to be greasy and R17 continued to have the dried dark red blood from his left nostril to the corner of his mouth and bear. R17 attempted to move his pillow under his head but his pillowcase was coming off exposing half of the pillow with an approximately 6-inch diameter circle of dried blood. RN-A stated, let me help you with that and, without putting on gloves, replaced the soiled pillowcase on R17's pillow and put it under R17's head. RN-A administered R17's medication but did not offer personal hygiene to R17 nor offered clean linens. - At 11:45 a.m., R17 was observed outside sitting in his wheelchair with a visitor on the covered porch area. R17 continued to have dried blood from his left nostril down his mustache to the left corner of his mouth and R17's disheveled hair is sticking out of the hood of his [NAME] jacket. During an interview on 10/23/24 at 8:24 a.m., RN-B stated R17 had sinus cancer and often had blood draining from his nostril. Sometimes R17 couldn't feel it. RN-B would assist R17 with cleaning up or would ask a nursing assistant to help R17. You don't leave him like that. R17 was dirty, bloody and needed to be cleaned up after gowning and gloving. During an interview on 10/23/24 at 8:58 a.m., nursing assistant (NA)-D stated R17 was pretty independent with cares because he liked to do things on his own. Staff pretty much just needed to set R17 up. If R17 was dirty or had blood on his face, you just politely told him and offered a washcloth or asked if you could help him. Sometimes, R17 could tell you and other times you had to point it out. NA-D stated you always offer clean linens when a bed was soiled. Who wants to lie in a dirty bed? During an interview on 10/23/24 at 10:39 a.m., the director of nursing (DON) stated R17 had continuous nose bleeds due to his condition. The DON expected staff to provide immediate basic cares including clean linens for cleanliness and comfort. During an interview on 10/23/24 at 12:47 p.m., R17 was lying in bed, was clean, groomed and had clean bed linens. R17 stated he had a shower that morning. Staff him up and R17 took it from there. However, that did not happen every morning. It was more like every 2-3 days, whatever, I'm just really tired. A facility policy regarding ADLs was requested but not received.

Based on observation, interview and document review, the facility failed to ensure a transfer belt was utilized while transferring 1 of 1 residents (R11) reviewed for ambulation. Findings include: R11's quarterly Minimum Data Set (MDS) dated [DATE], identified R11 had severe cognitive impairment and required supervision to touching assistance with walking (Helper provides verbal cues or touching/steadying assistance a resident completes activity). R11 had a diagnosis of Alzheimer's and identified a fall without injury since R11's assessment. R11's care plan dated 1/23/24, identified R11 was a limited to extensive assist of one for ambulation and to use a transfer belt. R11's physical therapy discharge note from 2/23/24, identified R11 needed contact guard assist (the caregiver places one or two hands on the patient's body to help with balance and assistance to perform the functional mobility task) with ambulation. R11's fall risk assessment dated [DATE], identified R11 was at risk for falls. During an observation on 10/21/24 at 2:15 p.m., activity staff (A)-B offered to assist R11 to walk to an activity. A-B took R11's hand and placed one arm behind R11's back and walked to the activity. R11 was steady on her feet. A transfer belt was not used while R11 ambulated. During an observation on 10/21/24 at 4:52 p.m., R11 was ambulated for 20 feet by trained medication assistant (TMA)-A and nursing assistant (NA)-A. A transfer belt was not used until they noticed the surveyor was present. R11 was taking short steps, was unbalanced and had two staff assisting her. TMA-A and NA-A then stopped and placed a transfer belt on R11 before they continued to the dining room. During an observation on 10/22/24 at 9:47 a.m., R11 was assisted with ambulation by NA-B from the dining room to the common area by holding R11's hand and an arm around her back. R11 was steady during transfer. A transfer belt was not used while R11 ambulated. During observation on 10/22/24 at 1:49 p.m., R11 was assisted to bingo by A-A who held R11's hand and had one arm behind R11's back. When they got to bingo, A-A assisted resident to sit in a chair. But R11 attempted to sit before the chair was under her and A-A had to grab at R11's waist band on her pants to guide her to sit in the chair without R11 falling to the floor. A transfer belt was not used. During an interview on 10/23/24 at 9:08 a.m., NA-C stated R11 was a limited to extensive assist for ambulation and required the use of a transfer belt while ambulated due to risk of falls or for sudden weakness. During an interview on 10/23/24 at 1:15 p.m., A-B stated she was trained as a NA and had her certification. A-B said she would assist residents to walk to activities when she was able to. When normally assisting R11 to walk, A-B would assist resident to stand and then place one arm behind her back and hold R11's hand. A-B was unsure of what the care plan stated for ambulation with the resident. A-B had not used a gait belt with R11 because R11 could be resistive, therefore A-B did not offer for R11 to use it. A-B was unable to explain the importance of using the gait belt for R11's safety. During an interview on 10/23/24 at 2:11 p.m., the director of nursing (DON) stated it was the expectation that all staff would follow the residents care plan with ambulation to remain safe. R11 should have been wearing a gait belt to ensure her safety. All staff had initial orientation and annual training regarding patient care and ambulation. The facility's Care Plan policy dated 5/2023 identified the staff would implement the interventions to assist the resident to achieve care plan goals and objectives.

Based on interview and document review, the facility failed to ensure they received an appropriate physician response to a gradual dose reduction for use for 1 of 5 (R9) residents reviewed for unnecessary medication. Findings include: R9's quarterly Minimum Data Set (MDS) dated [DATE], identified R9 had a moderate cognitive impairment and had diagnoses that included Alzheimer's disease, anxiety and depression. R9's physician orders dated 11/20/23, lorazepam (an antianxiety medication) 0.5 milligram (mg). Give 0.5 mg orally three times a day related to anxiety disorder. R9's Consultant Pharmacist's Medication Review dated 11/8/23, identified R9 was due for a second request for lorazepam GDR. R9's last GDR was rejected by family earlier this year. R9 currently takes lorazepam 0.5 mg orally three times a day for anxiety. Would you like to attempt a lower dose at this time or continue as is? (Could try lorazepam 0.5 mg every morning and at bedtime with 0.25 mg at noon.) A physician response dated 11/8/23, identified to change to lorazepam 0.5 mg every morning and at bedtime with 0.25 mg at noon. R9's Pharmacy Medication Review dated 11/16/23 at 12:15 p.m., identified staff spoke on the phone with family member (FM)-A regarding R9's Gradual Dose Reduction Request by Pharmacy and R9's medical provider: decrease lorazepam from 0.5mg three times a day to 0.5mg twice a day with 0.25mg at noon. The GDR request was rejected by FM-A. A fax sent to R9's provider with above text regarding GDR rejection by FM-A. R9's physician order dated 11/20/23, identified lorazepam 0.5 mg orally three times a day. R9's physician progress notes dated 11/20/23 to 10/23/24, identified R9 had major depression and anxiety with orders to continue to administer lorazepam. However, the physician progress notes failed to identify a justification of use for R9's lorazepam. During an interview on 10/23/24 at 10:33 a.m., registered nurse (RN)-B stated R9's lorazepam order was a long standing thing. R9 was in a bad accident years prior and family reported R9 had been taking it since then. Family refused the GDR. During interview on 10/23/24 at 10:35 a.m., the director of nursing (DON) stated the pharmacist sends all recommendations to the provider who then sends their response to us and I take care of them after I receive them. During a telephone interview on 10/23/24 at 12:54 p.m., consultant pharmacist (CP)-A stated a pharmacist did medication reviews for the facility every month. Upon review of R9's 11/16/23, GDR request, CP-A stated R9's family didn't want R9's medications touched. If a family refused a resident's attempt at GDR, the pharmacist relied on the physician's response. As long as an order to continue the medication was received, the pharmacist would not request further review of the medication until the next GDR was recommended. CP-A stated she believed the family refusing GDR was a justifiable reason for continued lorazepam use. However, CP-A stated, after a perod of time, a physician documented justification of use and education would be warranted. During an interview on 10/23/24 at 1:21 p.m., the director of nursing (DON) stated she had never spoken with R9's family regarding R9's medication. The nurses call the family to get the psychotropic medication consent. The DON stated if the family refused the GDR, they would refuse to sign a consent for lorazepam and, without the consent, R9 would not receive her medication. The DON had not addressed a documented justified use with R9's physician. The facility policy Monitoring of Psychotropic Medications effective date 2/2024, identified the consultant pharmacist shall monitor the use of psychotropic medications at least once monthly during the monthly Medication Regimen Review (MRR) and upon request between MRRs. The monitoring hall include, but is not limited to, the review of Behavior and Side Effect Monthly Flow Sheets. - During the monthly MRR, the pharmacist will identify a list of residents receiving psychoactive medications. This list may be obtained from the electronic medical record system. Each of the identified residents shall have Behavior and Side Effect Monthly Flow Sheets that are in PCC. - The Behavior and Side Effect Monthly Flow Sheets are located in the EMR in PCC under POC charting. The pharmacist must review the Flow Sheets, in addition to any other related documentation, and report any irregularities to the attending physician and Director of Nursing as outlined in the Consultant Pharmacist Services policy. Irregularities may include, but are not limited to, the following: - Lack of rationale identifying why a medication is required - Inappropriate diagnosis code(s) - Lack of care planning - Lack of resident specific monitoring - Inconsistent monitoring of side effects or behaviors - Lack of rationale identifying why a gradual dose reduction (GDR) is clinically contraindicated - Unnecessary drug, in which the drug is used: - in excessive dose - for excessive duration - without adequate monitoring or without adequate indications for use - in the presence of adverse consequences, which indicate the dosage should be reduced or discontinued without specific target symptoms.

Based on interview and document review, the facility failed to ensure behavior monitoring and gradual dose reduction (GDR) or justification of continued use was identified for 1 of 5 (R9) residents reviewed for unnecessary medication who were on a psychotropic medication. Findings include: R9's quarterly Minimum Data Set (MDS) dated [DATE], identified R9 had a moderate cognitive impairment and had diagnoses that included Alzheimer's disease, anxiety and depression. R9's physician orders dated 11/20/23, lorazepam (an antianxiety medication) 0.5 milligram (mg). Give 0.5 mg orally three times a day related to anxiety disorder. R9's Consultant Pharmacist's Medication Review dated 11/8/23, identified R9 was due for a second request for lorazepam GDR. R9's last GDR was rejected by family earlier this year. R9 currently takes lorazepam 0.5 mg orally three times a day for anxiety. Would you like to attempt a lower dose at this time or continue as is? (Could try lorazepam 0.5 mg every morning and at bedtime with 0.25 mg at noon.) A physician response dated 11/8/23, identified to change to lorazepam 0.5 mg every morning and at bedtime with 0.25 mg at noon. R9's Pharmacy Medication Review dated 11/16/23 at 12:15 p.m., identified staff spoke on the phone with family member (FM)-A regarding R9's Gradual Dose Reduction Request by Pharmacy and R9's medical provider: decrease lorazepam from 0.5mg three times a day to 0.5mg twice a day with 0.25mg at noon. The GDR request was rejected by FM-A. A fax sent to R9's provider with above text regarding GDR rejection by FM-A. R9's physician order dated 11/20/23, identified lorazepam 0.5 mg orally three times a day. R9's physician progress notes dated 11/20/23 to 10/23/24, identified R9 had major depression and anxiety with orders to continue to administer lorazepam. However, the physician progress notes failed to identify a justification of use for R9's lorazepam. R9's medical record failed to identify behavior monitoring and corresponding nursing assessment either supporting the continuation of the lorazepam does or recommending a dose reduction. During an interview on 10/23/24 at 10:33 a.m., registered nurse (RN)-B stated R9's lorazepam order was a long standing thing. R9 was in a bad accident years prior and family reported R9 had been taking it since then. Family refused the GDR. During an observation on 10/22/24 at 1:54 p.m., R9 was playing a bingo during a large group activity. R9 was relaxed, smiling and joking with the staff and other residents. During an observation on 10/23/24 at 7:13 a.m., R9 was awake and dressed for the day. R9 rang a bell on her overbed table. Trained medication aide (TMA)-A entered R9's room R9 stated her floor needed to be swept. TMA-A had housekeeping go into R9's room and clean. R9 was calm. TMA-A stated R9 just needed reassurance that she was safe, that staff were always there to help and staff just needed to try to figure out what R9 needed/wanted. During an observation on 10/23/24 at 8:36 a.m., nursing assistant (NA)-D provided morning cares for R9. NA-D explained each step in a calm voice and short, simple cues. R9 chose her clothing after NA-D gave her choices and participated during cares. R9 remained calm and smiling throughout cares. During interview on 10/23/24 at 10:35 a.m., the director of nursing (DON) stated the pharmacist sends all recommendations to the provider who then sends their response to us and I take care of them after I receive them. During a telephone interview on 10/23/24 at 10:50 a.m., R9's physician had never spoken to R9's family regarding R9's lorazepam order nor had provided education regarding lorazepam. During a telephone interview on 10/23/24 at 12:54 p.m., consultant pharmacist (CP)-A stated a pharmacist did medication reviews for the facility every month. Upon review of R9's 11/16/23 GDR request, CP-A stated R9's family didn't want R9's medications touched. If a family refused a resident's attempt at GDR, the pharmacist relied on the physician's response. As long as an order to continue the medication was received, the pharmacist would not request further review of the medication until the next GDR was recommended. CP-A stated she believed the family refusing GDR was a justifiable reason for continued lorazepam use. However, CP-A stated, after a perod of time, a physician documented justification of use and education would be warranted. During an interview on 10/23/24 at 1:04 p.m., NA-D stated R9 did not exhibit any behaviors. R9 could get a little confused but normally was not anxious, agitated, restless or anything like that. R9 was just normal. During an interview on 10/23/24 at 1:13 p.m., NA-C and NA-E stated R9 was pretty easy going. NA-E stated R9 had a lot of anxiety when she was first admitted to the facility but that had been a while. R9 did like to watch everything staff did during cares. If R9 didn't see you do it, it didn't happen. Staff just needed to let R9 do her thing. Staff needed to tell her or show her every step of the way and it usually went well. If R9 questioned anything, staff just did it again and it was all good. During an interview on 10/23/24 at 1:18 p.m., registered nurse (RN)-C stated R9 was pleasant, but forgetful. Other than that, R9 really didn't have any negative behaviors. During an interview on 10/23/24 at 1:21 p.m., the director of nursing (DON) stated she had never spoken with R9's family regarding R9's medication. The nurses call the family to get the psychotropic medication consent. The DON stated if the family refused the GDR, they would refuse to sign a consent for lorazepam and, without the consent, R9 would not receive her medication. The DON had not addressed a documented justified use with R9's physician and felt the familiies refusals were enough. Staff were expected document R9's behavior and assess R9 for possible interventions. The facility policy Monitoring of Psychotropic Medications effective date 2/2024, identified the consultant pharmacist shall monitor the use of psychotropic medications at least once monthly during the monthly Medication Regimen Review (MRR) and upon request between MRRs. The monitoring hall include, but is not limited to, the review of Behavior and Side Effect Monthly Flow Sheets. - During the monthly MRR, the pharmacist will identify a list of residents receiving psychoactive medications. This list may be obtained from the electronic medical record system. Each of the identified residents shall have Behavior and Side Effect Monthly Flow Sheets that are in PCC. - The Behavior and Side Effect Monthly Flow Sheets are located in the EMR in PCC under POC charting. The pharmacist must review the Flow Sheets, in addition to any other related documentation, and report any irregularities to the attending physician and Director of Nursing as outlined in the Consultant Pharmacist Services policy. Irregularities may include, but are not limited to, the following: - Lack of rationale identifying why a medication is required - Inappropriate diagnosis code(s) - Lack of care planning - Lack of resident specific monitoring - Inconsistent monitoring of side effects or behaviors - Lack of rationale identifying why a gradual dose reduction (GDR) is clinically contraindicated - Unnecessary drug, in which the drug is used: - in excessive dose - for excessive duration - without adequate monitoring or without adequate indications for use - in the presence of adverse consequences, which indicate the dosage should be reduced or discontinued without specific target symptoms.

