Every finding on record at Clark Fork Valley Nursing Home

Based on observation, interview, and record review, the facility failed to document a thorough investigation of an allegation of sexual abuse for 1 (#8) of 14 sampled residents. This had the potential to cause the facility to miss key parts of the investigation. Findings include: During an observation and interview on 4/7/26 at 8:36 a.m., resident #8 stopped two surveyors in the hall and stated, I just want to tell you guys about how wonderful this place is. During this conversation resident #8 stated she did have an incident at one point, and the facility handled it professionally and discretely. Resident #8's demeanor was happy and joyful. Resident #8 was joking and smiling during this whole conversation.During an observation and interview on 4/7/26 at 2:45 p.m., resident #8 stated the incident she was referring to earlier was an incident where she felt she was touched inappropriately by a male staff member. Resident #8 stated, It was total innocence on his part. He did apologize and he felt so bad he quit working here. Resident #8 described the incident and explained the staff member was assisting another staff member with powder application to private areas. Resident #8 stated she has had no other concerns, and the facility handled it appropriately. Resident #8 stated the staff treated her with respect and dignity through the whole process along with the officer that investigated the incident. Resident #8 stated she is no longer bothered by the situation. During this conversation the resident was smiling and appeared happy, she did not show signs of fear or sad emotion. During an interview on 4/8/26 at 8:02 a.m., staff member A stated, We have never had an allegation to this extent before and were unsure of how to go about the investigation. We followed our process and summarized it. We did not document all the conversations we had when interviewing other staff or residents. Since we could not determine the exact date of when the incident occurred, we did not do a physical assessment of the resident. We removed the staff member and reported it as soon as we were made aware of the concern. We provided the summary to APS and the police, and they conducted their own investigation. I guess we figured they were handling it. During an interview on 4/9/26 at 8:36 a.m., staff member B stated, Our process for incident investigations is to follow the investigation process. We go into Bounds and report it if it is reportable, then we conduct an investigation, and write up a summary of the investigation and the steps that were taken. Then we ensure it is care planned. For resident #8's incident, I reassigned skin checks to another nurse and removed the staff member. I did not realize I had to record all the conversations or details of each piece of the investigation. I just compiled it into a summary of what was done. Review of the facilities investigation file for an incident dated 1/29/26 failed to show what other residents were interviewed, all staff that were interviewed, the details found in those interviews, and the dates the interviews were conducted. The investigation file consisted of a brief summary of facility events, the APS report, a statement from the police department, and the bounds report. Review of a facility document titled Abuse, Neglect & Exploitation of Elderly and Disabled with an effective date of 1/2025, showed: .Purpose: The purpose of this policy is to promote and ensure the highest level of safety for our patients and residents by establishing a mechanism to monitor any complaint or incident of suspected physical or verbal abuse.Investigative Process:1. All alleged violations involving mistreatment, neglect, or abuse. shall be reported to the administration of the facility. (including to the State survey and certification agency).3. The facility will thoroughly investigate all alleged violations through established procedures. In the event of any case of suspected abuse, the Patient or Resident will be removed from the care of the alleged abusive party until the case is fully investigated and resolved.

Based on interview and record review, the facility failed to refer a resident with a new diagnosis of bipolar disorder to the appropriate state-designated mental health authority (PASRR) for review for 1 (#6) of 14 sampled residents. This deficient practice had the potential to cause a delay or missed services for resident #6 to meet their highest practicable mental health status. Findings include: Review of resident #6's PASRR screening with a date of 6/26/23, showed: .Review outcome: Approved. Diagnosis: CEREBRAL INFARCT D/T EMBOLISM MID CEREBRAL ART, APHASIA, DYSPHAGIA, DEPRESSION UNSPECIFIED, CHRONIC OBSTRUCTIVE PULMONARY DISEASE UNS, ESSENTIAL PRIMARY HYPERTENSION, TYPE 2 DIABETES MELLITUS, OSTEOARTHRITIS UNSPECIFIED SITE. [sic]Review of resident #6's diagnoses list in his electronic medical record showed: .Description: Bipolar disorder, unspecified, Date: 6/26/23, Created Date: 8/29/23.Review of resident #6's Quarterly MDS, with an ARD of 1/5/26, showed: MDS 3.0 Section I - Active Diagnosis, I5900. Bipolar Disorder: Yes.During an interview on 4/8/26 at 12:13 p.m., staff member H stated her process for completing the PASRR was to gather information through the Epic system (electronic health records) and the H&P, and she will enter whatever diagnoses are on them. She stated she would especially add any mental health diagnosis other than dementia. Staff member H stated she had never had a PASRR screening denied or that needed a Level II. Staff member H stated that a new diagnosis of bipolar disorder should prompt a new PASRR referral to be completed. Staff member H stated that for resident #6 specifically, she had used the diagnosis taken from the resident's H&P, as he came from another facility. Staff member H stated, Bipolar should be reflected on the PASRR, and another PASRR should have been submitted for resident #6. Staff member H stated she had never had to resubmit a PASRR for any of the long-term care residents because their diagnoses rarely change. Staff member H stated, I think that one of his (resident #6's) diagnoses just got missed.The facility did not have a policy for completion of the PASRR or when to resubmit a PASRR referral.