Based on observation, interview and document review, the facility failed to use standard and enhanced barrier precautions (EBP); and failed to maintain proper infection control procedures for insulin administration for 1 of 3 (R17) residents reviewed for activities of daily living (ADL's). Findings include: R17's quarterly Minimum Data Set (MDS) dated [DATE], identified R17 was cognitively aware and had diagnoses that included malignant neoplasm of accessory sinus (sinus cavity cancer), type 2 diabetes, heart failure and hypertension. R17 required set up or clean up assistance with personal hygiene and R17 completed the activity. R17 had indwelling urinary catheter. R17's care plan dated 10/1/24, identified R17 required extensive assist of one staff for personal hygiene. R17 had a diagnosis of left-sided sinonasal squamous cell carcinoma with left orbital involvement (a rare tumor that affected the nasal and sinus cavity). R17 had his sinus's irrigated twice daily and contact precautions needed to be taken. R17 used an indwelling urinary catheter and staff were directed catheter every shift and as needed. The care plan did not address R17's need for EBP precautions due to an indwelling device. During an observation on 10/22/24 at 9:36 a.m., registered nurse (RN)-A did not clean the rubber stopper at the end of R17's Lantus (a long-acting insulin that helped manage blood sugars levels in certain people) pen, applied a needle and dialed R17's dose of medication. RN-A entered R17's room without donning a gown and/or gloves and approached R17. R17 was lying in bed on his left side and had dried dark red blood from his left nostril to the corner of his mouth and beard. R17 attempted to move his pillow under his head but his pillowcase was coming off exposing half of the pillow with an approximately 6-inch diameter circle of dried blood. RN-A stated, let me help you with that and, without putting on gloves, replaced the soiled bloody pillowcase on R17's pillow and put it under R17's head. R17 rolled onto his back using his trapeze bar and stated to use the right side of his abdomen because everyone always used the left side. RN-A failed to don gloves, then cleansed R17's injection site with an alcohol wipe and administered R17's Lantus injection. RN-A withdrew the needle and wiped the area again with an alcohol wipe. - At 9:45 a.m., RN-A stated she did not need to clean the rubber stopper of R17's Lantus pen because she assumed the person before her had cleaned the pen with an alcohol wipe before putting it back into the cart when they were done. I guess you should never assume because they might not have done it. RN-A stated she did not wear gloves and never wore gloves with R17 because she thought it intimated him. RN-A stated if she had cleaned the blood from his face, she would have worn gloves then but not for this. RN-A then stated it didn't matter because she used hand sanitizer before going into R17's room. During an interview on 10/23/24 at 8:11 a.m., RN-C stated she cleaned the insulin pen rubber stopper before and after every use. You don't know where it's been. Even when it's capped. Disinfecting of the rubber stopper was to prevent bacteria from entering the pen and causing an infection. R17 had EBP due to having an indwelling foley catheter. Staff needed to don a gown, gloves and/or a mask and eye protection when they did catheter care. RN-C wouldn't necessarily put on a gown when she administered medications to R17 because you weren't coming into contact with R17. However, if RN-C needed to help R17 with changing his bedding or if you needed to get close to him and touch him, then RN-C would need to don a gown and gloves, especially with touching bodily fluids. That's just what you do. During an interview on 10/23/24 at 8:24 a.m., RN-B stated staff needed to don a gown and gloves during catheter care. RN-B stated if he was only administering medications or insulin, RN-B would not don a gown because RN-B would not come into contact with R17. However, if providing any type of direct care to R17, staff would need to don gown, gloves, mask and the whole works because you were coming into direct contact with R17. If it's bloody or wet and it's not yours, wear PPE to protect yourself and others. RN-B would clean the rubber stopper on the Lantus pen before applying the needle to prevent infection. During an interview on 10/23/24 at 10:39 a.m., the director of nursing (DON) stated R17 on EBP because R17 had a foley catheter. Staff were expected to clean the rubber stopper of an insulin pen prior to applying the needle to prevent bacteria from entering the pen. Staff were expected to don a gown and gloves during direct care and whenever in contact with bodily fluids to prevent infection. The facility policy Infection Control Practices: Standard Precautions Transmission Based Precautions dated 8/2024, identified EBP were an infection control intervention designed to reduce transmission of resistant organisms that employed targeted gown and glove use during high contact resident care activities. EBP may be indicated (when Contact Precautions do not otherwise apply) for residents with any of the following: wounds or indwelling medical devices, regardless of MDRO colonization status and/or infection or colonization with an MDRO. Effective implementation of EBP requires staff training on the proper use of personal protective equipment (PPE) and the availability of PPE and hand hygiene supplies at the point of care.

Based on interview and document review, the facility failed to offer and provide education regarding the pneumococcal conjugate vaccine 20 variant (PVC20) education for those elegible as directed by the Centers for Disease Control (CDC) for 5 of 5 residents (R2, R4, R16, R17, R71) reviewed for immunizations. Findings include: R2's quarterly Minimum Data Set (MDS) dated [DATE], identified R2 had diagnoses including chronic obstructive pulmonary disease (COPD). R2's undated, Minnesota Immunization Information Connection (MIIC) report identified R2 received the pneumococcal polysaccharide vaccine (PPSV23) on 4/19/18, and the pneumococcal conjugate vaccine 13 variant (PCV13) on 5/20/05. R2's medical record lacked evidence the PCV20 was offered and/or education was provided in conjunction with the provider to R2/R2's representative. R4's quarterly MDS dated [DATE], identified diagnoses of diabetes and atrial fibrillation. R4's undated Minnesota Immunization Information Connection (MIIC) report identified R4 received PPSV23 on 10/13/04, and the PCV13 on 3/29/17. R4's medical record lacked evidence the PCV20 was offered and/or education was provided in conjunction with the provider to R4/R4's representative. R16's admission MDS dated [DATE], identified diagnoses including diabetes, and multiple sclerosis. R16's undated MIIC identified R16 received PPSV23, on 9/27/12 and PCV13 on 7/21/15. R16's medical record lacked evidence the PCV20 was offered and/or education was provided in conjunction with the provider to R16/R16's representative. R17's admission MDS dated [DATE], identified diagnoses including asthma and thyroid disease. R17's undated MIIC report identified R17 received PPV23, on 9/21/15 and PCV13 on 4/22/19. R17's medical record lacked evidence the PCV20 was offered and/or education was provided in conjunction with the provider to R17/R17's representative. R71's quarterly MDS dated [DATE], identified diagnoses including coronary artery disease, heart failure and asthma. R71's pneumococcal immunization standing orders dated 5/17/23, identified R71 refused the PPSV23 and PCV13 vaccinations. The declination failed to identify if the PCV20 risk and benefits was discussed or offered. During interview on 11/15/2023 at 1:15 p.m., the director of nursing stated she was unaware of the new CDC guidance and had not completed education or offered the PCV20 vaccination to residents/resident representatives. The facilities Pneumococcal Vaccine Standing Orders revised 10/22, identified all adults who met the criteria established by the CDC Advisory Committee would be vaccinated to reduce morbidity and mortality. The standing orders enabled appropriately qualified personnel (e.g. nurses or pharmacist) to assess the need for vaccination and to vaccinate adults equal to or older than [AGE] years of age who met any of the procedural criteria, without a physicians order. The appropriate personnel would determine the need for vaccination, screen the individuals, provide a vaccine information statement (VIS), administer and document the vaccine information.

Based on observation and interview the facility failed to ensure proper placement of a full mechanical lift sling to ensure a safe transfer for 1 of 2 (R2) observed during full mechanical lift transfers. Findings include: R2's quarterly Minimum Data Set (MDS) dated [DATE], identified R2 was severely cognitively impaired, and diagnoses included hemiplegia, hemiparesis, and aphasia. R2's care plan dated 10/3/23, identified staff used the full mechanical lift for transfers to and from the bed. During observation on 11/14/23 at 3:13 p.m., nursing assistant (NA)-A and NA-B were assisting R2 from wheelchair to bed. NA-A and NA-B placed the full mechanical lift sling behind R2's back and buttocks. NA-A stated the lift sheet did not slide behind R2's back and under legs very well and was sticking to R2's clothing. NA-A reached for the strap and pulled hard on the sling under R2's leg. NA-B fastened the sling loops to the mechanical lift. NA-A attempted but was unable to fasten the sling loops to the mechanical lift clips. NA-B used the remote control to lower the lift closer to R2 until NA-A was able to fasten the loops to the sling clips. Using the remote control NA-B elevated R2 approximately six inches above the wheelchair. R2's buttocks was hanging through the opening of the lift sheet. NA-A stated R2 was sliding down out of the sling, NA-B lowered R2 back down into the wheelchair. -R2 was seated in the wheelchair in a slouched position with his buttocks at the front edge and hanging off of the wheelchair cushion. R2's buttocks started slowly slipping forward, off the wheelchair cushion and out of the wheelchair. Staff did not immediately assist R2. Surveyor intervened and reported to NA-A and NA-B that R2 was slipping out of the wheelchair. NA-B then used the remote control and slightly elevated the lift to tightened the sling around R2. R2 stopped sliding out of the wheelchair. During interview on 11/14/23 3:34 p.m., NA-B stated staff used the full mechanical lift to transfer R2 in/out of bed and did not usually have problems. R2 has never slipped out of the sling or the wheelchair. The transfer observed was not a good transfer because the sling was not under R2 far enough and R2 started slipping out of the sling. NA-B was trained to use the full mechanical lift by the assistant director of nursing (ADON). During interview on 11/14/23 at 4:48 p.m., NA-A stated the full mechanical lift was new to the facility and the ADON trained staff on correct placement of the sling and use of the lift. It was hard to place the sling under R2 because the sling stuck to the residents clothing and staff had a hard time getting the sling under the resident far enough. Transfers usually went well with the full mechanical lift. This transfer of R2 did not go well because the sling was not properly placed under the resident to safely transfer R2 and staff had to lower the resident back down to the wheelchair. During interview on 11/15/23 at 8:25 a.m., the ADON stated she received a call from NA-A regarding R2's transfer on 11/14/23. NA-A reported the transfer had not gone well and R2 nearly slid out of the lift sling. Both NA-A and NA-B received training for placement of the sling and use of the full mechanical lift. The ADON stated she expected staff to follow the education provided to ensure residents would not fall or slip out of the sling. During interview on 11/15/23 at 12:59 p.m., the director of nursing (DON) stated staff were expected to follow the education provided for proper sling placement and use of the full mechanical lift. If a transfer didn't go well, the staff were expected to notify one of the nurses who would follow up by sending a referral to therapy for an evaluation of the residents transfers and to see if there was a better way to transfer the resident. The Safe Patient Handling: Mechanical and Non-Mechanical Lifts policy review date 4/20, identified the purpose of the policy was to ensure proper use of Safe Patient Handling equipment. The policy directed staff on how to place the sling under and lift the resident while seated in a chair/wheelchair. The directions included staff to tuck the end of the sling at the coccyx or against the seat.

Based on interview and document review the facility failed to ensure an injury of unknown origin determined to be suspicious for abuse was reported to the state agency (SA) within the required timeframe for 1 of 3 residents reviewed. Findings include: A report to the SA dated 6/20/23, at 11:21 a.m. indicated R1 was observed to have swelling, an abrasion and bruising on his eyebrow and bruising on his upper eye lid. A facility Initial Incident Report dated 6/20/23, indicated staff went to check on R1 and noted unknown bruising to the top of his eyebrow and dark purple bruising. The facility's investigation report submitted 6/22/23, indicated when the nurse who identified the bruising was interviewed, she reported the Injury of unknown origin had been identified on 6/19/23, at 7:45 p.m. During interview on 6/23/23, licensed social worker (LSW)-A confirmed the nurse had seen the bruising on 6/19/23. LSW-A stated the nurse reported the injury to the assistant director of nursing (ADON) the following morning and when she and the ADON went to look at R1, they both felt the injury should be reported to the SA due to it being suspicious in nature. LSW-A stated anyone in the facility had the ability to report to the SA and said the report should have been made within two hours. Facility policy Reporting a VA (vulnerable adult) in OHFC (office of heath facility complaints) Procedure dated 12/2022, indicated alleged incidents will be reported to the SA immediately or within two hours. The policy indicated in the absence of the director of nursing, LSW or administrator the licensed nurse will file the report.