Based on interview and record review, the facility failed to address the aggressive and intrusive behavior of a resident with dementia toward others, and she was involved in many resident-to-resident abuse events. The resident's MDSs showed various declines occurred over the period of time, and the resident's mobility, pain, incontinence level, and mood/behaviors changed during the time many of the events were identified. The facility did not report the events as abuse or investigate the events fully (Refer to F609 and F610). The facility failed to assess the resident's individualized behaviors and antecedents to them, in a proactive attempt to prevent future events or alleviate the resident's anger/frustration. The facility failed to implement person-centered, individualized interventions, and staff were not successfully protecting others and being practice to prevent events before they occurred, for 1 (#19) of 17 sampled residents. Findings include: Review of resident #19's electronic health record showed the resident had a diagnosis of DEMENTIA IN OTHER DISEASES CLASSIFIED ELSEWHERE, MODERATE, WITHOUT BEHAVIORAL DISTURBANCE, PSYCHOTIC DISTURBANCE, MOOD DISTURBANCE, AND ANXIETY (F02.B0). A record review of resident #19's nursing notes showed that from April 2024 to January 2025, she displayed the following behaviors, almost all directed toward other residents, and more were documented from April 2024 to July 2024: Targeting others, pulling hair, seeking others out to [NAME] against them, attempting to bite staff, pinching a resident, pushing residents, taking the other resident's walkers, hitting other residents with her wheelchair, punching a resident, taking others' belongings, yelling, spitting, knocking pictures off walls and taking items off tables to throw them, caused a skin tear to a resident's eye area when she grabbed her, and almost knocked several residents over by running into them with her wheelchair. A review of resident #19's Quarterly MDS, with an ARD of 4/19/24, showed: - The resident was coded as being cognitively impaired, and she rarely understood others. - She had minimal depression and scored a 2 on her depression assessment but displayed a poor appetite and short temper. The resident took an antidepressant for 7 days of the 7-day assessment period but did not take an antipsychotic or anti-anxiety medication. - Under section E, for behaviors, the resident was coded as disturbing others 1 to 3 days a week. - #19 was independent with eating, but she was independent to max assist for mobility. - The resident had as-needed pain medications but did not display nonverbal indicators of pain. A review of resident #19's Annual MDS, with an ARD of 7/23/24, showed changes occurred with the resident, and: - The resident's mood slightly deteriorated, although still considered minimal depression. - She displayed behavior towards others in two categories showing 4 to 6 days of the look-back period she was affecting others, which was a decline from the prior assessment. - She continued to take her antidepressant but did not have any other meds for her mood/behavior. - The resident had no scheduled pain medications, but she had as-needed pain medications provided. She displayed pain in her facial expressions, her body movements, and her nonverbal indicators of pain, and this was 1-2 days in the look-back period. This was a decline from the prior assessment. - The resident was coded as being Frequently incontinent for bladder and bowel. A review of resident #19's Quarterly MDS, with an ARD of 10/23/24, showed: - Resident #19 did not have a change in her pain; she slightly declined in her mood but still coded as having minimal depression. Her self-care and mobility areas of care declined, and she required substantial to maximum assistance for ADLs and mobility. She was coded as being Always Incontinent. The resident now displayed hallucinations, and her behaviors toward others remained the same. A review of resident #19's Quarterly MDS, with an ARD of 1/23/25, showed: The resident displayed hallucinations and delusions, and her depression declined to a score of 7, mild depression. She displayed behaviors toward others in section E of the MDS 4 to 6 days in the look-back period. She was dependent for all ADL and mobility care and was now always incontinent. The resident also displayed non-verbal indicators of pain, although she did not have scheduled pain medication. The resident has lost a great deal of independence over the last ten months and her behaviors worsened. Review of resident #19's care plan showed a focus of I have aggressive behaviors physically and verbally with staff when they are trying to assist with care. I also have a history of sexual behaviors . Interventions: intervene as necessary to protect the rights and safety of others. Date initiated 07/24/2023. The care plan failed to show that the facility adequately identified the different individualized behaviors and assessed, planned, and implemented interventions to prevent the behaviors towards others and to assist with protecting the resident herself. The resident's care plan did not have person-centered interventions for specific dementia related behaviors displayed in the medical record or address the decline the resident experienced with her behaviors and loss of independence. During an interview on 2/12/25 at 11:40 a.m., staff member P stated resident #19 gets over-stimulated very quickly and resident #19 needs to be removed from the environment. Staff member P said interventions for aggressive behaviors were short lived and she (staff member P) will sit and talk to her (#19) for a little bit. During an interview on 2/12/25 at 3:25 p.m., staff member P stated interventions for resident #19's aggressive behaviors were a medication change maybe . re-guide her somewhere else. These interventions were shown to be unsuccessful in deterring the behaviors over time. During an interview on 2/12/2025 at 4:13 p.m., when asked about interventions for resident #19, staff member F stated, When I was aware (of aggressive behaviors) we did some medication reviews . if she was constipated, then she would be agitated. A review of the resident's medical record showed she had ongoing negative and or abusive incidents with other residents from April 2024 to the date of the survey (refer to F600 - Abuse for the events). The documentation for the behaviors did not show staff sufficiently took action to protect other residents or provide ongoing behavioral assessments, or that interventions were identified, implemented, and monitored in an attempt to ease the resident's behaviors, stress, or anger toward others while protecting the others residing around the resident, to include: - Effective Date: 07/03/2024 15:22 Type: Behavior Note, LATE ENTRY Note Text: this resident was in her wheel chair wondering the halls when she ran into another resident whom was walking in the day room. this resident what rolling fast and hit the other residents walker on the left side, hitting the walking residents fingers and almost knocking her over . staff said that this residents was intentionally trying to run over the walking resident . [sic] - Effective Date: 07/03/2024 16:40 Type: Behavior Note, LATE ENTRY Note Text: this resident was trying to hit another resident [unidentified resident initials] with a recliner remote . when staff stepped in the resident did laugh, looked over to [unidentified resident initials] and said 'i almost gotchya'. - Effective Date: 7/04/2024 09:35 Type: Behavior Note, LATE ENTRY Note Text: This resident was wondering in a wheelchair . this resident reached out and grabbed [unidentified resident initials] face. This resident was able to get ahold of [unidentified resident initials] left eye brow and did create a open area above [unidentified resident initials] left eye brow . behavior was intentional, due to the fact that this resident was angry that [unidentified resident initials] was not letting her take the supplies and did yell at [unidentified resident initials]. - Effective Date: 07/10/2024 15:35 Type: Behavior Note, LATE ENTRY Note text: this resident . started to torment another resident [unidentified resident initials]. this resident entered into the dining room where the activity was taking place and intentionally found [unidentified resident initials], started to poke her aggressively on [resident initials] left shoulder and back. [Unidentified resident initials] asked her to stop because it was hurting and this resident laughed, continuing to poke . 5 minutes later this resident returned to the dining room, seeking out [unidentified resident initials]. this resident tried to take [unidentified resident initials] walker from her by grabbing the bars and dragging it away from [unidentified resident initials]. [Unidentified resident initials] asked this resident to give her walker back in order to use it for walking. staff had to step in . this resident began to swear and yell at staff . [sic] - Effective Date: 07/10/2024 15:55 Type: Behavior Note, LATE ENTRY Note Text: . this resident then went over to the wall and started to take hanging pictures off the wall and tossed them on the ground. this resident also went to side tables and other dining tables where she would take anything that she could reach/grab or move and started to throw items on the ground while she made crying sounds . - Effective Date: 07/17/2024 14:10 Type: Behavior Note, Note Text: resident was running into other residents while in her wheelchair while wondering the halls . then swung at [unidentified resident initials] head and spit at her . [sic] - Effective Date: 07/27/2024 13:30 Type: Behavior Note, LATE ENTRY Note Text: resident . reach over and pinched [unidentified resident initials] on her right arm a few times before staff was able to separate the residents. [unidentified resident initials] did say 'ouch'. nurse notified by staff. [sic] - Effective Date: 07/31/2024 13:50 Type: Behavior Note, LATE ENTRY Note Text: this resident was grabbing onto another residents arm [resident #10 initials], and trying to pull her down to the ground . [Resident #10 initials] started yelling 'Hey Stop, Ouch that hurt' staff was able to separate the residents and bring [resident #10 initials] to a safe spot to sit down. [sic] - Effective Date: 08/02/2024 13:52 Type: Behavior Note, LATE ENTRY Note Text: resident . took the recliner remote and used it to hit [unidentified resident initials] on the right arm multiple times . yelling out 'ouch, that hurts' as well as 'stop it'. [sic] - Effective Date: 08/03/2024 15:57 Type: Behavior Note, LATE ENTRY Note Text: this resident . came up behind her and grabbed [resident #10 initials] arm the proceeded to try to pull her down to the floor . at that time this resident took her other hand and grabbed [resident initials] shirt and pulled on the shirt to try to pull [resident #10 initials] to the ground. staff was able to remove this residents hand from the shirt quickly. [sic] - Effective Date: 08/03/2024 17:02 Type: Behavior Note, LATE ENTRY Note Text: This resident . went over to another resident [unidentified resident initials] and slapped the other residents right arm . staff also witnessed this resident hit [unidentified resident initials] on her chest and grab the front of [unidentified resident initials] shirt, pulling on it back and forth hitting this residents chest with her fist . [sic] - Effective Date: 08/15/2024 11:22 Type: Behavior Note, LATE ENTRY Note Text: this resident . grabbed the back of this residents shirt and pulled her shirt back and forth, hitting the resident back with her fist . [sic] - Effective Date: 08/15/2024 16:00 Type: Behavior Note, LATE ENTRY Note Text: this resident . began to hit the back of [unidentified resident initials] head and pull [unidentified resident initials] hair . [sic] - Effective Date: 08/16/2024 Type: Behavior Note, Note Text: This resident was wondering down the halls in her wheelchair when she went up to another resident . grabbed the clean laundry cart and continued to push the cart into the other resident [resident #10 initials] . continued to push the laundry cart into [resident #10 initials] . [sic]

Based on observation, interview, and record review, the facility staff failed to complete proper hand hygiene during resident medication pass, and use proper PPE when transporting dirty housekeeping equipment, to the washing machine. This deficient practice had the potential to spread infection to all residents in the facility receiving care. Findings include: During an interview and observation on 2/11/25 at 8:29 a.m., staff member G was observed while dispensing medications to the facility residents. Staff member G stated she was confused as to the correct process for when to perform hand hygiene. She said she was told to perform hand hygiene after she touched all high touch surfaces and between each resident. Staff member G said she would usually perform hand hygiene when she was dispensing the medication into the medication cup. Staff member G was observed to dispense medication to a facility resident and then approached another facility resident, without performing proper hand hygiene, and took the resident's heart rate. Staff member G returned to the medication cart, documented the medications dispensed, then performed hand hygiene prior to dispensing medication into the medication cup for the next resident. Record review of a facility policy, Hand Hygiene, last review date 11/2024, showed: .7. Clean hands: a. Before touching any patient . c. After touching any patient . e. After touching items in patient rooms f. After touching items outside patient rooms (telephones, keyboards, etc. 47752 2. During an observation and interview on 2/12/25 at 8:25 a.m., staff member I walked into the dirty side of the laundry area with a clear, plastic bag which contained a dirty mop head. Staff member I walked over to the washing machine and placed the mop head into the washing machine. Staff member I did not don gloves or any other PPE equipment prior to putting the dirty mop head into the washing machine. Staff member I stated he should have put on the required PPE and gloves prior to putting the dirty mop head in the washing machine, and he had been educated on infection control practices. Review of a facility document titled, Handling Guidelines, Infectious Wastes, Sharps Containers, Blood Spills, and Contaminated Laundry, with a last approved date of 11/2024, showed: . Contaminated Laundry 1. Contaminated laundry is to be handled as little of possible . 2. All laundry personnel involved in sorting and/or handling contaminated laundry are to wear appropriate personal protective equipment.