Based on interview and document review, the facility failed to immediately report to the administrator and no later than 2 hours, to the State Agency (SA) an allegation of staff to resident verbal abuse for 1 of 1 residents (R1) who was reviewed for allegations of abuse. Findings include: R1's annual Minimum Data Set (MDS) dated [DATE], indicated R1 had diagnoses which included Alzheimer's, anxiety, depression and was severely cognitively impaired. Identified R1 required staff assistance with bed mobility, transfers, dressing, toileting, personal hygiene, bathing and was independent with eating after set up assistance. R1's care plan revised on 12/5/22, identified R1 was a vulnerable adult due to her placement and indicated R1 would have been safe while living at the facility and her basic needs would have been met. The care plan indicated R1 had a diagnoses of dementia with very short term memory and would ask the same question numerous times. The care plan identified R1 required assistance with bed mobility, transfers, dressing, grooming, bathing, toileting and set up help for eating. R1's care plan indicated she had anxiety and depression and demonstrated verbally abusive behavior at times during cares. Review of R1's Initial Incident Report form dated 11/28/22, revealed the following: On 11/27/22, an allegation of verbal abuse occurred in the aspen dining room with R1. Staff reported kitchen staff had been rude and yelling at R1 and telling her to just eat her meal and soup. Review of the Nursing Home Incident Report (NHIR) submitted to the SA identified there was an allegation of emotional/mental abuse. The report indicated on 11/27/22, at 5:00 p.m. nursing assistant (NA) brought R1 soup from the kitchen, when R1 began to yell out she did not like the soup and wanted some salt. The report identified dietary staff yelled at R1, informed her they did not have any salt and it did not matter as they did not believe she would eat the soup anyway. Shortly after the incident a charge nurse entered the dining room where R1 and dietary staff were present and stated to the dietary staff do I have permission to put duct tape on her mouth? The charge nurse and the dietary staff laughed after the comment had been made. The NHIR identified the incident occurred on 11/27/22, at 5:00 p.m. and was reported to the SA on 11/28/22, at 1:38 p.m. over 20 hours after the incident had occurred. During an interview on 12/6/22, at 4:25 p.m. dietary staff (DS)-B indicated on 11/27/22, she entered the dining room at about 5:00 p.m. and heard R1 using vulgar language while asking for salt. DS-B stated she heard DS-A respond to R1 to shut up in a harsh manner. DS-B indicated DS-A walked away from R1 while she continued to call DS-A vulgar names and indicated the words said between R1 and DS-A became very heated. DS-B stated she was not aware of who to report the allegation of abuse to since her boss had already left for the day. During an interview on 12/6/22, at 5:48 p.m. NA-B indicated on 11/27/22, at about 5:10 p.m. R1 was eating chicken noodle soup in the dining room and asked for some salt in a very loud tone of voice. DS-A informed her they did not have any salt and R1 responded the soup was gross and she could not eat it. NA-A indicated the verbal exchange between DS-A and R1 about the salt escalated when DS-A responded in a loud tone of voice there is no salt, I don't know what to tell you. NA-B stated DS-A proceeded to respond by telling R1 to shut up and I'm tired of feeding you. NA-B indicated she had not reported the allegation of abuse as she did not have the time to write up the report. During an interview on 12/7/22, at 11:26 a.m., the director of nursing (DON) confirmed the above findings and indicated the administrator had called her on the morning of 11/28/22, to report the allegation of abuse to her. The DON indicated the allegation occurred in the dining room on 11/27/22, around 5:00 p.m. when DS-A told R1 to shut up in a loud voice. The DON stated staff were expected to report any allegation of abuse to their supervisor immediately and to notify her and the administrator right away. The DON indicated staff were to report to the SA within two hours of the incident occurring and she would expect staff to follow the facility policy with any allegation of abuse. During an interview on 12/7/22, at 11:58 a.m. the administrator confirmed the above findings and indicated he had been notified of the allegation involving DS-A on the morning of 11/27/22. The administrator stated the facility's abuse policy instructed staff to report the incident immediately to their supervisor and the supervisor would notify him as soon as possible. The administrator indicated the facility had two hours to report any type of elder abuse to the SA and if the allegation involved a staff member they would have been removed from the schedule until the investigation had been completed. The administrator stated he would expect staff to follow the facility's abuse policy and to report the SA in a timely manner. Review of the facility policy titled, Senior Services Abuse Prevention Plan revised 4/22, indicated if suspected or alleged abuse (physical, verbal, sexual, financial exploitation) a report was expected to be made to the facility designated SA immediately or no later than 2 hours after the allegation/suspicion. The policy instructed staff to call the administrator or the DON immediately.

Based on observation, interview and document review, the facility failed to follow standard infection control practices when handling and sorting soiled and potentially infectious resident laundry. This practice had the potential to affect all 20 residents residing in the facility and who had their personal laundry laundered at the facility. Findings include: On 6/23/22, at 10:57 a.m. the facility's laundry room was observed with housekeeper (HK)-A. There were two protective gowns and gloves in the laundry room. HK-A stated after he gathered each residents soiled laundry he sorted through it examining each item for stains, checking pockets and separating whites from [NAME], before putting the clothing into the facility washer. HK-A did the quarantined (infectious) resident's laundry last to keep from contaminating other's clothing. HK-A stated he sorted the quarantined laundry in the same manner as the other laundry. HK-A also stated he took the large, waterproof isolation bag and turned it inside out and put in with the wash. - HK-A demonstrated how he sorted and inspected the soiled clothing (included quarantined laundry) and handled the clothing isolation bag to wash. HK-A put on gloves to handle the soiled laundry, but did not put on a protective gown over his uniform. HK-A stated there was a potential for the soiled laundry to come into contact with his bare arms or uniform, and only used a protective gown when adding bleach to the washer to disinfect it at the end of the shift. Further, HK-A stated the facility completed all 20 residents personal laundry. During interview on 6/23/22, at 11:28 a.m. housekeeping supervisor (HKS)-B stated all staff were to wear a washable protective gown when sorting through resident's soiled laundry and the gowns were to be washed each time it was worn. When quarantined laundry was handled, the staff were to wear a disposable gown and discard it immediately after use. The facility policy Clarification of Interpretive Guidance Laundry and Infection Control from the Center For Medicare and Medicaid Services dated 1/25/13, identified it was important all potentially contaminated linen be handled with appropriate measures to prevent cross-transmission. It was important laundry areas had appropriate personal protective equipment such as gloves and gowns for workers to wear when sorting linens.

Based on observation, interview and document review the facility comprehensively assess safety with self- administration of medication for 1 of 1 residents (R5) observed to have medications left in their room unsupervised by staff after staff set-up. Findings include: R5's quarterly Minimum Data Set (MDS) dated [DATE], identified R5 was cognitively intact and required assistance of one staff for activities of daily living (ADLs). On 6/21/22, at 1:34 p.m. R5 was observed seated in a wheelchair in her room with no staff present; and there were three pills and one capsule in a medication cup on R5's bedside table. R5 stated the four medications in the med cup were left by the nurse about 30 minutes earlier and the staff always left her medications for her to take unsupervised. R5's medical record lacked a self- adminstration of medication assessment. - At 1:53 p.m. registered nurse (RN)-A stated when dispensing medications to a resident she would verify med orders, place them in a med cup, give the medications to the resident and then sign the medication administration record (MAR) after observing the resident swallowed the medication. RN-A stated R5 would not swallow the medications in front staff so she always left the medications for R5 to take on her own. RN-A checked back after about 30 minutes to be sure R5 took the medications. RN-A signed R5's MAR at 12:15 p.m. on 6/21/22. - At 2:11 p.m. RN-A stated she could not find anything in R5's care plan directing staff to leave R5's medication's to take unsupervised. - At 2:30 p.m. RN-B stated she defined self-administration of medication as when a nurse sets up a residents medication and allows the resident to take the med's unsupervised. The facility policy directed staff to complete an assessment, obtain an MD order and add an item to the care plan before a resident was able to self-administer med's. R5's medical record lacked any assessment, MD orders and was not on the care plan to take medications without nurse supervision. During interview on 6/23/22, at 1:50 p.m. the director of nursing (DON) stated if a resident was deemed unable to administer their own medications, the medications shouldn't be left in their room unsupervised by staff. An assessment must be completed indicating the resident was capable of taking the medications unsupervised and the nurse would need to follow-up with the resident within 15 minutes. If a resident is capable of administering their own medications and there was not an assessment, they would be responsible to notify RN-B to complete an assessment. The facilities Self-Administration of Medications LTC policy last approved 6/22, identified residents were able to self-administer medication if they were evaluated to do so. The evaluation would include assessments of the resident's mental and physical abilities, their decision-making capacity and an order from the MD identifying the resident is clinically appropriate to self-administer medications.

Based on observation, interview and document review, the facility failed to ensure dental services were provided for 1 of 1 residents (R10) reviewed who had broken/chipped teeth in poor condition. Findings include: R10's quarterly Minimum Data Set (MDS) dated [DATE], identified R10 had moderate cognitive impairment and diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . However, the R10's dental/oral status was not required to be assessed during the MDS assessment period. During an observation on 6/21/22, at 2:34 p.m. R10 had missing and broken teeth along the upper right side of R10's mouth that were visible while she was speaking. R10's nursing progress note dated 5/29/21, at 4:56 p.m. identified R10 voiced a complaint of a loose tooth. Staff identified an upper incisor tooth was observed to be loose and wiggling on the left side. R10 did not state she hit the tooth and there was no apparent bruising to R10's lips or gums. R10 stated stated she would just chew to either side. R10 denied pain unless she bit down with the broken tooth and staff encouraged her to not wiggle the tooth manually. A message to contact hospice and/or the dentist during the following business week. R10's nursing progress noted dated 6/12/21, at 1:20 p.m. identified R10's loose tooth had cracked and a piece of the tooth had fallen out during lunch. A small amount of blood was surrounding the tooth at the base of the gums. There was no swelling or signs of infections. R10 was encouraged to not wiggle the tooth. R10 did not complain of any increased pain at the site, continued to eat, and forgot the tooth had fallen out. Nursing communicated the broken tooth to hospice in regards to making a dental appointment and hospice agreed with this plan. A reminder was placed on the message board in the electronic medical record to make an appointment and arrange transportation during the following business week. During an interview on 6/23/22, at 7:56 a.m. registered nurse (RN)-A stated she reviewed R10's chart and found notes which stated a dental appointment should have been made. However, there was no documentation or notes which identified the facility attempted to make a dental appointment for R10. RN-A stated an attempt to make a dental appointment after a resident had broken a tooth was expected. During an interview on 6/23/22, at 1:07 p.m. the health unit coordinator (HUC) stated she was out of the facility on leave when R10 broke her tooth and was not notified to schedule an appointment for R10 when she returned to work. During an interview on 6/23/22, at 1:58 p.m. the director of nursing (DON) stated all the nurses and/or the social worker were able to make medical and/or dental appointments for the residents and the responsibility did not rest solely on the HUC. R10's dental appointment should have been scheduled timely or at least an attempt to do so with documentation reflecting what had occurred. The facility policy Dental Services revised 12/21, identified the facility would assist elders to obtain routine and 24-hour emergency dental care. Each elder was encouraged to choose a dentist who was ale to provide dental care to meet the elder's needs. The nursing staf would assist elders, as necessary in making appointment and arranging transportation to and from the dentist's office if services were not provided in the facility.

Based on interview and document review, the facility failed to ensure allegations of sexual abuse were reported to the State Agency, within 2 hours, for 1 of 1 resident (R4) who reported a male nursing assistant inappropriately touched her. Findings include: R4's quarterly Minimal Data Set (MDS) dated [DATE], indicated R4 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of MDS indicated R4 exhibited delusions, physical and verbal behaviors. R4's care plan revised 3/17/21, identified R4's target behaviors; behaviors included as hallucinations/delusions, restlessness, crying, and paranoia. R4's care plan did not address or identify R4 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] On 3/29/22, at 3:28 p.m. nursing assistant (NA)-A reported to state surveyor approximately 3 weeks ago, she had reported to the director of nursing (DON) an allegation of sexual abuse between R4 and NA-D. NA-A indicated the facility had not addressed the allegation at that time. NA-A was not sure on the date of the allegation. NA-A indicated she remembered NA-D had assisted R4 to the bathroom, the two had been in R4's room for a while. NA-C then brought R4 back into the commons area, NA-A stated R4 appeared shaky, mopey and head was tilted. NA-A indicated she then saw R4 attempt to self-transfer and R4 told her I don't care if I fall it is better than him putting himself up and down me and R4 repeated it again to NA-A. NA-A indicated R4 did not state a name but pointed in the direction of NA-D. NA-A grabbed another staff NA-E, which R4 then stated, she [R4] was raped. NA-A stated she didn't like the way R4 was shaking, and she was scared. Further, NA-A indicated both her and NA-E reported this allegation to registered nurse (RN)-C and then to the DON. In addition, NA-A stated nothing has been done about this allegation and NA-A indicated on 3/29/22, she reported this incident to the social worker (SW). Review of the facility's reported incidents identified that this allegation was not reported to the State Agency. On 3/29/22, at 4:33 p.m. state surveyor reported the sexual abuse allegation to SW and Minimum Data Set (MDS) coordinator, as DON and Administrator were not available. SW indicated she was not aware of the allegation until 3:00 p.m. on 3/29/22, and MDS coordinator was not aware prior. On 3/30/22, at 9:29 a.m. DON indicated she was aware of R4's sexual abuse allegation and had completed an investigation already. DON indicated the allegation was not reported to the SA due to the regulation says reasonable suspicion which myself and other nurses discussed, and I didn't feel it was reasonable. Further, DON stated if I had any inkling that I thought anything happened I would have reported. When asked what the facility's process was for reporting allegations of abuse, DON indicated most of the time she reports the allegations immediately but, this allegation was a touchy nature. On 3/30/22, at 3:51 p.m. SW indicated the facility's policy was to report any suspected or allegations related to abuse to the SA within two hours. SW confirmed R4's allegation should have been reported to the SA. SW indicated R4 has a history of delusions, however the accusation alleging rape was new for R4. SW indicated timely reporting to the SA was important to ensure all residents are safe and to prevent future incidents from happening. Review of the facility's internal investigation did not identify a specific date and time of the allegation occurred. The internal investigation included a statement written by RN-C dated 3/3/22 and statements written by NA-A, NA-E, and DON on 3/8/22. Review of facility's internal investigation included the following: -Statement by RN-C dated 3/3/22, indicated she was the floor nurse on the day of the allegation. NA-D assisted R4 to the restroom. At this time, R4 was exhibiting sun downing and appeared confused and tired. NA-D returned to the commons area with R4 and assisted her into the recliner and R4 appeared calm. Moments later NA-A reported to RN-C R4 stated she didn't like that man going up and down. RN-C indicated she reported the allegation to the DON. Review of facility's policy titled Senior Services Abuse Prevention Plan revised 7/21, indicated if suspected or alleged abuse (physical, verbal, sexual, financial exploitation) a report must be made to the facility designated SA immediately or no later than 2 hours after the allegation/suspicion.

Based on interviews and document review, the facility failed to protect and prevent further potential abuse after an allegation of sexual abuse was made by 1 of 1 resident (R4) and failed to ensure the allegation was thoroughly investigated. Findings include: R4's quarterly Minimal Data Set (MDS) dated [DATE], indicated R4 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of MDS indicated R4 exhibited delusions, physical and verbal behaviors. Review of the facility's internal investigation did not identify a specific date and time of the allegation occurred. The internal investigation included a statement written by registered nurse (RN)-C dated 3/3/22 and statements written by NA-A, NA-E, and DON on 3/8/22. -Statement by RN-C dated 3/3/22, indicated she was the floor nurse on the day of the allegation. NA-D assisted R4 to the restroom. At this time, R4 was exhibiting sun downing and appeared confused and tired. NA-D returned to the commons area with R4 and assisted her into the recliner and R4 appeared calm. Moments later NA-A reported to RN-C R4 stated she didn't like that man going up and down. RN-C indicated she reported the allegation to the DON. -Statement by NA-A dated 3/8/22, indicated at 4:00 p.m. R4 stated she would rather fall, it would be better than having him put himself up and down her and appeared to be upset. NA-A reported the allegation to RN-C. - Statement by NA-E dated 3/8/22, indicated R4 reported to NA-E he took her to the small room [bathroom] and said he was saving her, then cornered her and raped her. NA-E reported this allegation to RN-C and DON. -Statement by DON dated 3/8/22, indicated after speaking with staff there was no evidence that anything happened while she [R4] was toileted, no evidence of rape, as she had no physical or emotional signs. R4 had not shown any signs of distress towards NA-D and R4 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . DON indicated R4 had difficulty in making herself understood due to cognition. DON observed R4 at approximately 4:30 p.m. and R4 appeared to be sleeping and was not anxious. DON interviewed NA-D who denied the allegation and indicated R4 did not have any complaints or concerns while assisting her to the bathroom. Facility lacked evidence of protection measures and/or plan to keep R4 and other residents safe during the investigation. In addition, the facility's investigation did not include nor was it evident in R4's records a completed skin assessment or medical examination after the allegation. On 3/30/22, at 9:29 a.m. When asked how the facility investigated the allegation and what was put into place for protection, director of nursing (DON) indicated she interviewed and got statements from all staff involved at the time of the allegation. In addition, DON indicated there was no reasonable suspicion the sexual allegation occurred therefore DON confirmed no additional measures were implemented following interviews with staff . Review of facility policy titled Senior Services Abuse Prevention Plan revised 7/21, indicated immediate steps should be taken to ensure no resident remains in danger of mistreatment. Further review of policy indicated Bigfork Valley will prevent further potential abuse from occurring while it investigates the allegation which included but not limited to all parties involved or having observed the alleged incident are interviewed and when a specific staff member is implicated in the alleged even, the person will be removed from the resident care area immediately, suspended pending investigation, and interviewed. The facility's Abuse program polices did not identify or address procedures for investigating sexual abuse allegations.