Based on interview and record review, the facility failed to ensure residents were free from resident to resident abuse incidents, and failed to provide protection before or following each event to prevent further resident to resident abuse, by resident #19, who was the aggressor; and, the abuse resulted in injury for 1 (#10) of 17 sampled residents and affected many others. Findings include: Review of resident #19's, electronic medical record showed the following resident to resident altercations between #19 and other residents, and #19's various behaviors exhibited towards others: a. Effective Date: 06/22/2024 12:57 Type: Behavior Note, Note Text: (resident #19) is very unsafe in her wheelchair unattended. She has the ability to run people over with her wheelchair with no regard for safety of self or others. Today she almost ran into another resident walking down the hall while she was mobile in her wheelchair. [sic] b. Effective Date: 07/03/2024 15:22 Type: Behavior Note, LATE ENTRY Note Text: this resident was in her wheel chair wondering the halls when she ran into another resident whom was walking in the day room. this resident what rolling fast and hit the other residents walker on the left side, hitting the walking residents fingers and almost knocking her over. this incident was witnessed by activity staff. staff said that this residents was intentionally trying to run over the walking resident as this resident saw walking resident from across the room and quickly made her was to her. [sic] c. Effective Date: 07/03/2024 16:40 Type: Behavior Note, LATE ENTRY Note Text: this resident was trying to hit another resident [unidentified resident initials] with a recliner remote. [unidentified resident initials] was not sitting close enough for this resident to make contact and staff was able to remove the remote from this residents hands before she hit anyone with it but when staff stepped in the resident did laugh, looked over to [unidentified resident initials] and said 'i almost gotchya'. this incident was witness by activity staff. [sic] d. Effective Date: 7/04/2024 09:35 Type: Behavior Note, LATE ENTRY Note Text: This resident was wondering in a wheelchair when she wondered into the dining room where staff was leading a scheduled group activity. this resident went to a attending resident [unidentified resident initials] and tried to group her supplies. when [unidentified resident initials] put her hand on the supplies to prevent this resident from taking them, this resident reached out and grabbed [unidentified resident initials] face. This resident was able to get ahold of [unidentified resident initials] left eye brow and did create a open area above [unidentified resident initials] left eye brow. activity staff witnessed this and said that this behavior was intentional, due to the fact that this resident was angry that [unidentified resident initials] was not letting her take the supplies and did yell at [unidentified resident initials]. CNA staff notified of this incident. [sic] e. Effective Date: 07/10/2024 15:35 Type: Behavior Note, LATE ENTRY Note text: this resident was roaming in her wheelchair during a scheduled daily activity and she started to torment another resident [unidentified resident initials]. this resident entered into the dining room where the activity was taking place and intentionally found [unidentified resident initials], started to poke her aggressively on [resident initials] left shoulder and back. [Unidentified resident initials] asked her to stop because it was hurting and this resident laughed, continuing to poke. staff had to remove this resident from the area in order for her to stop bothering [resident initials]. 5 minutes later this resident returned to the dining room, seeking out [unidentified resident initials]. this resident tried to take [unidentified resident initials] walker from her by grabbing the bars and dragging it away from [unidentified resident initials]. [Unidentified resident initials] asked this resident to give her walker back in order to use it for walking. staff had to step in and try to getthe walker back, when staff was able to get [resident initials] walker out of the hand of this resident, this resident began to swear and yell at staff. resident was taken out of the area in order to not disturb other residents. [sic] f. Effective Date: 07/10/2024 15:55 Type: Behavior Note, LATE ENTRY Note Text: resident was wondering in her wheelchair and entered into the dining room, another resident [unidentified resident initials] that this resident had been separated from because of previous behaviors, was moved to a new location which this resident could not get to with her wheelchair. after trying to work her way around the dining table to get to [unidentified resident initials] and not being able to maneuver to reach her, this resident then went over to the wall and started to take hanging pictures off the wall and tossed them on the ground. this resident also went to side tables and other dining tables where she would take anything that she could reach/grab or move and started to throw items on the ground while she made crying sounds. while staff tried to pick those items up, this resident began running into staff with her wheelchair and laughed. before items could safely be picked back up. this resident had to be relocated out of the area so that staff was not being ran into by this resident. [sic] g. Effective Date: 07/17/2024 14:10 Type: Behavior Note, Note Text: resident was running into other residents while in her wheelchair while wondering the halls, when this resident ran into another one of these residents [unidentified resident initials], began to yell and told this resident to 'go away, move away from me, leave me alone' this residentthen swung at [unidentified resident initials] head and spit at her. residents were separated by staff. [sic] h. Effective Date: 07/27/2024 13:30 Type: Behavior Note, LATE ENTRY Note Text: resident was wondering around in her wheelchair in the activity room when she got close to another resident [unidentified resident initials] and then this resident reach over and pinched [unidentified resident initials] on her right arm a few times before staff was able to separate the residents. [unidentified resident initials] did say 'ouch'. nurse notified by staff. [sic] i. Effective Date: 07/31/2024 13:50 Type: Behavior Note, LATE ENTRY Note Text: this resident was grabbing onto another residents arm [resident #10 initials], and trying to pull her down to the ground while she was wondering the halls. [Resident #10 initials] started yelling 'Hey Stop, Ouch that hurts, staff was able to separate the residents and bring [resident #10 initials] to a safe spot to sit down. [sic] j. Effective Date: 08/02/2024 13:52 Type: Behavior Note, LATE ENTRY Note Text: resident was sitting in a recliner next to another resident [unidentified resident initials] and this resident took the recliner remote and used it to hit [unidentified resident initials] on the right arm multiple times. staff heard [unidentified resident initials] yelling out 'ouch, that hurts' as well as 'stop it'. staff was able to remove the remote from this residents hand. at that time this resident grabbed staffs arm and tried to bite the staff member. [sic] k. Effective Date: 08/03/2024 15:57 Type: Behavior Note, LATE ENTRY Note Text: this resident was wondering down the hall in her wheelchair. another resident was walking down the hallway as well [resident #10 initials] and this resident came up behind her and grabbed [resident #10 initials] arm the proceeded to try to pull her down to the floor. staff witnessed this and was able to get to this resident quickly and separate this residents hand from [resident #10 initials]. at that time this resident took her other hand and grabbed [resident initials] shirt and pulled on the shirt to try to pull [resident #10 initials] to the ground. staff was able to remove this residents hand from the shirt quickly. [sic] l. Effective Date: 08/03/2024 17:02 Type: Behavior Note, LATE ENTRY Note Text: This resident was wondering in her wheelchair in the activity room when she went over to another resident [unidentified resident initials] and slapped the other residents right arm. staff heard [unidentified resident initials] start to yell at this resident. staff also witnessed this resident hit [unidentified resident initials] on her chest and grab the front of [unidentified resident initials] shirt, pulling on it back and forth hitting this residents chest with her fist. Staff was able to separate these residents but staff needed to remain with this resident because if the staff let go of this residents wheelchair, she headed back to [resident initials]. [sic] m. Effective Date: 08/12/2024 13:13 Type: Behavior Note, LATE ENTRY Note Text: this resident was wondering in and out of the activity room in her wheelchair when she ran onto the back of another resident [unidentified resident initials] while she was walking to a activity. this was witnessed by staff and before staff could reach this resident to redirect her, she was able to back up slightly and run into the back of the other resident [resident initials] again. [unidentified resident initials] became unbalanced and almost fell but staff was able to hold her arm and stabilize her again so she didn't fall. this resident was then redirected away from [unidentified resident initials]. n. Effective Date: 08/15/2024 11:22 Type: Behavior Note, LATE ENTRY Note Text: this resident was wondering in the hallway in her wheelchair when she ran into the back of another resident while she was walking to an activity [unidentified resident initials]. this resident then grabbed the back of this residents shirt and pulled her shirt back and forth, hittingthe resident back with her fist. staff witnessed and was able to reach the residents. staff was able to separate the residents and when they removed this residents hand from [resident initials] shirt, this resident started making crying shouldn't and continued to try and hit staff. [sic] o. Effective Date: 08/15/2024 16:00 Type: Behavior Note, LATE ENTRY Note Text: this resident was wondering in her wheelchair in the activity room when she went over to another resident [unidentified resident initials] and started to pull on the back of the other residents wheelchair. [Unidentified resident initials] and started to pull on the back of the other residents wheelchair. [Unidentified resident initials] started to yell at this resident saying 'Stop it' and then this resident began to hit the back of [unidentified resident initials] head and pull [unidentified resident initials] hair. staff witnessed this and was able to separate the residents. [sic] p. Effective Date: 08/16/2024 Type: Behavior Note, Note Text: This resident was wondering down the halls in her wheelchair when she went up to another resident who was also wondering the hallway [resident #10 initials]. this resident grabbed the clean laundry cart and continued to push the cart into the other resident [resident #10 initials]. [Resident #10 initials] tried to walk about her but this resident continued to wheel Infront of [resident #10 initials] so she could not walk around her and this resident continued to push the laundry cart into [resident #10 initials]. Staff witnessed this and was able to reach these resident and separate them. [sic] During an interview on 2/12/2025 at 11:49 a.m., staff member P said resident to resident altercations did happen with resident #19. Staff member P said resident #19 doesn't comprehend very well and will run into people and other days she will focus on a specific resident. During an interview on 2/12/2025 at 3:25 p.m., staff member P stated resident to resident abuse is when another resident purposefully hurts another resident. Staff member P said resident to resident abuse had occurred in the past. She further stated when resident to resident abuse was witnessed a progress note was written and it was reported to the nurse. During an interview on 2/12/2025 at 4:13 p.m., staff member F stated abuse was harm to a resident that was mental, physical, or sexual that was unwanted. Staff member F stated resident to resident abuse becomes a gray area for cognitively impaired residents because it was difficult to determine if they were meaning to do it. Staff member F stated she was unaware of resident to resident abuse as it was not reported to her. During an interview on 2/13/2025 at 8:50 a.m., staff member F said the notes in resident #19's EHR related to resident to resident altercations were written by staff member P. Staff member F stated she had identified a progress note she was concerned about in September 2024 that was written by staff member P and restricted staff member P's access to write progress notes in the medical record.

Based on interview and record review, the facility failed to report resident to resident abuse allegations to the State Survey Agency within the required reporting period, for 1 (#19) of 17 sampled residents. The events occurred over many months and involved different residents, without staff taking appropriate action for reporting the events. Findings include: Review of resident #19's EHR showed many resident to resident interactions, to include ones of abuse, in which the resident acted out on others, often in a purposeful manner or targeting residents. Refer to F600 Abuse, for detail related to the different resident to resident incidents of abuse not reported to the State Survey Agency. Review of four Facility Reported Incidents, forwarded to the State Survey Agency, for 2024, showed no reports of resident to resident abuse allegations involving resident #19. During an interview on 2/12/25 at 3:25 p.m., staff member P stated resident to resident abuse was when one resident purposefully hurts another resident. Staff member P stated in her opinion, resident to resident abuse had occurred in the past. Staff member P said when she witnessed resident to resident abuse, she would write a progress note and report it to the nurse. When asked who could report abuse, staff member P stated, It goes up the chain of command, and I would assume that anyone can report abuse. During an interview on 2/12/2025 at 4:13 p.m., staff member F stated she was the abuse coordinator and had access to the reporting portal. Staff member F stated she had provided education to staff multiple times about abuse reporting. Staff member F said there was a call log posted with staff phone numbers to contact for abuse reporting. Staff member F said she was not aware of resident to resident abuse allegations for resident #19. During an interview on 2/13/2025 at 8:15 a.m., staff member L stated she was not aware of any resident to resident abuse allegations for resident #19. During an interview on 2/13/2025 at 8:50 a.m., staff member F said the notes in resident #19's EHR related to resident to resident altercations were written by staff member P. Staff member F stated she had identified a progress note she was concerned about in September 2024 that was written by staff member P and restricted staff member P's access to write progress notes in the medical record. Review of the facility's policy, Abuse, Neglect & Exploitation of Elderly and Disabled, last approved 01/2025, showed: Policy: [Facility Name] prohibits the mistreatment, neglect, and abuse of its patients and the misappropriation of patient's property. Furthermore, the use of verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion is prohibited by [Facility Name] . . Reporting: All health care providers are required by law to report known abuse or neglect or suspicion of abuse or neglect immediately . . When in doubt, err on the side of protecting the elderly or developmentally disabled Patient or Resident until further investigation or evidence can confirm or deny the suspicion . . Notify the appropriate supervisor and Social Worker of any report make to DPHHS Adult Protective Services for any necessary follow up for the Patient or Resident . .'Immediately' means as soon as possible but ought not to exceed 24 hours after the discovery of the incident. This report can be preliminary notification that complete report will follow. This report can be faxed. Results of investigation must be reported to State agency within 5 business day of incident. [sic]

Based on interview and record review, the facility failed to recognize abuse and thoroughly investigate the potential for abuse; and failed to take appropriate action to prevent and protect other residents from further resident to resident abuse events which occurred repeatedly over a period of time, for 1 (#19) of 17 sampled residents, and the resident acted out aggressively towards others to include causing minor injuries. Findings include: Review of resident #19's EHR showed many resident to resident altercations. Refer to F600 and F609 related to the concerns of abuse initiated by resident #19. Review of the four Facility Reported Incidents, sent to the State Survey Agency, in 2024, showed no reports of resident to resident abuse allegations involving resident #19. During an interview on 2/12/2025 at 4:13 p.m., staff member F said if she was aware of resident to resident altercations concerning abuse, she would have investigated the situation 'for sure.' During an interview on 2/13/2025 at 8:50 a.m., staff member F said the notes in resident #20's EHR related to resident to resident altercations were written by staff member P. Staff member F stated she had identified a progress note she was concerned about in September 2024 that was written by staff member P and restricted staff member P's access to write progress notes in the medical record. A request was made for social service notes related to resident to resident incidents involving resident #19 and any notes from social service for potential victim follow-up. No documentation was received prior to the end of survey. Review of the facility's policy, Abuse, Neglect & Exploitation of Elderly and Disabled, last approved 01/2025, showed: Policy: [Facility Name] prohibits the mistreatment, neglect, and abuse of its patients and the misappropriation of patient's property. Furthermore, the use of verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion is prohibited by [Facility Name] . .Investigative Process: 1. All alleged violations involving mistreatment, neglect or abuse, including injuries of unknown source and misappropriation of Patient or Resident property, shall be reported to the administration of the facility to include unit Manager, Chief Nursing Officer (CNO), and the Chief Executive Officer (CEO) and other officials in accordance with State law (including to the State survey and certification agency). 2. All alleged violations involving resident to resident and resident to staff will be investigated. 3. The facility will thoroughly investigate all alleged violations through established procedures . 4. The results of investigation will be reported to the Administrator (including the Unit Manager, CNO and the CEO and to other officials in accordance with State law (including the State Survey and Certification Agency) within five working days of the incident .

Based on observation, interview, and record review, the facility failed to complete MDS assessments accurately for restraint use for 3 (#s 8, 16, and 24), and accurately identify an antidepressant medication for 1 (#10) of 17 sampled residents. Findings include: 1. During an observation and interview on 2/10/25 at 3:19 p.m., resident #24 was sitting up in her bed, coloring. Resident #24's bed had a narrow side rail attached to the right side of her bed. Resident #24 had grabbed the side rail and repositioned herself in the bed. Resident #24 stated the side rail helped her reposition herself in bed, but also helped her stand when she wanted to get out of bed. Resident #24 stated the side rail did not restrict her movement. During an observation and interview on 2/10/25 at 3:40 p.m., resident #8 was seated in a recliner in her room. A small narrow side rail was attached to the right side of resident #8's bed. Resident #8 stated the side rail on her bed was to help her reposition and get in and out of the bed. Resident #8 stated the side rail did not restrict or restrain her to the bed. Resident #8 stated if she wanted to get up she could. During an observation and interview on 2/10/25 at 3:57 p.m., resident #16 was sitting on the edge of his bed. He had a small, narrow side rail attached to the right side of his bed. Resident #16 stated he used the side rail to help him get out of bed and to reposition himself. Resident #16 grabbed the side rail and stood up from the bed. Resident #16 stated the side rail does not restrict his movement; it helped him stay more independent. Review of resident #8's Quarterly MDS assessment, dated, 1/31/25, showed section P011 was marked for daily use of restraints. Review of resident #16's Annual MDS assessment, dated 12/25/24, showed section P011 was marked for daily use of restraints. Review of resident #24's Quarterly MDS assessment, dated 1/23/25, showed section P011 was marked for daily use of restraints. A request was made on 2/11/25 for an MDS policy. No policy was received prior to the end of the survey. During an interview on 2/11/25 at 10:38 a.m., staff member F stated, We do not have a specific policy for MDS, no written policy, we follow the RAI guidelines. During an interview on 2/12/25 at 4:11 p.m., staff member C stated she thought she had to code the side rails as restraints on the MDS. Staff member C stated she was just told by staff member F that she did not have to code the side rails as a restraint. 51133 2. Review of resident #10's January 2025, Medication Administration Record showed, traZODone HCI Tablet 100 MG Give 100 mg by mouth at bedtime for insomnia -Start Date- 11/16/2022 0800. Review of resident #10's Significant change MDS, with an ARD dated 1/9/2025, showed under section, N0415 - High-Risk Drug Classes: Use and Indication, 1. Is taking .C. Antidepressant? The response was marked, No . During an interview on 2/12/2025 at 2:35 p.m. staff member C stated Trazadone is an anti-depressant and it (Trazadone) was not coded on the Significant change MDS with an ARD dated 1/9/25 for resident #10.

Based on observation, interview, and record review, the facility failed to dispose of expired stock medication, and ensure the medication cart was secure prior to leaving the area where the medication cart was located. This deficient practice had the potential to affect residents receiving medications dispensed from the medication cart. Findings include: During an observation and interview on [DATE] at 8:29 a.m., staff member G provided access to the medication cart stock medications. Staff member G was unable to provide information on the process for handling expired medication because she was a travel nurse and had not been at the facility very long. The following medications were found to be expired: - Senna Plus Tablets with an expiration date of ,d+[DATE]. - Acetaminophen Suppositories with an expiration date of ,d+[DATE]. - Glucagon Injection, Gvoke Hypopen, with an expiration date of ,d+[DATE]. Record review of a facility policy, Medication Outdates, with a review date of ,d+[DATE], showed: .2. Expiration dates are to be monitored on a monthly basis. Areas to be monitored include: Medication Refrigerator, Locked Medication Cupboard, Medication Cabinet, Medication Cart & Locked Narcotic Drawers, and Treatment Cart. 3. If outdated medications are found, the nurse will list the name of the expired medication on the medication expiration sheet and fax sheet and return medications to the designated local pharmacy. 47752 During an observation on [DATE] at 8:11 a.m., staff member G was in the activity/dining room area with the medication cart. Staff member G walked away from the medication cart, left the activity/dining room, and walked down the main hallway. The medication cart was left unlocked and unattended. Staff member G returned to the medication cart at 8:16 a.m. The top drawer of the medication cart had two white paper cups with medications in them. During an interview on [DATE] at 8:17 a.m., staff member G stated, I did not lock the cart because it was parked in the corner, and nobody should bother it. Staff member G stated she should have locked the medication cart prior to leaving the room. Review of a facility document titled, Medication Administration, with a last approved date of ,d+[DATE], showed: . The focus of medication administration is to ensure the process if performed correctly, safely and without errors while maintaining the security of the medication .