Based on observation, interview and document review, the facility failed to provide range of motion (ROM) services in order to maintain and/or prevent loss of ROM ability for 1 of 2 residents (R1) who experienced a decline in ROM of the left hand which was not identified nor assessed. This failure resulted in actual harm for R1. Findings include: R1's annual Minimum Data Set ((MDS) dated [DATE], indicated R1 had severe cognitive impairment and [DIAGNOSES REDACTED]. The MDS also indicated R1 required extensive assistance to total dependence for all activities of daily living. The MDS further indicated R1 had no impairment in functional range of motion to upper or lower extremities. R1's Pain Care Area Assessment (CAA) dated 1/20/20, indicated R1 had had a decline in mobility in the past quarter which could increase her risk for pain and stiffness with her arthritis and [MEDICAL CONDITION]. R1's LTC (Long Term Care) Mobility assessment dated [DATE], indicated R1 had moderate head and trunk range of motion, but poor shoulder, elbow, wrist and fingers, hips, knees and ankle muscle strength and ROM. The assessment also indicated R1 was cooperative and her behavior was non-aggressive. The assessment further indicated R1 had not actively participated in the evaluation and the evaluation was done passively. R1's Care Plan dated 1/23/20, indicated R1 had a self-care deficit related to dementia and required assistance with activities of daily living. The care plan also indicated R1 had limited mobility, and difficulty following directions and processing information, which made it difficult to participate in physical therapy (PT). The care plan further indicated R1 no longer walked and directed staff to stretch R1's arms and legs daily. The care plan lacked further interventions related to ROM for the prevention of contractures. On 1/22/20, at 11:16 a.m. R1 was observed in the community area, seated in an easy chair, watching television. R1 was awake but did not respond when greeted. R1's left hand was clenched tightly into a fist. R1's right hand was also clenched into a fist, however, the right forefinger was extended approximately half way. -At 12:41 p.m. R1 was seated at the dining room, waiting for her meal. -At 1:30 p.m. NA-A assisted R1 to eat the meal. Throughout the meal, R1's hands remained in clenched fists against her chest. Splints were not in place. -At 1:32 p.m. NA-A wheeled R1 to the community area, by the television. R1 did not verbally respond to being greeted. R1 loosened her right hand to shake hands, however, the hand did not fully open rather remained in a cupped position. -At approximately 2:00 p.m. NA-A stated R1 did not wear hand splints of any kind, the facility did not have a restorative nursing program, and the NAs did not provide any type of exercises or ROM services during cares. On 1/23/20, at 8:40 a.m. NA-B entered R1's room to provide morning cares. NA-B washed R1's face, provided peri cares, and applied a clean brief while rolling R1 from side to side. NA-B applied R1's socks, shoes and pants while R1 remained in bed and then assisted R1 to sit at the side of the bed. R1's elbows were bent close to her chest with both hands clenched into tight fists. NA-B applied a standing lift sling around R1 and struggled to position the sling under R1's arms as they were held tight against her body. NA-F entered the room and assisted R1 to grasp the handle bars of the standing lift. R1 grasped the right bar with her right hand, but only grasped the left bar with her left thumb and forefinger as R1 was unable to fully open the hand. NA-F stated she could open R1's hand, but she would immediately close her fingers again and would only hold the bar with her thumb and forefinger. NA-F stated R1 had no restorative program or exercises in place for her hands, and did not use hand splints or rolls to prevent contractures. NA-B and NA-F proceeded to transfer R1 to a wheelchair via the standing mechanical lift. R1 was noted to bear own weight throughout the transfer. NA-F left the room with bagged garbage and NA-B removed R1's nightgown, washed her upper body, applied deodorant and assisted R1 to dress. NA-B put R1's shirt over her arms first and lifted the shirt over her head. R1 did not move her arms. NA-B did not offer or provide range of motion exercises for R1's upper extremities. NA-B attempted to put a sweatshirt on R1 using the same process, however, was unable to lift the sweatshirt over R1's head. Therefore, NA-B removed the sweatshirt and obtained a zippered sweatshirt. After several attempts, NA-B was able to pull the sweatshirt over R1's elbows and finish dressing R1. NA-B stated no one had ever talked to her about R1's joints or mobility. NA-B provided R1 her glasses, perfume, dentures, and assisted R1 to the dining room for breakfast. On 1/23/20, at 9:30 a.m. registered nurse (RN)-A stated he had noticed that today, R1's hands were held more into her chest. RN-A reviewed R1's MDS dated [DATE], to determine if she had an identified contracture and verified R1 was dependent upon staff for all activities of daily living but stated, I don't see where they say she does (have a contracture), but I'm trying to find where they assess for that. RN-A verified the MDS identified R1 had no impairment in range of motion and stated she was able to extend both her arms. RN-A also stated once R1 relaxed more, her arms would straighten out and indicated he found it odd she was positioned with her arms so tight to her body, that morning. RN-A stated the NA's were supposed to provide the residents with ROM exercises with their morning cares and confirmed the facility did not have a formal restorative nursing program which provided those services. RN-A indicated the facility assessed residents' ROM abilities quarterly with the MDS assessment. RN-A also verified R1 did not have splints or other interventions identified to prevent contractures. On 1/23/20, at 10:08 a.m. RN-B stated she did not know if R1 had contractures and stated R1 could open her hands, if R1 wanted to do so. RN-B stated she thought R1 stiffened up all joints due to her disease process and had guarded movement. RN-B indicated R1 had exhibited non-verbal indications of pain including furrowed brows with her last assessment. RN-B indicated interventions to prevent contractures would include exercises; however, verified the facility did not have a restorative nursing program to provide restorative services. RN-B stated the NAs were supposed to provide exercises during resident cares. RN-B stated R1's significant other provided R1 exercises when visiting. RN-B stated her expectation was for the NAs to provide exercises in all planes of motion with 10 repetitions to each joint. RN-B stated when completing R1's last assessment, she had performed five motion repetitions with all joints and R1 had shown no decline in her abilities from the previous assessment. However, it took a while to complete the exercises as R1 would get angry with it. RN-B confirmed R1 did not utilize splints or other physical devices to prevent contractures. -At 10:13 a.m. RN-B and NA-E were observed to perform ROM exercises for R1. R1's significant other was present during the exercises. RN-B completed ROM to R1's right elbow and shoulder, which revealed some limitations, however, RN-B indicated these limitations were not new and were unchanged from the previous assessment. R1 made facial grimacing and RN-B stated this indicated R1 was getting mad. At this point, NA-E assisted to complete ROM exercises to R1's right hand/fingers and was able to fully extend R1's fingers. NA-E then assisted R1 to complete ROM of her left elbow and shoulder without difficulty, however, when NA-E attempted to extend R1's left fingers, R1 was only able to extend her fingers approximately 45 degrees. R1's significant other commented, She is so stiff today. RN-B verified the limitation of extension to R1's left fingers was a new decline and indicated she would get an occupational therapy (OT) assessment for R1. On 1/23/20, at 11:33 a.m. the director of nursing (DON) verified the facility did not have a designated restorative nursing aid or a restorative nursing program. DON stated she did not know exactly what the facility currently did to provide ROM services for the residents and was unaware of any required exercise routine provided during the provision of cares. The DON also stated she was unaware of R1's decline in ROM and was unsure if this had ever been reported. The DON indicated it was her expectation that any change in a resident's condition be reported to the nurse so it could be assessed. The DON verified R1 should have been provided ROM services in order to maintain her ability and prevent a decline in ROM. After the completion of the survey, the facility provided an OT Initial Evaluation for R1 dated 1/24/20, which revealed R1 had some upper extremity ROM limitations most noted in left MCP (metacarpophalangeal) extension of digits 3-5, but her ROM was appropriate for proper hygiene and dressing. Presumed arthritis of MCPs noted. OT to continue for ROM, to assist patient with appropriate hand splints to promote ROM of fingers into extension, and staff education as needed. Equipment needs included bilateral hand splints for at night. Recommend wearing splints every other day in order to alternate which hand is wearing brace so both hands are not braced at the same time. The facility policy titled, Quality of Care LTC last revised 12/2016, indicated a resident with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. A resident with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable.