Based on observation, interview, and record review, the facility failed to ensure a comprehensive care plan reflected a high risk medication and side effects for 1 (#8), and account for the sleeping preferences for 1 (#20) of 17 sampled residents. Findings include: During an observation and interview on 2/11/25 at 7:44 a.m., resident #8 was sitting in a recliner and a small, dime sized brownish, yellow bruise was noted to the back of her left hand. Resident #8 stated she bumped her hand on her bedside table. Resident #8 stated she bruised easily, and always had bruises, but sometimes she was not sure where they came from. During an interview on 2/11/25 at 1:50 p.m., staff member H stated resident #8 would bruise easily. Staff member H stated there was nothing noted on the care plan about anticoagulant use or side effects of anticoagulant use. Review of resident #8's physicians orders, dated November 2024-February 12, 2025, showed resident #8 had an order for apixaban, an anticoagulant. Review of resident #8's comprehensive care plan failed to show any focus, goals, or interventions related to the use of a daily anticoagulant. Review of a facility document titled, Care within Long Term Care Unit, with a last approved date of 6/2023, showed: The Long Term Care Manager, shall ensure that the Long Term Care unit accomplishes a comprehensive, accurate, standardized, and reproducible assessment of each long term care resident's capacity and provides at minimum: . M. A description of the resident's drug therapy. [sic] 51133 During an observation on 2/10/25 at 3:16 p.m., resident #20 had no blankets, sheets or pillows on her bed in her room. During an interview on 2/11/25 at 9:08 a.m., staff member P stated resident #20 liked to sleep in a recliner in the common area. During an observation and interview on 2/12/25 at 7:32 a.m., resident #20 was observed sleeping in a recliner in the common area. Staff member Q stated, This is where she (resident #20) sleeps at night. During an interview on 2/12/25 at 7:58 a.m., staff member K said resident #20 sleeps in a recliner in the common area, She doesn't like being in her room because it makes her feel claustrophobic. During an interview on 2/12/25 at 2:50 p.m., resident #20 stated, I have claustrophobia, and I hate being locked in my room. I like the pictures and stuff in my room, but I don't like being in there, and I sleep in a recliner in here (common area). Review of resident #20's care plan lacked any documentation related to the resident's preference to sleep in a recliner in the common area or feelings of claustrophobia when being in her room.

Based on interview and record review, the facility failed to ensure a care plan was revised to include comfort care for 1 (#22) of 17 sampled residents. This deficient practice increased the risk of the resident's needs to be unmet by facility staff. Findings include: Review of resident #22's physician orders, dated 10/2/24, showed an order was written for resident #22 to be on Comfort Care. Review of resident #22's care plan, with an initiation date of 7/25/24, showed no revision had been made to resident #22's care plan to include focus, goals, or interventions, related to comfort care. A request was made on 2/11/25 at 9:58 a.m., for a comfort care policy. The policy was not received prior to the end of the survey. During an interview on 2/11/25 at 10:38 a.m., staff member F stated there was not an actual comfort care policy or procedure. Comfort care was based on conversations with the family and resident. During an interview on 2/12/25 at 10:36 a.m., staff member N stated she was the one who would talk with the residents and the families about comfort care. Staff member N stated there was not always an order put in for comfort care, but she would order the comfort care medications. Staff member N stated there was not a policy for comfort care that she knew of. Staff member N stated, I will do comfort care with residents after a conversation with them and the family, I individualize it to the person and their needs, because I know these residents.

Based on interview and record review, the facility failed to ensure a program was in place to maintain or restore bladder function for 2 (#s 8 and 18) of 17 sampled residents. This deficient practice had the potential to cause an increase in urinary incontinence. Findings include: During an interview on 2/12/25 at 9:10 a.m., staff member K stated resident #8 and 18 are frequently incontinent of urine, and they (the residents) are not on a set toileting program or schedule. Staff member K stated both residents can independently take themselves to the bathroom, but there was no set time where staff would go in and toilet the residents. Staff member K stated she had access to the care plans, but they did not address a toileting schedule or program. Review of a facility assessment titled, Bowel and Bladder Program Screener, dated 1/24/25, showed resident #8 had a score of 19 and was a Good candidate for retraining, and had the Ability to get to the BR/transfer to toilet/commode/urinal, adjust clothing and wipe etc. independently with reasonable speed. Review of a facility assessment titled, Bowel and Bladder Program Screener, dated 2/1/25, showed resident #18 had a score of 14 and was a candidate for scheduled toileting (timed voiding). A request was made on 2/11/25 at 2:38 p.m., and 2/12/25 at 9:25 a.m., for a bladder/incontinence policy or bladder retraining program. No policy was received prior to the end of the survey. During an interview on 2/11/25 at 4:33 p.m., staff member F stated they did not have a bladder retraining program or have any written policies.

Based on observation, interview, and record review, the facility failed to ensure weights were accurate and correct in the medical record and failed to ensure a process was in place and followed for re-weights, for 1 (#24) of 17 sampled residents. Findings include: During an observation and interview on 2/11/24 at 8:10 a.m., resident #24 was in her room eating breakfast. Resident #24 stated the food was good but had lost some weight since she was admitted . During an interview on 2/11/25 at 10:03 a.m., NF2 stated resident #24 had lost weight since she had been admitted , but she was eating her meals. Review of resident #24's monthly weights showed the resident weighed 190.2 pounds on 11/4/24 and 164.0 pounds on 2/4/25, representing a 13.77 percent weight loss in three months. During an interview on 2/11/25 at 2:56 p.m., staff member C stated the weights in resident #24's chart were not accurate. Staff member C stated, There was a time when resident #24 had a lot of edema and that may have contributed to the weight changes. Staff member N was not concerned about resident #24's weight and she did not want a diuretic, so there was no need to weigh her more frequently than monthly. I get the weights from the CNAs, go through them and let them know if a re-weight is needed. A re-weight is done if there is a greater than 5-pound weight gain or loss. If there is a concern I will email staff member M. Staff member M is only here one day a week. Staff member C could not verbalize why a re-weight was not completed. During an interview on 2/12/25 at 10:44 a.m., staff member N stated it was her expectation for staff to notify her of any weight gains or losses. Staff member N stated, I review all resident weights monthly. I know these residents and that is how I care for them, it's all individualized. A re-weight should have been gotten especially if there is an excessive loss or gain. During an interview on 2/12/25 at 2:33 p.m., staff member M stated she was not sure if there was a weight policy. Staff member M stated she had verbally addressed her concerns with staff members C and F about needing a re-weight on resident #24. Staff member M stated her concerns were not addressed by staff members C and F. Staff member M stated, When I have concerns or recommendations, I will write them down and give them to staff members C and F to forward to the physician, I am not sure that even happened. Review of resident #24's physician progress notes, from November 2024-February 2025, did not address a weight gain or loss, edema, or resident #24's refusal for a diuretic. Review of resident #24's monthly weights showed: - On 9/10/24 resident #24 weighed 179.0 pounds, - 10/4/24 resident #24 weighed 194.2 pounds, - 11/4/24 resident #24 weighed 190.2 pounds, - 12/10/24 resident #24 weighed 168.6 pounds, - 1/7/25 resident #24 weighed 163.2 pounds, and - 2/4/25 resident #24 weighed 164.0 pounds. No re-weights were documented during this time frame. Review of a facility document titled, Long Term Care Weight Management Orders, undated, showed: Weight Loss, . add to weekly weights x4 weeks for 5%, add weights twice a week for 10% Weight Gain, . add to weekly weights x 4 weeks and notify Dr and Dietician . A request for a weight loss policy or procedure was requested on 2/11/25 at 9:58 a.m., and was not received prior to the end of the survey. During an interview on 2/11/25 at 10:38 a.m., staff member F stated they did not have a formal policy or procedure for weight loss or gain .

Based on interview and record review, the facility failed to identify and address past trauma for a resident; and provide trauma informed care, within professional standards that accounted for a resident's experiences and preferences, for 1 (#24) of 17 sampled residents. Findings include: During an interview on [DATE] at 3:19 p.m., resident #24 stated she had many traumatic experiences in her life, starting as a child. Resident #24 stated, My horrible life started when I was a child. My mother was a drug addict and slept around. There was always a new man in the house every night. This went on for most of my childhood. When I became an older teenager or young adult I found my mother dead with a needle in her arm. When I got married, I ended up marrying a man that beat me for years, I never left him because I was too scared to get away. I was with him until he died . I took years of physical beatings and emotional abuse from him. There was one Christmas Eve when I found out that my sister had been murdered by her husband. These are all very painful memories. I get angry and sad when I think about it, and lately I seem to be thinking about my past a lot. I have never been talked to by a social worker or therapist since my family moved me here. I have talked with some of the girls that take care of me, but I feel like no one believes me. During an interview on [DATE] at 10:03 a.m., NF2 stated resident #24 did have a very traumatic life and had suffered a lot. NF2 stated he did not think anyone had every talked to her about her past experiences and knew she had never seen a counselor or therapist since being moved to Montana. NF2 stated he was not sure if resident #24 had ever talked to anyone about her experiences. During an interview on [DATE] at 9:10 a.m., staff member K stated she had taken care of resident #24. Staff member K stated, Resident #24 is very vocal about her past trauma. It is so sad; she has been through a lot. Staff member K stated she had not received education from the facility on trauma informed care. During an interview on [DATE] at 9:20 a.m., staff member H stated resident #24 talks about her past frequently and about the multiple issues that happened in her life. Staff member H stated resident #24 would benefit from talking to someone about her trauma and was not sure if anyone had ever talked with the resident. Staff member K stated she had received some education on trauma informed care, and stated there was nothing on the care plan about resident #24 having past traumatic experiences. During an interview on [DATE] at 11:58 a.m., staff member L stated, If a patient or resident has any past trauma and it is known to us, we will go and speak with them, and set them up for resources, if they want. We do have a behavioral counselor on site we can refer to. We do a depression assessment on everyone. I am not sure if resident #24 was ever assessed for trauma, I am not sure if there is a trauma care plan in place. Staff member L stated she could not find any Social Services notes on resident #25. Staff member L stated, I will go down and talk with the resident, and all I can do is start from here. Review of a facility document titled, September Staff meeting, diet review-liquids, new staff onboarding, dated [DATE] showed, education post-traumatic stress disorder was provided. The staff sign in sheet showed staff member K was not present for the education. Review of resident #24's progress notes, dated [DATE]-February 12, 2025, showed no social services notes. A request was made on [DATE] at 9:25 a.m., for a trauma informed care or post-traumatic stress disorder policy and procedure. The policy was not received prior to the end of the survey. During an interview on [DATE] at 10:55 a.m. staff member F stated there was not a policy or procedure for trauma informed care or post-traumatic stress disorder.

Based on interview and record review, the facility failed to provide medical social services for 1 (#24) of 17 sampled residents. This deficient practice had the potential to negatively impact the resident's mental well-being. Findings include: During an interview on 2/10/25 at 3:19 p.m., resident #24 stated she had many traumatic experiences in her life, starting as a child. Resident #24 stated, My horrible life started when I was a child. Resident #24 went on to describe her traumatic events (Refer to F699 for more information), and stated, I get angry and sad when I think about it, and lately I seem to be thinking about my past a lot. I have never been talked to by a social worker or therapist since my family moved me here. I have talked with some of the girls that take care of me, but I feel like no one believes me. During an interview on 2/11/25 at 10:03 a.m., NF2 stated resident #24 did have a very traumatic life and had suffered a lot. NF2 stated he did not think anyone had every talked to her about her past experiences. During an interview on 2/12/25 at 11:58 a.m., staff member L stated, If a patient or resident has any past trauma and it is known to us, we will go and speak with them, and set them up for resources, if they want. We do have a behavioral counselor on site we can refer to. We do a depression assessment on everyone. I am not sure if resident #24 was ever assessed for trauma, I am not sure if there is a trauma care plan in place. Staff member L stated she was not sure if there was a trauma policy and did not know what it was if there was one. Staff member L stated she could not find any Social Services notes on resident #24. Staff member L stated, I will go down and talk with the resident, and all I can do is start from here. Review of a facility document titled, Care within Long Term Care Unit, with a last approved date of 6/2023, showed: . Social Service function provides medically-related services to long term care residents, to allow them to attain or maintain the highest practicable level of physical, mental and, psychological well-being. Such social services will be made available . [sic]

Based on interview and record review, the facility failed to ensure an as needed antianxiety medication was limited to 14 days, or provide a rationale for continued extension of the medication, for 1 (#24) of 17 sampled residents. Findings include: During an interview on 2/10/25 at 3:19 p.m., resident #24 stated at one point she was getting a medication that would make her feel out of it. Resident #24 stated it was not her pain medication but thought it may have been an anxiety medication. Resident #24 stated she was not sure why she would be on something like that and she did not like how it made her feel. Review of resident #24's medication orders, dated 9/17/24, showed an order for Ativan 0.5 mg by mouth every 4 hours as needed for anxiety, and a D/C order was received on 12/18/24. Review of resident #24's medication administration record showed resident #24 received 1 dose of Ativan in September 2024, 2 doses of Ativan in October 2024, 3 doses in November 2024, and 1 dose of Ativan in December 2024, for a total of 7 doses in a three-month period. Review of a facility document titled, Consultant Pharmacist's Progress Note, dated 9/1/24, 9/27/24, 11/1/24, and 12/1/24 showed: . The resident is taking the following psychoactive medications: Lorazepam (Ativan) 0.5 mg every 4 house as needed for anxiety. Effective November 28, 2017, new orders for PRN antipsychotic drugs beyond 14 days will require a resident evaluation to determine if a new order is appropriate. Other PRN psychotropic drug orders beyond 14 days must be accompanied by documentation in the medical record of the duration for extended use. Review of resident #24's physician's progress notes, dated 10/23/24, showed no documentation for the continued use of Ativan as needed. During an interview on 2/12/25 at 10:36 a.m., staff member N stated resident #24 was being seen by a different provider and could not speak to the Ativan order. During an interview on 2/12/25 at 10:50 a.m., staff member C stated when the medication regimen reviews are received, they are placed in a folder for the physician to review. Staff member C stated if the physician agrees with the recommendations, they will place an order to continue or discontinue the medication. Review of a facility document titled, Psychotropic Medication -Long Term Care, with a last approved date of 6/2023, showed: . G. Orders for PRN psychotropic medications will be time limited (14 days) and only for specific clearly documented circumstances and rationale must be provided.