Based on observation, interview, and document review, the facility failed to ensure an effective resident elopement notification system was implemented to minimize the risk of serious injury or death for 1 of 5 residents (R1) whom had a history of [REDACTED]. The IJ began on 10/18/19, when R1 eloped from the facility at approximately 7:30 p.m. and was found .6 miles from the facility and returned by an unknown community member at approximately 8:18 p.m. The administrator and director of nursing (DON) were notified of the IJ on 10/28/19, at 5:30 p.m. The IJ was removed on 10/30/19, at 3:15 p.m., when the facility developed and implemented interventions to ensure residents at risk for elopement were safe however, non-compliance remained at the lower scope and severity level D, isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: R1's History and Physical dated 6/26/19, indicated R1 was brought to the emergency room (ER) by assisted living staff. R1 was out in the parking lot with car keys in hand, believing his wife and another person were in his pickup truck. R1 became agitated, shouting at the empty truck and the staff were concerned he would drive away. R1 was admitted to the nursing home. R1's undated, [DIAGNOSES REDACTED]. R1's admission Minimum Data Set ((MDS) dated [DATE], indicated R1 was severely cognitively impaired, and experienced hallucination and delusions. The MDS also indicated R1 did not have any mood concerns, and wandered 1-3 days of the assessment reference period. The MDS question which read, Does the wandering place the resident at significant risk of getting into potentially dangerous places? was marked No. The MDS indicated R1 required physical assist of one person, walker and wheelchair for ambulation/locomotion. R1's Cognitive Loss/Dementia Care Area Assessment (CAA) dated 7/9/19, indicated R1 was having long and short term memory loss prior to admission. R1 had hallucinations/delusions increasing risk for falls and injury R1's Behavioral Symptoms CAA dated 7/9/19, indicated R1 had hallucinations, delusions, and aggressive behaviors which have caused injury and could increase risk for future injuries. R1 was admitted the the facility with new [DIAGNOSES REDACTED]. R1 had shown the same behaviors since admit, and had been physically aggressive towards staff. R1's Individual Resident Care Plan dated 6/27/19, indicated R1 had hallucinations, delusions, and was at risk for elopement. Although R1 had an identified risk for elopement, an Elopement Risk Assessment was not completed at the time of admission. R1's Care Plan dated 6/28/19, indicated R1 was legally blind in left eye and had vision loss in the right eye. Updates to the care plan were made on the following dates: -7/3/19, R1 had sundowning (restlessness, agitation, irritability, or confusion that can begin or worsen as daylight begins to fade) and hallucinations. -7/12/19, R1 was independent with ambulation, required supervision when leaving the unit and used a walker when ambulating. -7/15/19, encourage R1 to be in a common area when experiencing hallucinations since R1 was unaware of safety or limitations and hallucinations and delusions had caused R1 injury. -9/7/19, R1 had a wanderguard on wrist to prevent from wandering out of the long term care unit. -10/18/19, medium risk for elopement and resident was moved to secured, Aspen Circle unit for personal safety. R1's Progress Note (PN) dated 8/6/19, at 5:59 p.m. indicated the maintenance staff stated R1 was walking in the adjoining hospital area. No further information was noted. R1's Physician order [REDACTED].>The Nurses Communication to Provider form dated 9/7/19, indicated on 9/6/19, at approximately 4:30 a.m. R1 had gotten up and went out to the enclosed patio off the Tamarack unit. R1 was escorted back into the facility and back to his room. He did not know where he was or how he got out there. Wanderguard removed from walker and placed on R1's right wrist. Multidisciplinary Care Conference Summary note on 10/8/19, indicated R1 was a high fall risk and continued to self transfer. R1 continued to show visual hallucinations, delusional behaviors and would refuse care on occasion. R1 required staff assistance with locomotion and wore a wander guard. Social summary section indicated the staff would monitor R1 for behaviors of sundowning and the risk of exit seeking when having hallucinations. Aspen Unit might benefit R1 and ensure his safety. R1's Comprehensive Behavioral assessment dated [DATE], indicated R1 had sporadic behaviors of aggression, hallucinations, wandering, delusions. There was no pattern to the behaviors but they occurred more often in the evening. R1 required close supervision when actively having hallucinations and delusions for personal safety. The assessment identified there was a safety concern, R1 was admitted with [DIAGNOSES REDACTED]. Current interventions included 1:1 when needed, attempt reorientation if able, and use of a wander guard. Multiple behaviors would be addressed in the care plan such as aggressive-verbal and physical, hallucinations/delusions. Would continue to work with primary physician to reduce [MEDICAL CONDITION] medications, if able. Will continue to work with R1 and staff to find alternative to aggression, and interventions that would decrease anxiety. R1's quarterly MDS dated [DATE], indicated R1 remained severely cognitively impaired, experienced hallucinations, did not wander, and was independent with ambulation with walker. R1's Behavior Monthly Flowsheets from (MONTH) 2019, to present did not identify or track R1's wandering behavior. A facility Health Regulation Division - Nursing Home Incident Reporting form submitted by the facility on 10/18/19, at 9:34 p.m. indicated at approximately 7:35 p.m. the door alarm was activated. An alert came over the staff's pager system and certified nursing assistant (CNA) went to the door where the alarm went off. CNA went through the adjoining hallways of Bigfork Valley Hospital and did not find (R1). Nursing staff looked in the facility and did not find the resident. CNA informed hospital and ancillary staff. Search was initiated. At 7:55 p.m. a Code Alert was initiated with the information being passed on to the Hospital CEO, Administrator, DON and Itasca County Sheriff's Department at 8:03 p.m. At 8:18 p.m. R1 was returned to the facility by a private vehicle. Vital signs were taken. All vitals were within normal limits. Skin assessment was completed with no injury noted. R1 was interviewed and was able to tell staff that he was going to Faribault to look for his mother. Resident did not know the people who brought him back. On 10/28/19 at 9:15 a.m. a tour of the Tamarack unit was conducted with the DON. The unit was observed to be a large C shaped unit with 10 doors that exit from this unit. All doors were equipped with a wander guard alarm system which would alarm when an individual wearing a wander guard went through the door. Two of these doors entered the main hospital which had many unalarmed exits to the outside. When exiting all hospital doors, an individual would be able to leave the facility grounds unnoticed. Three of the 10 Tamarack unit doors exited into an enclosed area, although these areas may be exited by a gated fence. A thick, wooded area which lead the the Bigfork river was noted when exiting the facility to the north. Thick wooded areas were also noted to the east and south exits of the facility and had paths leading into them. The town of Bigfork was to the west of the facility. The DON verified the aforementioned observation. A PN dated 9/18/19, at 4 a.m. indicated R1 had briskly walked out the front door setting the alarm off. R1 was found standing outside the front door, looking around. A PN noted dated 10/18/19, at 9:26 p.m. indicated at 7:25 p.m. R1 went through the door leading to the adjoining Bigfork Valley Hospital (BVH) and Villa (Assisted Living). The facility's door alarm sounded and a message was sent over the staff's pager system. Initiated Facility Alert policy. At 8:02 p.m. contacted BVH CEO, administrator, DON, and the Itasca County Sheriff's department. R1 was returned safely to the facility via a private vehicle. R1 was moved to the Aspen secured unit. On 10/24/19, at 1:53 p.m. R1 was observed lying in bed, awake. R1 was confused, calm and hard of hearing. R1's room is located at the back right corner of the Aspen unit (3rd room from the end). There is an exit door at this end of unit with an automatic sliding door. Signage read, please note: Push to open (arrow pointing down to handicap push button wait for three second delay for the door to open.) On 10/28/19, at 9:07 a.m. R1 was observed sitting on the edge of bed eating breakfast. R1's walker was positioned at the end of the bed. At 11:46 a.m. R1 was observed walking out of the bathroom pushing the walker with one hand. R1 had a slow, shuffling gait. On 10/24/19, at 11:44 a.m. the DON showed the surveyor R1's previous room location where he resided at the time of the elopement, and the door R1 had exited from on 10/18/19. The DON stated when R1 had eloped, a nursing assistant (NA)-A was in room [ROOM NUMBER] (located across the hall and two doors away, approximately 30 feet away from R1's room), completing cares with another resident. The DON stated the NA had heard the alarm going off when she exited room R21 which was around a corner and out of sight from room [ROOM NUMBER] where NA-A was working. The DON stated anyone could pass through the alarming door which led right into the adjoining hospital and assisted living sections, but the door would only alarm if the person was wearing a wander guard. The DON verified that once through that door, a person had many unalarmed exit doors to leave the campus, unnoticed. The DON also stated there was no system in place to determine how long the alarm had been going off following R1's exit. At this time, measurements were taken from R1's room to the door that was exited, which was approximately 138 feet. -At 2:00 p.m. registered nurse (RN)-A stated he was attending to a resident fall in the Aspen area when staff alerted him of R1's elopement, but could not recall the exact time he was notified. RN-A stated he searched throughout the adjoining hospital and the assisted living before being directed to search a wooded area behind the facility. RN-A stated he was notified that a community member had returned R1 to the facility. RN-A could not recall the timeframe of being informed of when R1 had eloped and when R1 had returned. RN-A confirmed the doors of the Aspen unit alarmed if exited by a resident with a wander guard in place. -At 2:18 p.m. the administrator and surveyor entered room [ROOM NUMBER], and closed the door to hallway while the DON set off the alarm to the door R1 exited on 10/18/19. When the room door was closed, the alarm could not be heard by the administrator or surveyor. When door was open and the privacy curtain pulled, the alarm was barely audible. Both the administrator and the DON stated that the alarm was often hard to hear. On 10/28/19, at 9:15 a.m. DON stated after the hospital staff had viewed the security surveillance video, it was determined R1 had went into the hospital area and exited the door by the loading dock. The DON stated the video also verified R1 had exited the campus without his walker. The DON stated in addition to alarm systems, the nursing staff also carried pagers with then that also alerts them as to when an alarm goes off. However, the DON could not confirm if the NA-A that responded on 10/18/19, had a pager with her or not. The DON provided a list of four other residents on the Tamarack unit who have wander guards on. -At 2:04 p.m. The elopement surveillance camera footage was viewed with the DON. The video revealed when R1 had eloped, he was wearing shoes, a [NAME]et, a hat, pants, and did not have his walker with him when exiting the hospital through the loading dock area. Time stamp was 7:35 p.m. on 10/18/19. -At 2:15 p.m. NA-A stated when R1 had eloped, she was in room [ROOM NUMBER] providing cares. Upon completion of the cares, she exited the room which was when she had first heard the alarm going off. NA-A stated she took the dirty items she had been holding to the soiled utility room across the hall and then responded to the alarm. NA-A stated she opened the adjoining hospital door, but did not seen anyone so she went to R1's room to see if R1 was gone. NA-A could not state how long the alarm had been going off before she responded, but thought she had been in room [ROOM NUMBER] for no more than 15 minutes. NA-A stated the staff did not utilize walkie talkies because the ones we have do not work well and they are too bulky to carry. NA-A confirmed the use of pagers, however stated she did not have a pager that evening and if she did, it would have indicated which resident had exited the door. When asked why she did not have a pager, NA-A stated there are times when other staff take the pagers home therefore there were not enough pagers in house for all staff to use during their shift. NA-A stated about a couple times a week there were not enough pagers for the staff to use. -At 3:07 p.m. licensed practical nurse (LPN)-A stated she did not carry a pager or walkie talkie when she worked because she would just visualize the hallways to see if resident call lights were on or the NA's would come to her when they need help. -At 3:50 p.m. RN-B confirmed R1 was admitted with exit seeking behaviors and verified R1 did not have initial exit seeking interventions in place. RN-B verified R1's wander guard was placed on R1's walker on 8/10/19, and moved from the walker to R1's wrist on 9/7/19. -At 4:29 p.m. NA-A stated she regularly looked for a pager to use at the beginning of her shift and when there was not enough pagers for all staff to use, she would let her charge nurse or the Health Unit Coordinator (HUC) know that she did not have one. -At 4:32 p.m. NA-B confirmed he was working the night of incident and had been helping another resident with toileting cares when his pager went off. However, NA-B stated he did not check his pager when it had went off because he had gloves on and the pager was in his pocket. NA-B stated the pager also go off when a door alarm goes off as well as when a resident turns on their call light. NA-B stated NA-A alerted him that R1 was missing. NA-B verified there have been times when there are not enough pagers for all staff to use and when that happens, he would let his charge nurse know, watch for call lights and conduct every 15 minute resident rounds. -At 4:37 p.m. the DON stated she would expect all aides and nurses to carry pagers while working. The DON stated she was not aware there were not enough pagers for the staff and had she known, she would have ordered more. On 10/29/19, at 11:10 a.m. when asked about routine testing of the wanderguard functionality, the health unit coordinator (HUC) stated the wanderguard were identified on a spread sheet which indicates when the alarm was placed on the resident, when wanderguard expires as well as the wanderguard identification number. However, the HUC stated she did not do any frequent checking or testing to ensure the wanderguard's functioned properly. The HUC stated she was not aware the wanderguard's needed to be checked weekly to assure they were functioning. -At 11:13 a.m. NA-C & NA-D stated all the door alarms except for the door R1 had exited, could be heard really well when the staff were in resident rooms. Both stated the alarm on the door adjoining the hospital and assisted living was very faint sounding and was difficult to hear when in a resident room. -At 11:18 a.m. the DON provided the HUC with a list of job responsibilities which included routine testing of the wanderguard to ensure functionality. The HUC verified the wanderguard had not been checked weekly, as indicated. -At 11:29 a.m. a tour of the Tamarack unit's courtyard was conducted with the Environmental supervisor. The enclosed courtyard gate had a chain around the door handle that could be removed and the gate could be opened. Anyone who removed the chain could exit the courtyard area. The After Action Report, completed on 10/23/19, included information about what occurred on 10/18/19, after R1 had eloped from facility. The report indicated at the time of incident, the outdoor temperature was 57 degrees and R1 was located at the 3-way stop at the corner of Scenic 7/Golf Course Road, approximately 0.6 miles away from the facility. The report did not address how to prevent future elopements from occurring for R1. Elopement Risk Assessment policy dated 1/17, directed the admitting nurse or MDS Coordinator to perform an elopement assessment upon admission. Pager and Walkie Talkie Usage policy was developed as a result of this I[NAME] The policy directed all nursing staff to have a pager on their person at all times. Walkie talkies would be on their person during the evening/night shift hours. Pagers and walkie talkies will be stored on each unit. Licensed nursing staff and aides will do a hand off of the equipment and sign out the pagers and walkie talkies at each start of the aides shift. If a staff person does not turn in their pager at the end of their shift, the nurse on unit will call them and tell them to return it. Staff are to notify the nurse if pager was not working or was missing. Back up pagers are kept at the Tamarack Nurse's Station. Upon hire, staff will be educated on the Pager and Walkie Talkie policy. Audits of pagers will be done to ensure compliance with policy and procedure. The immediate jeopardy that began on 10/18/19, and identified on 10/28/19, at 5:30 p.m. was removed on 10/30/19, at 3:10 p.m. after the facility implemented the following interventions which were verified through document review and multiple staff interview: -Additional pagers were ordered, all staff were re-educated on the policy and procedure of use. A monitoring system was developed to ensure compliance. -The routine wanderguard functionality checking was incorporated onto the resident's electronic medication record (EMR) to ensure checks completed. -All Tamarack unit residents who utilize a wanderguard were re-assess for continued need. Care plans were reviewed and/or revised. The wanderguard system company, RFT, to conduct an onsite evaluation of the system to ensure upgrades completed as needed. -Elopement and Elopement Risk assessment policy reviewed and/or revised as needed. Staff re-education provided related to the completion of comprehensive elopement assessments and documentation. -Elopement policy and procedure was incorporated into the facility wide QAPI program.

Based on observation, interview and document review, the facility failed to monitor pain and consistently administer as needed pain medication in order to minimize pain for 1 of 4 residents (R23) who had severe, chronic pain. This resulted in actual harm for R23 who was not administered medication as ordered, when needed, and when experiencing severe pain. Findings include: R23's [DIAGNOSES REDACTED]. R23's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R23 had severe cognitive impairment and required extensive assistance of 1-2 staff for all activities of daily living (ADLs) except eating which required supervision. The quarterly MDS further indicated R23 frequently had pain, rating the pain a 6 on a 0-10 pain rating scale (0=no pain, 10=severe pain), and received as needed pain medication. R23's significant change MDS dated [DATE], also indicated R23 frequently had pain, rated the pain a 6 on a 0-10 scale, and received as needed pain medication. R23's Pain Care Area Assessment (CAA) dated 8/24/18, indicated R23 had chronic pain related to his [DIAGNOSES REDACTED]s. R23 described his [DIAGNOSES REDACTED]s as moderate to severe pain which increased R23's risk for depression symptoms such as isolation. The CAA also indicated R23's headaches worsened with bright lights and loud noises and indicated pain medication was not always effective. R23's Care Plan dated 1/28/19, indicated R23's cognition had declined, he was able to answer yes or no questions with ease but had difficulty with complex interviews. The Care Plan indicated R23 was able to voice his needs but at times, got confused over words. Interventions identified in the Care Plan indicated R23 needed to sit in a less well lit area of the dining room due to bright lights causing headaches. The Care Plan also included: (MONTH) need to eat in Common's area. Has pain related to [DIAGNOSES REDACTED]s, bursitis, sciatica and right shoulder pain. The plan directed staff to administer medications as ordered, apply Freeze It gel to the shoulder and a [MEDICATION NAME] every morning, and indicated R23 was on comfort cares and could receive [MEDICATION NAME] for pain as ordered, and could also receive Tylenol as needed for pain. Staff were to monitor [DIAGNOSES REDACTED] pain four times a day while awake, monitor the effectiveness of the medication with use of the 0-10 pain scale, offer diversional activities, offer warm and cold packs, and set up chiropractic appointments as needed. Further, the Care Plan indicated R23 preferred to have his room dark due to lights causing him to have headaches therefore, staff were to ensure lights were turned off and the curtains were closed. Staff were to make sure R23 was comfortable, allowing him to adjust to situations and most days he liked to be in his room, in the dark. R23's Pain assessment dated [DATE], indicated R23 had experienced chronic headaches for many years due to multiple traumas and past head injuries. The assessment indicated R23 had been evaluated by numerous specialists and has been to pain clinics without improvement in pain management. The assessment further indicated R23 had been placed on comfort cares with the goal of pain control, and indicated bright lights and loud noises increased R23's headaches. The assessment indicated R23's Care Plan would be updated with comfort measures to promote comfort and decrease R23's pain levels. Review of R23's current physician's medication orders indicated R23 could have [MEDICATION NAME]/[MEDICATION NAME] 5/325 milligram (mg) 1 tablet by mouth every four hours as needed for pain. Review of R23's medication administration records (MAR) revealed R23 received the medication the following times: December (YEAR) MAR: R23 was given [MEDICATION NAME]/[MEDICATION NAME] 41 out of 186 opportunities. January 2019, MAR: R23 was given [MEDICATION NAME]/[MEDICATION NAME] 59 out of the 186 opportunities. February 2019 MAR: R23 was given [MEDICATION NAME]/[MEDICATION NAME] 47 out of the 168 opportunities. (MONTH) 1-6, 2019 MAR: R23 was given [MEDICATION NAME]/[MEDICATION NAME] 13 times out of the possible 36 opportunities. Each administration of the [MEDICATION NAME]/[MEDICATION NAME] was documented as having been effective. Additionally, R23's current physician's medication orders indicated R23 could have [MEDICATION NAME] solution 20 mg/milliliter (ml), 2 mg by mouth every hour as needed for moderate pain. The order further directed staff to give 2 mg for pain scale rating of 1-5 every hour for moderate to severe pain or dyspnea, and to give 4 mg for pain scale rating of 6-10 every hour for moderate to severe pain or dyspnea. Review of R23's Medication Administration Record [REDACTED] December (YEAR) MAR: [MEDICATION NAME] was not given January 2019 MAR: [MEDICATION NAME] was not given February 2019 MAR: [MEDICATION NAME] was given five times March 1-6, 2019 MAR: [MEDICATION NAME] had been given twice. Documentation indicated the [MEDICATION NAME] doses adminsitered were effective in reducing pain. On 3/4/19, at 6:01 p.m. R23 was observed to not have eaten his supper meal. R23 stated his head hurt so bad that he just could not eat and reported the [MEDICATION NAME] dose he had been given had not helped at all. A staff person offered R23 a bowl of cheerios, but R23 refused and while pointing at his head, stated he just could not take it. At 6:10 p.m., R23 reported his pain was a 10 on a 0-10 pain scale. Trained medication aide (TMA)-A was observed to administer R23 an [MEDICATION NAME]/[MEDICATION NAME]. On 3/5/19, at 1:39 p.m. R23 was observed lying in bed on his back with his eyes closed. R23 reported his headache was a 6-7 on a 0-10 pain scale. According the (MONTH) 2019 MAR, the nurse had signed off as having administered the [MEDICATION NAME]/[MEDICATION NAME] at 12:16 p.m. and had documented the medication result as effective. On 3/6/19, at 8:38 a.m. nursing assistant (NA)-I was observed to enter R23's room to provide morning cares. When NA-I turned on the ceiling light, R23 held his hands over his eyes to block the light. At 8:42 a.m. R23 stated to NA-I turn them damn lights off. They'll kill ya. However, NA-I did not turn off the ceiling light and continued to assist R23 with morning cares. At 8:45 a.m. R23 again stated shut them damn lights off. NA-I turned off the ceiling light and turned on the bedside lamp. At 8:47 a.m. as NA-I continued to provide morning cares, R23 stated I should get up later on. I just don't know anything. At 8:49 a.m. following completion of the cares, NA-I assisted R23 to a comfortable position, covered him with a blanket and provided R23 his call light. At 8:53 a.m. NA-I stated she really did not know much about R23's headaches, but knew they happened frequently and said she believed he had one every day. NA-I further stated she didn't know what caused R23's headaches, but she knew the lights really bothered him. NA-I stated R23 had tried wearing sunglasses in the dining room in order to decrease the brightness because he would not eat with the bright light. On 3/6/19, at 12:57 p.m. registered nurse (RN)-B stated R23's family had told him R23 had experienced two head injuries in the past. RN-B stated R23 currently had MEDICATION ORDERS FOR [REDACTED]. RN-B stated R23 had received [MEDICATION NAME]/[MEDICATION NAME] earlier that day and the [MEDICATION NAME]/[MEDICATION NAME] usually touched R23's headache when taken, during the day. RN-B also stated R23 required [MEDICATION NAME] at night due to his headaches worsening throughout the day due to the lighting. RN-B verified R23 did have sunglasses for use when in the dining room, but added R23 did not always leave them on. RN-B stated the nursing assistants were expected to report when R23 was in pain. RN-B stated he was not hesitant about giving R23 [MEDICATION NAME], but R23 had not exhibited the signs or symptoms of needing it. RN-B verified the staff were to assess R23's pain level 3-4 times per shift by using the 0-10 pain scale. RN-B stated he had never seen R23 moaning or holding his head and R23's usual pain rating was 4-5 during the day. RN-B stated non-pharmacological approaches such as ice/cold packs were not usually offered because R23 had internal pain so those type of approaches would not help. RN-B stated R23's family had reported R23 had suffered from the headaches for many years. On 3/7/19, at 12:25 p.m. R23 was observed seated at the dining room table with his dinner meal in front of him, but was not eating. R23 had his head down and his hand covering his eyes. R23 did not have sunglasses's on. At 12:26 p.m. R23 used his left hand to guide fruit onto his adaptive spoon. R23 took a bite of the fruit, then sat back and covered his eyes with his hand. At 12:30 p.m. R23 took a drink of milk. At 12:32 p.m. R23 covered his eyes with his hands. At 12:33 p.m. R23 unlocked his wheelchair brakes, wheeled himself closer to the table and re-locked the wheelchair brakes. At 12:35 p.m. R23 picked up his fork and touched his garlic toast, moved it around his plate, but did not take a bite of the food. At 12:38 p.m. R23's tablemate asked R23 if he was hungry. R23 stated yes and no. R23 had eaten only one bite of fruit. At 12:39 p.m. R23 covered his eyes with his hands and exhibited facial grimacing. At 12:45 p.m. R23 continued to sit with his eyes covered and had still not eaten. No staff had approached R23 to make additional offers of different food or assistance. At 12:48 p.m. R23 took a sip of coffee and had drank his milk, but still did not eat. At 12:51 p.m. R23 continued to cover his eyes with his hand. At 12:55 p.m. NA-K asked R23 if he was done. R23 stated yes, but NA-K walked away. At 1:00 p.m. R23 continued to cover his eyes with his hand. NA-I offered a bowl of cheerios and R23 stated he would try it. NA-I did not ask R23 anything about his pain. At 1:07 p.m. R23 was given cereal, but R23 did not take any bites. At 1:08 p.m. NA-I asked R23 how the cereal was, but R23 stated he had not tried it yet. At 1:10 p.m. R23 moved the bowl closer to him, but did not take a bite and covered his eyes. At 1:11 p.m. review of R23's current MAR indicated [REDACTED]. R23 continued to cover his eyes with his hand. At this time, R23 stated he had a headache and stated he wished someone would just shoot me and get it over with. When the surveyor asked about his pain, regarding a 0-10 pain rating, R23 stated it hurt so bad he did not even know any more. At 1:15 p.m. R23 was assisted to the community room table to wait for assistance to lie down. R23 did not eat nor did any staff ask R23 about his pain. On 3/7/19, at 1:35 p.m. RN-B verified R23 should have had sunglasses on during his dinner meal. RN-B stated R23 had been sleeping before going to dinner and was really confused, which probably made R23's headache worse. RN-B stated the [MEDICATION NAME]/[MEDICATION NAME] generally did work in lessoning R23's headaches and R23 did not complain about it. RN-B stated he thought R23 truly had headaches therefore he would frequently administer the as needed pain medication. On 3/7/19, at 1:52 p.m. RN-A stated R23's headaches were not new for him and his pain had not changed. RN-A stated she believed R23 experienced severe pain with the headaches. When asked if the [MEDICATION NAME] should be use more, RN-A acknowledged the nursing staff could administer the prescribed [MEDICATION NAME] more often to help control the pain. On 3/7/19, at 2:13 p.m. the director of nursing (DON) verified R23 had a long standing problem with pain and that the facility's pain committee reviewed R23 weekly in order to consider better pain control options for him. The DON stated members of the pain committee included the DON, RN, Pharmacy and the Physician. The DON verified nursing staff were expected to provide R23 pain control via the use of as needed medications which were available to be used, as needed. The DON stated the nursing staff had received education regarding R23's pain monitoring and administration of pain medications and stated she had even sent an email to all staff encouraging them to use the [MEDICATION NAME] as ordered for better pain control. On 3/7/19, at 3:49 p.m. RN-B verified he had not provided any additional pain medication for R23 after R23 had stated he wanted someone to shoot him due to the pain. RN-B stated he felt the [MEDICATION NAME] was effective because the pain had lessoned. RN-B stated when he asked R23 if he had pain, R23 reported he did and pointed to his mid-forehead and had asked to lie down. RN-B stated he'd assisted R23 to lie down, turned the lights off and R23 was lying quietly. Because R23 was quietly lying down, RN-B stated he'd thought no further medication was needed. On 3/8/19, at 8:51 a.m. family member (FM)-B stated he had not been able to get to R23's care conferences recently due to work, but stated his wife (FM-B's wife) visited R23 frequently. FM-B stated R23 had experienced the painful head aches for years, but was really unsure what the nursing home had been doing for R23's pain. FM-B stated he thought the facility had tried many things but stated R23 was worn out. FM-B stated light made R23's pain worse and shutting the blinds, and laying down for naps seemed to make it better. FM-B stated if nursing needed to administer as needed pain medications for R23 to be pain free, the family approved, but FM-B added the nurses know best. On 3/8/19, at 9:29 a.m. RN-A verified pain medication should be offered to R23 when R23 had complaints of pain. On 3/8/19, at 11:04 a.m. RN-A verified R23 was able to express his wants and needs. RN-B further verified R23 was able to report when he was in pain and nursing should use the pain scale in order to determine R23's level of pain. RN-A stated she reviewed R23's pain scale documentation quarterly, and also during pain committee reviews. Review of R23's Pain committee documentation revealed R23's headaches/pain had been discussed in (MONTH) 2019, but no interventions or recommendations were noted as having been recommended. The facility's Pain Management Program policy revised 11/2018, indicated effective pain management resulted in optimal levels of comfort while maintaining as much function as possible. The policy further indicated licensed nursing staff would be made aware of any pain and would provide an assessment and/or evaluation to determine location, rating, description, alleviating factors, interventions, onset, etc. which would be recorded in the resident's electronic medication record.

Based on observation, interview and document review, the facility demonstrated a systematic failure to comprehensively assess and effectively implement interventions in order to minimize the risk of serious injury or death from elopements for 1 of 8 residents (R63) reviewed with a history of elopement from the secured memory care unit, resulting in immediate jeopardy (IJ). This had the potential to affect the other 8 residents (R29, R33, R25, R35, R60, R5, R17, R49) who resided on the secured unit who had wandering behavior. Findings include: The IJ began on 2/28/15, when R63 first displayed wandering and exit seeking behaviors. The facility's systematic failure to comprehensively assess and effectively implement interventions for R63's exit seeking behaviors was identified on 3/25/15. The administrator and the interim director of nursing (IDON) were notified of the IJ on 3/25/15, at 4:22 p.m. The IJ was removed on 3/27/15, at 12:30 p.m., however, non-compliance remained at the lower scope and severity level E, pattern scope and severity, which indicated no actual harm with potential for more than minimal that is not immediate jeopardy. R63's admission Minimum Data Set ((MDS) dated [DATE], indicated R63 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. R63 was admitted from a behavioral unit and was placed in the facility's newly constructed secured memory care unit. The MDS dated [DATE], indicated R63 had the ability to ambulate on and off of the nursing unit without assistance of any type. The assessment indicated R63 displayed behaviors such as having little interests, being tired or having little energy, displaying delusions, refusal of cares and wandering. In addition the MDS question which read: Does the wandering place the resident at significant risk of getting into potentially dangerous places? was marked Yes. The Cognition Care Area Assessment (CAA) dated 3/5/15, indicated R63 had dementia Wernicke's Korsakoff syndrome and short term memory loss. The staff must anticipate and meet his needs. The Behavioral CAA dated 3/5/15, indicated R63 exhibited behaviors of exit seeking, wandering and resistance of cares. The CAA directed the staff to provide one to one care and anticipate his needs. The Elopement Risk assessment dated [DATE], identified R63 at high risk for elopement. The assessment indicated R63 had the ability to ambulate without assistance, he displayed memory impairment, was admitted within the past 72 hours and was a wanderer. The care plan dated 2/27/15, indicated R63 displayed dementia related behaviors and directed the staff to administer as needed antianxiety medications (Ativan), anticipate needs, encourage R63 to talk to spouse on the telephone or engage him in television shows. The care plan also identified R63 as an elopement risk/wanderer as evidenced by R63 wanders aimlessly, impaired safety awareness, disoriented to place, history of attempts to leave facility unattended. The goal was to maintain R63's safety and the identified care plan interventions included, distract R63 from wandering by offering pleasant diversion, structured activities, food, conversation, television or book. Identify the pattern of wandering and intervene as appropriate. The Aspen unit was observed to be a large open unit with resident rooms on either side. The east end of the unit was equipped with a foyer area and sliding doors. The west end of the unit was equipped with three sets of doors. The first door was a fire door which led outside, the second set of doors (two sets of french doors) led into the glassed in dining room, and the third set of doors led into the Tamarack unit. The dining room was observed to have french doors on either side of the room. One set to enter the dining room and one two sets of french doors to exit the building and enter a patio area. The patio area was a large cement slab area under a covered awning. The ground was uneven as the landscaping had not yet been completed. The patio area was not fenced in which left direct access to the facility driveway. Beyond the driveway was a thick wooded area to the west and the hospital parking lot to the south. The door to the patio was not observed to have any alarm system. On 3/24/15, at 12:45 p.m. R63's spouse stated she was aware R63 had attempted to leave the facility on one occasion when he was first admitted to the facility. She stated she was not aware of any other concerns of R63 attempting to leave the facility. On 3/24/15, at 4:40 p.m. R63 was observed walking on the Aspen unit. R63 was a physically fit male who ambulated without any type of assistive devices. His gait was steady without limitations observed. At 4:55 p.m. R63 was observed to attempt to leave the Aspen unit by pushing on the exit door which led into the Tamarack unit (other area of the facility.) R63 stated, I am trying to get out of here. R63 was approached by cook-A who directed R63 back to the nurses station. Licensed practical nurse (LPN)-D approached R63 and informed him to stay in the unit. R63 explained he was trying to locate the kids. LPN-D attempted to reason with R63 to stay in the unit but R63 informed her he needed to get out of here. On 3/24/15, at 5:55 p.m. R63 had finished his meal, walked out of the dining room and attempted to leave the unit by exiting the doors to the Tamarack unit. Nursing assistant (NA)-C approached R63 and asked him where he was going. R63 informed NA-C he had to go upstairs to get his timecard. NA-C redirected R63 back to his room. On 3/24/15, at 6:20 p.m. NA-B stated R63 had history of attempting to leave the facility via the patio door. NA-B stated the patio doors were not locked nor were they alarmed. She explained when R63 exited the facility he was easily redirected. R63's progress notes revealed the following information regarding documentation about attempts at or actual elopements from the facility. It was noted that it could not always be determined which exit was referred to, and administrative staff were not aware of the incidents so could not provide clarification. - 2/27/15, R63 was admitted to the facility. - 2/28/15, at 10:14 a.m. R63 eloped out the dining room door in Aspen (outside facility). R63 informed the staff he was looking for the girls. R63 responded to staff verbal prompt to return to the facility. - 2/28/15, at 2:37 p.m. (R63's name) has eloped outside x 3 today. (outside facility). R63 was directed verbally to return to the facility. - 3/3/15, at 5:58 p.m. R63 had been up and attempting to get out doors since 5:00 am. He was also attempting to remove his wanderguard. - 3/3/15, at 10:37 p.m. R63 packed a basket of clothes after supper and brought it to the west doors by the kitchen area. He informed the staff he was going to get in his car and leave the facility. - 3/9/15, at 6:-4 p.m. R63 eloped out the door during supper. -3/13/15, R63 eloped out the door x 2. R63 informed the staff he was looking for the DMV (department of motor vehicles) and wanted to get his car registered. - 3/15/15, at 5:11 a.m. R63 pushed the emergency panel on the door on the east end door. R63 was able to get outside and another resident (R17) exited the building with him. (front entrance of Aspen unit which accesses parking lot outside facility) - 3/19/15, 8:24 p.m. R63 eloped x 4 this pm, he got out the door x 2 this pm. R63 was anxious about his car and family. R63 was directed by staff to participate in the evening activity. The note also read: (R63's name) still was set against leaving and going home. - 3/21/15, at 11:07 p.m. (R63's name) has been up greater than 24 hours. He is constantly trying to get out the doors, he is concerned about his truck, he needs to go to work, wants to go and visit a friend. The documentation lacked identification of when R63 left the facility, how far from the facility he eloped, and if the wanderguard system was working on the exits equipped with alarm system. On 3/25/15, at 7:50 a.m. NA-D stated she was aware of R63 leaving the building. On 3/25/15, at 8:00 a.m. LPN-D stated R63 had been out of the facility on one occasion since his admission. On 3/25/15, at 8:15 a.m. the director of maintenance stated the facility doors were equipped with a wanderguard system which would prevent the residents from being able to exit the door if they had a wandergaurd alert on their bodies. He explained the east door, the west fire doors and the doors between the Aspen and Tamarack units were all equipped with wandergaurd systems. When questioned if the patio doors in the dining room were equipped with the same type system he stated, No. He explained the patio doors were not going to be locked so the residents had the ability to go onto the patio and sit outside as they wanted. In addition, he explained the patio doors were not a designated fire door, and they did not have the ability to be locked to prevent somebody from going onto the patio. He stated when the patio doors were locked, they prevented people from coming into the building from the outside, but they would not prevent the people from the inside from the ability to go outside. On 3/25/15, at 10:00 a.m. registered nurse (RN)-C/Aspen unit manager stated R63 had attempted to elope from the facility. RN-C was able to located two incident reports both dated 2/28/15, in which R63 had left the nursing unit. The first report dated 2/28/15, at 9:35 a.m. indicated R63 was found outside of the building. He had left the facility via the patio doors. At that time, a wandergaurd (door alert system) was placed on R63. The second incident report dated 2/28/15, at 11:30 a.m. indicated R63 eloped outside via the dining room door and eloped to the Tamarack unit via the Aspen door. No new changes were made as the wandergaurd had been placed. On 3/25/15, at 10:15 a.m. RN-C reviewed R63's progress notes. She stated she was unaware R63 had made multiple attempts and had exited the building unattended. She stated she was only aware of elopements on 2/28/15. She explained any time a resident left the facility unattended an incident report was to be completed, but the reports had not been completed. On 3/25/15, at 11:45 a.m. RN-C confirmed the Aspen unit was a secured memory care unit and R63, R25, R33, R35, R60, R50, R17, R13 and R29 all displayed wandering behaviors and had the potential to exit the facility. On 3/25/15, at 11:50 a.m. housekeeper (HSKP)-B stated she was aware R63 had been outside a couple of time, but could not state when, or how far R63 had gotten from the facility. On 3/25/15, at 11:52 a.m. LPN-A stated she was aware R63 had exited the facility without accompaniment. On 3/25/15, at 11:57 a.m. RN-A/MDS coordinator stated she was aware of one occasion in which R63 had exited the building. She stated any time a resident exited/eloped from the facility, the staff were to ensure the resident's safety, escort them back to the building, document the incident in the progress notes and complete an incident report. She confirmed R63 had exit seeking behaviors, had exited the building unattended, and the staff had not completed incident reports or alerted their supervisors of the concern. In addition, she confirmed the facility had not attempted new interventions, updated the care plan or attempted to prevent R63 from wandering away from the facility. She stated she had been made aware of R63's attempts to leave the facility on the morning of 3/25/15. On 3/25/15, at 12:03 p.m. the IDON stated she was aware of the incident on 3/15/15, in which R63 had attempted to leave the facility. She stated she was the nurse working that shift and she had notified the director of senior services about the concern. She confirmed she did not complete an incident report regarding the incident on 3/15/15. On 3/25/15, at 12:05 p.m. the Aspen unit doors were tested with the IDON and RN-A. IDON confirmed the patio doors did not lock and were not equipped with the ability to prevent the residents from leaving the unit unattended, despite being a secured unit. On 3/25/15, at 2:23 p.m. NA-J stated she had observed R63 leave the Aspen unit via the patio doors. She stated R63 did not leave the cement patio and was directed back into the facility by staff. She explained R63 could easily be directed. She was not aware of any type of interventions or changes for R63's behaviors. On 3/25/15, at 2:26 p.m. the director of senior services and the facility administrator were interviewed. The director of senior services and the administrator stated they were not aware of a pattern of R63's behaviors in which he would attempt to elope. The director of senior services stated the facility was planning on having a fence placed after the ground thaws and they had ordered alarming mesh stop signs to prevent residents from leaving the patio doors unattended, but this measure had not been correlated to R63's behaviors. On 3/25/15, at 2:30 p.m. NA-C stated R63 would wander at night. He explained R63 frequently was looking to go upstairs, looking for his children or waiting for a meeting. He explained R63 frequently was searching for someplace to go. He stated the facility did not have any specific protocols for dealing with wandering residents. He confirmed he was aware R63 was exiting the facility but was unable to say how far R63 had gotten from the facility or how often the behavior had occurred. On 3/25/15, at 2:30 p.m. NA-G stated she had observed R63 leave the facility. She stated she went to the door and told him to come back into the facility. NA-G could not say how far R63 had gotten away from the facility. On 3/25/15, at 2:50 p.m. LPN-B stated she had observed R63 outside of the facility 2 - 3 times. She stated R63 was easily redirected back into the facility but could not recall how far he had gotten away from the facility. The Unsafe Elder Wandering policy dated 8/16/11, directed the staff to ensure the residents were safe while attaining the least restrictive environment. The staff were to identify the residents at risk for wandering, update the care plan as needed and the staff were to notify the administrator and the DON immediately of any elopements. The immediate jeopardy that began on 2/28/15, and identified on 3/25/15, at 4:22 p.m. was removed on 3/27/15, at 12:30 p.m. after the facility implemented a removal plan. The plan included: - Completed a comprehensive elopement assessment for R63. - Updated the care plan and determined diversional activities for R63 during heightened exit seeking behaviors. - Established a system in which the dining room doors were locked except during meal times and updated the elopement policy. - Staff were educated on the changes to the elopement policy and changes to R63's POC. member verified through interview they had received education on R63's comprehensive interdisciplinary care plan/ exit seeking behaviors.

Based on interview and document review the facility failed to prevent adequate supervision for 1 of 1 residents (R1) when R1 was allowed to smoke a cigarette while oxygen was on while in the presence of staff. R1 smoked with oxygen running per nasal cannula and ignited a fire that caused harm when R1's checks and nostrils were burned. Findings include: Medical records revealed R1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. physician's orders [REDACTED]. The resident's initial assessment, dated 12/18/2014, revealed the resident used oxygen by nasal cannula, and was a current smoker. The resident's smoking assessment, dated 12/18/2014 revealed facility staff assessed the resident as smoking 2-5 times per day and required supervision while he smoked. There was no further instruction provided to staff of what type of supervision was needed. Nursing notes dated 12/19/2014 at 11:38 p.m. and written by Registered Nurse (RN)-E, revealed the resident was outside smoking with Nursing Assistant (NA)-F, when NA-F stated the resident required first aide due to injuries experienced when his oxygen ignited while the resident was smoking. The RN-E's note revealed the resident smelled of burned hair and skin, and the resident had blackened skin on his nose, under his nose, and bilaterally on both cheeks. The resident was sent to the emergency room for assessment of burns experienced while smoking with oxygen on. Hospital records dated 12/19/2014 revealed the resident was seen in the emergency department for first degree burns. R1 was admitted to the hospital for observation and returned back to the nursing home on 12/20/14. NA-F was interviewed on 12/23/2014 at 2:07 p.m. and stated about 6:00 p.m. on 12/19/2014 the resident approached NA-F about smoking outside. NA-F stated he looked for a care-plan related to smoking for the resident, and could not find one. NA-F stated he then asked his coworker if there was a care plan for smoking for the resident, and there was none. NA-F stated he was not aware there was no smoking allowed in the courtyard, so he took the resident outside to the courtyard to smoke and asked the resident to take off his oxygen before he smoked. NA-F stated he did not watch to be sure the resident took off the oxygen. NA-F stated the oxygen started on fire and NA-F pulled the tubing from the resident's nose, but it was still burning, he then threw the tubing on the ground, stepped on it, and unhooked it from the oxygen canister. The resident's face was black, his mustache was burned, and he was bleeding from the outside of his nostrils. RN-E was interviewed on 12/29/2014 at 4:00 p.m. and stated R1 requested to go outside to smoke on 12/19/2014. As soon as an aide was available to go with him, RN-E gave R1 a cigarette and a lighter, and he went outside to smoke. NA-F came back in and stated R1 needed first aide for burns. When RN-E assessed R1, she observed burns to his nose, cheeks, and mustache, and open skin on his cheeks and nose. RN-E sent R1 to the emergency room for treatment of [REDACTED]. Director of Nursing-A was interviewed on 12/23/2014 at 12:00 p.m. and stated the resident was smoking on the facility property and the policy for the facility was that smoking was prohibited on the facility property. The DON indicated the no smoking policy on facility grounds was inconsistently enforced. The facility policy titled Tobacco-free Environment and dated Revised 12/14 was reviewed. Under the section titled Policy the following was noted: To establish and maintain the safest possible environment in which to deliver care, Bigfork Valley's buildings, parking lots and operated vehicles are tobacco-free. Under the section titled Patients: 1. Assessment of the patient's tobacco use will be part of the initial nursing assessment. Support programs will be offered for those desiring to use their hospitalization as an opportunity to quit smoking...4. The department managers or supervisors will speak with non-compliant patients reminding them of our policies, again offering to seek out alternatives...5. If the patient persists in using tobacco, support from the administration staff will be enlisted to determine, with the patient's physician, reasonable alternatives, which may include: transferring the patient, and/or confiscating the smoking materials, etc. Patient safety should also be a paramount concern.

Based on interview and document review, the facility failed to analyze falls to identify and implement adequate interventions to minimize the risk of further falls for 2 of 5 residents (R41, R38) reviewed for accidents. R41 sustained actual harm related to a fall which resulted in a hip fracture. Findings include: R41's Admission Record report dated 7/10/14, indicated R41 [DIAGNOSES REDACTED]. R41's quarterly Minimum Data Set ((MDS) dated [DATE], indicated R41 had severe cognitive impairment and required extensive assistance of two plus staff for transfers, walking and toilet use. The MDS also identified R41's balance during transfers and walking was not steady, he was only able to stabilize with human assistance and had functional limitations in range of motion of his upper and lower extremities with impairment on both sides. The MDS further indicated R41 utilized a walker and wheelchair for mobility and received an active range of motion restorative program 4 days during the assessment period. R41's undated Care Area Assessment (CAA) for falls indicated R41 fell at home multiple times before admission. R41's wife was unable to care for R41 at home due to the falls, incontinence and ADL (activity of daily living) needs. The CAA identified R41 had a history of [REDACTED]. The CAA indicated a bed alarm was added to the bed and identified R41 had physical and cognitive impairments that placed him at increased risk for falls. R41's care plan dated 7/7/14, identified R41 was at risk for falls, had a history of [REDACTED]. -Ensure R41's call light was within reach, encourge him to use it for assistance, and respond promptly to all requests. -Ensure R41 was wearing appropriate footwear when ambulating or mobilizing in wheelchair -If R41 was restless this may be a sign of pain or need to use the bathroom. -If R41 wanted to get up and walk, assist him to walk as far as he would like as this may keep him from getting up as much on his own. -PT (physical therapy) evaluate and treat as ordered or PRN (as needed). Review of R41's medical record revealed the following: The Initial Fall Risk assessment dated [DATE], indicated R41 was at high risk for falls. Interventions: Fall risk care planned. Pressure alarm in wheelchair and bed when sleeping. Fall floor mats placed on both sides of bed and bed placed in lowest position when alone. R41's progress notes indicated R41 had sustained the following falls: -On 9/29/13, at 1:30 a.m. R41 was found on the floor after an unwitnessed fall out of bed. R41 sustained a small abrasion on the lateral side of his right knee. R41 was incontinent. Bed was in low position, call light within reach. Immediate action: vital sign and neurological checks initiated, 15 minute safety checks. 10/3/13, (4 days later) Interventions: Fall floor mats added to both sides of bed. A different wheelchair was to be used on a trail basis as it appeared to fit him better and he did not lean quite as far forward. No changes made to the care plan. -On 9/30/13, at approximately 12:00 a.m. R41 was found on the floor after an unwitnessed fall out of bed. No injuries. Immediate action: vital sign and neurological checks initiated. 10/3/13, (three days later) Interventions: Fall floor mats added to both sides of bed. A different wheelchair was to be used on a trial basis as it appeared to fit him better and he did not lean quite as far forward. No changes made to the care plan. -On 10/5/13, at approximately 7:15 p.m. R41 was found on his hands and knees on the mat on the right side of the bed near the door after an unwitnessed fall from bed. No injury. Immediate action: neurological checks initiated. Bed alarm placed. 10/7/13, (two days later) every 30 minute checks while R41 was in bed. No changes made to the care plan. R41's Fall Risk assessment dated [DATE], indicated R41 was a high risk for falls. Interventions: bed alarm on bed and chair, bed in lowest position and gray mats on floor beside bed. -On 10/20/13, at approximately 7:22 p.m. R41 was found on the floor on his left side after an unwitnessed fall in an unidentified location. No injuries. Immediate action: vital signs and neurological checks initiated. No incident report completed. No interventions identified. -On 10/21/13, at 11:00 p.m. R41 had a witnessed fall from bed. No injuries. Immediate action: supervison. No incident report completed. No interventions identified. -On 10/23/13, at 9:05 p.m. R41 had a witnessed fall to the floor while standing in the common area by the birdcage. No injuries. Immediate action: none identified. No incident report completed. No interventions identified. -On 10/25/13, at 8:46 p.m. R41 was found lying on the floor on his left side after an unwitnessed fall in the dining room. No injuries. Immediate action: vital signs and neurological checks initiated, use chair alarm wherever R41 sits. No changes made to the care plan -On 10/27/13, at 10:38 p.m. R41 found on the floor next to the bed after an unwitnessed fall out of bed. No injuries. Immediate action: none identified. No incident report completed. 11/1/13, (5 days later) Health Status Note: " follow up for falls on 10/25, and 10/27. (R41) was to get as much 1 on 1 attention as possible in the evenings. He could be in Balsam at times during the day when he wanted to or when staffing was stretched too thin. Staff to try to pick up a routine for him." No changes made to the care plan. -On 11/4/13, at 10:39 p.m. R41 was found on hands and knees in front of chair, in front of the tv after an unwitnessed fall. No injuries. Immediate action: none identified. No incident report completed. 11/12/13, (8 days later) R41 moved to the Balsam unit. -On 11/12/13, at 11:45 p.m. R41 was found on the mat next to his bed after an unwitnessed fall from bed. No injuries. Immediate action: vital signs and neurological checks initiated. No incident report completed. No interventions identified. -On 11/16/13, 11:57 p.m. R41 was found crawling on knees and hands at the end of his bed, after an unwitnessed fall from bed. He sustained an abrasion to his right knee measuring approximately 1 centimeter (cm) in circumference. Immediate action: brought to a chair in the common area and given food and drink. No incident report completed. The 11/19/13, Fall Risk Assessment indicated R41 was a high risk for falls, was diagnosed with [REDACTED]. The assessment also indicated R41 had multiple recurrent falls, was sometimes understood and able to understand others, verbalized very little, staff anticipated needs daily, had poor safety awareness and recognition of his physical limitations. Additionally, the assessment indicated R41 was impulsive with self transfers and used a bed and chair alarm at all times. One of the most recent falls was the result of R41 trying to turn off the air conditioner in his room r/t (related to) being cold. The asssesment indicated R41 would be moved to the bed near the door so he could be easily visualized by staff and away from the air conditioner unit. -On 11/21/13, at 11:30 a.m. R41 had a witnessed fall when he stood to walk and fell landing on his right knee sustaining a right knee abrasion measuring 1 cm x 0.5 cm. Immediate action: none identified. No incident report completed. 11/29/13 (8 days later) "Follow up for incidents on 11/18, and 11/21, indicated (R41's) previous evening routine was to watch the news every evening before bed. Staff were to put R41 in his recliner at 9:00 p.m. to watch one news station and then switch the channel to the next news broadcast at 10:00 p.m. Staff were also to take him for a walk outside of Balsam occasionally." Care plan updated. -On 12/1/13, at 7:30 p.m. R41 had a witnessed fall from the bed to the mat on the floor. No injuries. Immediate action: assisted to the common area and given 1:1 time with staff. No incident report completed. The 12/2/13, Fall Risk Assessment indicated R41 was a high risk for falls. Interventions: Mobility assessment completed. Action: Staff are encouraged to get him up to walk often, use assistance of 2 whenever possible, and attempt to keep his walker as close to his body as possible when walking. No changes made to the care plan. -On 12/14/13, at 3:37 p.m. R41 had an unwitnessed fall when attempting to transfer from the sofa in the common area. No injuries. Immediate actions: vital signs and neurological checks initiated. No incident report completed. The 12/15/13, Fall Risk Assessment indicated R41 was a high risk for falls. "Interventions: standing walker. 12/17/13, Mobility Assessment completed. Action: Staff will continue to allow (R41) to walk as often as they can, and take him off unit to walk on occasion if he gets restless as well. Also staff are to try the new EZ-Way battery powered walking aid." No changes made to the care plan. -On 1/5/14, at 9:36 p.m. R41 had a witnessed fall from the bed to the mat on the floor and sustained a left elbow laceration that measured approximately 2 cm x 0.2 cm. Immediate action: vital signs and neurological checks initiated and R41 brought to sit in recliner in the common area. The 1/6/14, Fall Risk Assessment indicated R41 was a high risk for falls. No interventions identified. -On 1/27/14, at 11:07 p.m. R41 had an unwitnessed fall from the bed to the floor and sustained a skin tear to the right elbow approximately 1.5 cm in a triangular shape. The 1/29/14, Fall Risk Assessment indicated R41 was high risk for falls. Interventions: "restorative aide to try and start walking with (R41) once per shift during the daytime, and CNAs will attempt to get help him walk more often during each shift." No changes made to the care plan. -On 2/28/14, at 10:27 p.m. R41 was found on the floor after an unwitnessed fall from the bed. No injury. Immediate action: "(R41) brought to the common living area and given food and drink. Vital signs and neurological checks initiated. 3/6/14 (R41) was started on antibiotics for a URI (upper respiratory infection) and started on Tamiflu (treats and helps prevent influenza) for prophylactic purposes. Interventions: 1) R41 likes to watch TV prior to bed. Will continue to go to bed in between 10-11 p.m. Toileting will continue to be prior to bed. 2) Likes to have cocktail prior to bed. Will continue prior to bed." -On 3/7/14, at 4:00 p.m. R41 attempted to self transfer from his recliner and was assisted to the floor. No injuries. Immediate action: None identified. No incident report completed. No interventions identified. A 3/27/14, Fall Risk Assessment indicated R41 was a high risk for falls. Interventions: "Staff to attempt to walk R41 at least 2-3 times per shift. (R41) is a very significant fall risk due to what has appeared to be worsening Parkinson's, he is very unsteady on his feet. He has not had any falls in the last 30 days, (R41) tries to get up many times during each shift without help. When CNAs (nursing assistants) get him up to walk though sometimes he will refuse. This is occasionally because he wants to use his walker, instead of the electric walker." -On 4/7/14, on the night shift, R41 was witnessed to put his hands on the floor and crawl onto his mat next to the bed. Immediate action: R41 brought to recliner in the common area to watch television. No incident report completed. No interventions identified. -On 4/12/14, at 3:53 p.m. R41 had an unwitnessed fall from the recliner in the Balsam living room. No injuries. Immediate actions: vital signs and neurological checks initiated. No interventions identified. -On 4/16/14, at 9:44 p.m. R41 had a witnessed fall from the sofa to the floor and sustained an abrasion to the left side of his forehead measuring 2 cm x 1 cm. Immediate actions: vital signs and neurological checks initiated. No interventions identified. -On 5/30/14, at 2:15 a.m. R41 was found sitting on the mat on the foor in his room after an unwitnessed fall from bed. No injuries. Immediate actions: vital signs and neurological checks initiated. No interventions identified. -On 5/31/14, at 10:30 p.m. R41 had an unwitnessed fall while self ambulating in the hallway. No injury. Immediate actions: taken to common area. No interventions identified. -On 6/19/14, at approximately 4:30 a.m. "(R41) was found sitting on the floor next to his bathroom with his knees bent and his back against the wall after unwitnessed fall in his room . He sustained a skin tear to his left elbow approximately 5 cm x 3 cm." Immediate actions: vital signs and neurological checks initiated. The 6/20/14, Fall Risk Assessment indicated R41 was a high risk for falls. Resident does walk with eyes closed at times and seldom opens them to prompting. Staff ambulates with resident at all times. No interventions identified. -On 7/5/14, at 11:28 p.m. R41 was found on the floor at the foot of his bed after an unwitnessed fall in which he sustained a hip injury. R41 was sent to the emergency room where xray confirmed a left hip fracture and R41 was admitted to the hospital. Review of R41's fall history revealed a system that lacked proper documentation of falls on an incident report. The system also lacked identification of causal factors of the falls as well as identification of interventions to prevent further falls. On 7/10/14, at 6:04 p.m. nursing assistant (NA)-G stated he did not notice any trends in R41's falls and R41 never fell with him. NA-G stated R41 got up by himself in his room and "actually tried to run." NA-G stated R41 needed constant reminders to use his walker as he would get up and begin ambulating without using his walker. NA-G further stated they took R41 for walks and had a program to walk him. On 7/10/14, at 6:09 p.m. NA-H stated R41 fell when he tried to get up by himself and got aggressive at times when he tried to walk with R41. NA-H stated "I tried to let him do the walking and walk with him to keep him balanced and make sure he didn't fall." NA-H stated he had been pulled to work with R41 as he sometimes "needed a one on one to watch him." On 7/10/14, at 6:10 p.m. NA-F and NA-E were interviewed and both were familiar with R41. NA-F stated R41 had a tendency to self transfer and get up by himself. NA-F also stated that a bed alarm was used for R41 when he was in bed but did not remember the alarm being used when R41 was in a chair. NA-F further stated, "We would take him for long walks; he also liked to follow the staff and would propel himself with his wheelchair around and follow us. One on one time consisted of walking with him, I would also sit down and reminisce with him about where he lived or read him a magazine." NA-E stated, "We always used a gait belt to transfer him and he always used his walker; we did lots of one on one time; when he was tired I would take him for rides in his wheelchair." On 7/10/14, at 6:14 p.m. NA-D stated, "I can't remember everything we did for (R41's) falls, but I know that walking with him helped, because we would be with him and try to do one on one with him. We would put him in the recliner. It is so open on Cedar that it is hard to watch everything, so him moving to Balsam, which is a smaller area, made it easier to watch him." On 7/10/14, at 6:18 p.m. NA-I stated R41 was very independent and "when he wants to go, he goes." NA-I also stated R41 used a front wheeled walker but he did not always use it appropriately and would sometimes carry it when he walked with it or use it to open doors. NA-I indicated they took R41 for many walks and tried to keep him as safe as possible. On 7/10/14, at 6:23 p.m. licensed practical nurse (LPN)-C stated she was familiar with R41. She also stated she really did not notice a trend in R41's falls. She futher stated R41 liked to walk and he was very quick on getting up on his own. LPN-C stated, "We tried to keep him in our sight. We walked with him often and tried to keep him away from the windows as he would try to hit the window with his walker. We did a lot of one on one time; he liked to walk, so we walked a lot. We always used a transfer belt to assist him and he always used a walker. We always made sure he wore shoes when up and at night we put gripper socks on him; we tried to go with his lead and let him walk as much as he wanted." One 7/10/14, at 6:07 p.m. R41's falls were reviewed with director of nursing (DON) and registered nurse (RN)-C. RN-C confirmed the bed and wheelchair pressure alarms, fall mats and bed in lowest position fall interventions were not on R41's care plan. After the fall on 10/5/13, a new intervention of 30 minute checks while R41 was in bed was identified on the incident report. DON confirmed they did not have any documentation of the thirty minute checks. RN-C confirmed the 30 minute check interventions were not on the care plan. RN-C confirmed the chair alarm intervention identified after the 10/25/13 fall was not on the care plan. RN-C confirmed the intervention to use a battery powered walking aid identified after the fall on 12/14/13 was not on the care plan. RN-C stated there was a pattern to R41's falls in that the majority were from out of bed onto the fall mat and took place between 4:00 p.m. and 4:00 a.m. DON and RN-C both confirmed they did not have an opportunity to do an analysis of causal factors after each fall. DON stated they attempted to provide one on one attention for R41 which meant that one staff member would watch him as much as possible on the evening shift. DON indicated they had one staff member always located in the Balsam lounge area and they would try to bring R41 there for supervision. However, DON also stated they did not always bring him to that area and it was R41's choice to go there. DON confirmed R41 required additional supervision and stated they had considered moving R41 to a room closer to the nurses' station, adding an audible monitor to his room to better hear the bed alarm or R41 moving in the room, and adjusting the nursing schedule based on acuity to provide better supervision for R41 but had not had the opportunity to do so. R38 was at risk for falls and the facility failed to identify and implement adequate interventions to minimize the risk of further falls. R38's admission record dated 7/10/14, identified [DIAGNOSES REDACTED]. R38's quarterly MDS dated [DATE], indicated R38 had severe cognitive impairment, required supervision and one assist with ambulation, limited assist of one for transfers, had falls and one fall with injury. R38's care plan dated 6/11/13, identified focus of moderate risk for falls with interventions of but not limited to if in an unsafe situation please re-direct or provide assistance, ensure wearing appropriate footwear when ambulating, review information on past falls and attempt to determine cause of falls, record possible root causes, alter/remove any potential causes if possible and educate resident/family/caregivers/IDT (interdisciplinary team) as to causes. R38's current Fall Risk assessment dated [DATE], indicated R38 was at risk for falls, had a history of [REDACTED]. Nurse Progress note dated 5/9/14, indicated R38 was at risk for falls. Interventions: staff try and keep an eye on R38 as much as possible. Comments: R38 walks with a pigeon toed stance, toes pointing outwards, and often walks somewhat hunched over. R38 wears ACE wraps for severe peripheral edema most prevalent in ankles and feet, because of this often just wears non-slip socks as shoes only fit depending on his edema level, R38 was frequently incontinent to some extent, but this may be mostly dribbling, ambulates independently, but sometimes does needed guidance and had not demonstrated any orthostatic hypotension. Document review of R38's incident reports revealed the following: -Incident report dated 5/31/14, at 10:10 p.m., "staff person doing a unit check and resident grabbed staff person's wrist and would not let go, (R38) was pulling staff person toward the lounge chair saying, 'down, sit down now and do not get up.' When staff person asked (R38) to let go of wrist (R38) replied, 'You asking for this.' And hit staff person on the chin with a closed fist hard enough to cause pain, (R38) than stepped back like (R38) was going to hit staff person again and (R38) lost his balance and fell backwards onto (R38's) bottom. Immediate action taken description: nursing assistant alerted to situation and assist (R38) to feet and to the bathroom to change soiled brief (had been incontinent of stool), refusing vital sign checks." R38's clinical record post fall lacked evaluation of causative factors related to the fall in order to initiate adequate interventions to minimize the risk for further falls. Incident report dated 6/1/14, at 1:45 a.m., R38 remained agitated after fall on 5/31/14, at 10:10 p.m. R38 was unable to sit still or lay down in bed and started pacing the unit. Nursing assistant found R38 sitting on the floor in the hall near his prior room facing the main entrance holding onto the railing with left hand. R38 had stated, " I do not know, I had to sit down than I could not get back up. " Immediate action taken: R38 was checked for mobility of extremities and assisted to standing position, escorted and assisted into bed and post fall protocol implemented. Level of pain: hurts a little bit. R38's clinical record post fall lacked evaluation of causative factors related to the fall in order to initiate adequate interventions to minimize the risk for further falls. Incident report dated 6/10/14, at 11:57 p.m. R38 had been laid down in bed at 11:15 p.m. and 15 minutes later staff checked on R38 and found R38 laying on the floor on his back with head at the foot end of the bed, in room between R38's bed and roommates bed. Immediate action taken: R38 had been checked for pain and injuries, had no new complaints of pain or injury, neuro's were initiated, staff assisted off the floor using a Hoyer mechanical lift and laid R38 back down in bed. R38 got out of bed and walked a few steps, complained of normal knee pain, was given Tylenol pain medication. R38's clinical record post fall lacked evaluation of causative factors related to the fall in order to initiate adequate interventions to minimize the risk for further falls. Incident report dated 6/29/14, at 1:45 a.m., nursing assistant informed R38 was on floor, upon entering R38's room R38 was observed on the floor, on back with feet toward the vanity and head toward the wall, between the beds, holding own head and shoulders off the floor. R38 had stated, "I fell , help me up. No I did not hit my head." Immediate action taken: R38 was examined for injuries, no external wounds found. R38 was assisted to a sitting position and then to a standing position, continued to deny hitting head and denied any discomfort, post fall protocol implemented for unwitnessed fall. R38's clinical record post fall lacked evaluation of causative factors related to the fall in order to initiate adequate interventions to minimize the risk for further falls. Incident report dated 7/5/14, at 12:50 p.m. staff alerted nurse R38 was on floor on knees in living room. Staff stated R38 had bent down onto the floor to pick up some small pieces of paper, R38 got on his knees and then could not get back up, R38's wheelchair was stationed directly behind R38. R38 had stated "get me up, get me up." When staff asked R38 what happened R38 continued to tell staff to get him up. Immediate action taken: observed for injury, R38 denied pain, assisted R38 from floor to wheelchair with assist of two staff, redness noted on bilateral knees, blanches with touch. R38's clinical record post fall lacked evaluation of causative factors related to the fall in order to initiate adequate interventions to minimize the risk for further falls. On 7/9/14, at 7:58 a.m., The DON stated they reviewed falls daily at stand up meetings and registered nurse (RN)-C should be documenting what is implemented, IDT signs off on falls weekly on Thursdays. On 7/9/14, at 8:30 a.m., RN-C stated regarding R38's falls: -fall incident on 5/31/14, isolated incident, R38 was agitated, no changes made, verified no documentation had been made in R38 clinical record post fall regarding IDT review and no investigation had been completed to identify root cause of fall. -fall incident dated 6/1/14, RN-C stated occurred a couple hours after fall on 5/31/14, made no changes, R38 was agitated, staff was trying to get him to lay down in bed or sit down and R38 refused, verified no documentation had been made in R38's clinical record post fall regarding IDT review and no investigation had been completed to identify root cause of fall. -fall incident dated 6/10/14, RN-C verified no documentation had been made in R38's clinical record post fall regarding IDT review and no investigation had been completed to identify root cause of fall. -fall incident on 6/29/14, RN-C stated IDT discussed giving more natural diuretics to decrease peripheral edema without giving more medication. R38 had peripheral edema in feet and feet almost rounded at bottom, provide ace wraps and try to keep on as much as R38 allowed, edema likely cause of fall. RN-C verified no documentation had been made regarding this in R38's clinical record. RN-C stated (in regards to what interventions attempted that were non- medication) R38 was given watermelon, hot green tea, tried cold green tea and had stated not sure if documented anywhere. -fall incident dated 7/5/14, RN-C had stated we have not reviewed or discussed this fall yet. On 7/10/14, at 8:44 a.m. RN-C verified no documentation was done in R38's clinical record regarding the non-medication interventions attempted nor the effectiveness of the non-medication interventions.. On 7/10/14, at 2:12 p.m. The DON stated after a fall she would expect staff to immediately discuss how to keep the resident safe until other managers got there and would also expect staff to document what they were doing. The DON stated she would expect the managers to discuss the falls at stand up rounds and then document what interventions were going to be implemented and to do an investigation to figure out root cause of fall. The Monitoring Falls and Their Causes policy dated 9/17/13, indicated an incident report must be completed for all elder falls. Incident reports must be completed no later than 30 minutes after the fall. The policy also directed within 24 hour of a fall, the nursing staff will begin to try to identify possible or likely causes of the incident. The staff will continue to collect and evaluate information until they either identify the cause of falling or determine that the cause cannot be found. The policy further directed staff to document completion of a falls risk assessment within 24 hours of fall and appropriate interventions taken to prevent future falls.