Based on observation and interview, the facility failed to post a list of names and contact information for state regulatory and advocacy groups, the State Survey Agency or State licensure office, or include information for residents wishing to file a complaint with the State Survey Agency. This deficient practice had to potential to affect all residents, resident representatives, or staff wishing to view or know the information. Findings include: During an observation on 2/12/25 at 7:26 a.m., the bulletin board next to the nurses' station contained a posting of contact information for the state Ombudsman. It did not contain a posting with the names and contact information for required state regulatory or advocacy groups. During an interview on 2/12/25 at 1:28 p.m., NF4 stated the facility had been provided a laminated poster by the state ombudsman office that contained all the required information. During an interview on 2/12/25 at 1:39 p.m., a resident council meeting was conducted in the facility. Resident council members were not aware of the location of a sign that contained information on contacting the state regulatory agency or ombudsman. During an interview on 2/12/25 at 2:38 p.m., staff member F stated the sign was removed when the nurses' station had undergone renovations. The posting had not been replaced following the renovations.

Based on observation and interview, the facility failed to post the results of the most recent recertification survey in an area readily accessible to residents, family members, and residents' legal representatives, or staff. This deficient practice had the potential to affect all residents or resident representatives wishing to view the most recent recertification survey results. Findings include: During an observation on 2/12/25 at 7:26 a.m., no binder containing the most recent recertification survey results were found within the long-term care area of the facility. During an interview on 2/12/25 at 1:39 p.m., a resident council meeting was conducted in the facility. Resident council members were not aware of the location of a binder that contained the most recent recertification survey results. During an interview on 2/12/25 at 2:38 p.m., staff member F stated the survey information was removed when the nurses' station had undergone renovations. The survey information had not been replaced following the renovations.

Based on interview and record review, the facility failed to establish and maintain an antibiotic stewardship program with the required elements, including using a standardized assessment tool and criteria for the evaluation of infections, and a system to monitor the use of antibiotics for the duration of treatment, for 2 (#s 8 and 20) sampled residents. This deficient practice had the potential to affect any resident with an antibiotic prescribed. Findings include: During an interview on 2/28/24 at 2:48 p.m., staff member F stated she was not aware of any criteria the facility followed for determining infections and antibiotic use. Staff member F stated the nurses called staff member H with any resident symptoms, and staff member H determined what antibiotics and labs to run. Staff member F stated the facility staff did not wait to receive laboratory results to start antibiotics. Staff member F stated the nurses were to get vital signs, assess the resident, and document progress notes daily through the duration of a course of antibiotics. Staff member F did not know what was expected of the nurse entering orders in the EHR that triggered an allergy or drug interaction warning. During an interview on 2/28/24 at 3:19 pm., staff member G stated she reported any resident changes to the nurse. If the concerns or changes were related to a suspected UTI, the nurses usually asked about the resident's intakes, and to try to increase the resident's fluid intake. During an interview on 2/28/24 at 10:34 a.m., staff member H stated she oversaw antibiotic stewardship for the facility and tried to be careful with antibiotic prescribing for the right dose and length of treatment. Staff member H stated the facility staff would start treating with antibiotics from a urine dip, if a resident was symptomatic, and she would change the treatment if needed once the laboratory results were received. Staff member H stated staff member E tracked the antibiotic use. During an interview on 2/28/24 at 4:42 p.m., staff member H stated there was no protocol for the nurses to follow for antibiotics because they were not prescribers. Staff member H stated when entering an order in the hospital EHR it would show the options for antibiotics to use, and the options came from the hospital system pharmacy policies, but it would not show up for the facility nurses in their EHR the same way. 1. During an interview on 2/29/24 at 9:10 a.m., staff member D stated she could not find documentation for why resident #8 was prescribed a dose of antibiotics or documentation if he had an infection or not. Review of resident #8's January 2024, nurse progress notes showed: - 12/31/23, Resident having intermittent hematuria. Pushing cranberry juice. No c/o dysuria or frequency. - 1/1/24 through 1/10/24, no progress notes regarding symptoms of an infection or other clinical concerns. - 1/11/24 at 3:48 p.m., Staff reports small amount of out put this shift. Hematuria noted. Resident c/o discomfort with palpation. Bladder scan shows greater than 270. Call out to [physician]. [sic] - 1/11/24 at 4:28 p.m., Received order to cath resident and send UA with culture as indicated. 16 F Foley placed. Resident tolerated well. 600 ml return amber urine. - 1/11/24 at 6:08 p.m., UA results sent to [physician] for review. - 1/12/24 at 11:09 a.m., The system has identified a possible drug allergy for the following order: cefTRIAXone Sodium Injection Solution Reconstituted 1 GM (Ceftriaxone Sodium) Inject 1 gram intramuscularly STAT for UTI. - 1/12/24 at 1:06 p.m., UA reviewed by [physician], Rocephin 1 GM IM ordered and given. Waiting on culture. Foley draining well Hematuria noted. - 1/13/24 and 1/14/24, no progress notes for resident #8. - 1/15/24, urine out put every shift every night 250cc, - 1/16/24, urine out put every shift every night shift 300cc, - 1/17/24, urine out put every shift every night shift 150 ml, - 1/17/24, . Antibiotic(s) since last evaluation: YES. Rocephin for possible UTI, Vitals: Temperature: Blood Pressure: Pulse: Respiration: . - 1/17/24, Order received to dc Foley. 300 ml in bag. Urine amber in color. Review of resident #8's January 2024, MAR showed: - UA/culture if indicated. one time only for 1 Day Start Date 1/11/24, - ceftriaxone Sodium Injection Solution Reconstituted 1 GM (Ceftriaxone Sodium) Inject 1 gram intramuscularly STAT for UTI Start Date 1/12/24 D/C Date 1/12/24. [sic] - urine out put every Day shift every day shift Start Date 01/14/2024 D/C Date 1/17/24. - urine out put every shift every night shift Start Date 01/14/2024 D/C Date 1/17/24. - Foley catheter care every shift every day and night shift for routine catheter care Start Date 1/12/24 D/C Date 1/17/24. 2A. Review of resident #20's February 2024, nurse progress notes showed: - 2/2/24, Spoke with [clinic staff name] from [Clinic Name] regarding Monday appt and the need for labs. She originally called the clinic. Provided her with correct contact information. She wants CBC, Vit D, urine protein creatinine and UA reflex, BMP. Blood work done will obtain urine today. [sic] - 2/3/24 - 2/6/24, No notes related to laboratory results, infection symptoms, or antibiotics use. - 2/7/24, Residents UA and culture positive for Ecoli. [Physician] aware and Cephalexin 500 mg ordered Bid x 5 days. - 2/8/24, No progress notes related to antibiotic monitoring or infection. - 2/9/24, Resident continues on antibiotic therapy for UTI. No adverse reactions observed. Vital signs are stable. - 2/10/24, No progress notes related to antibiotic monitoring or infection. - 2/11/24, No progress notes related to antibiotic monitoring or infection. - 2/12/24, Resident continues on ABX for UTI. afebrile. no s/sx of adverse reaction observed this shift. [sic] Review of resident #20's February 2024, MAR showed: - Cephalexin Oral Tablet 500 MG, Give 500 mg by mouth STAT for UTI Start Date 2/7/24. Given at 3:11 p.m. - Cephalexin Oral Tablet 500 MG, Give 500 mg by mouth one time only for UTI for 1 Day Start Date 2/7/24. Given at 11:00 p.m. - Cephalexin Oral Tablet 500 MG, Give 500 mg by mouth two times a day for UTI for 4 Days, Start Date 2/8/24. Administered from 2/8/24 through 2/12/24. 2B. Review of resident #20's October 2023, nurse progress notes showed: - 10/23/23 to 10/25/23, no progress notes related to signs or symptoms of an infection. - 10/26/23, resident #20 was sent to the emergency room for critical potassium levels by an outside provider order. - 10/26/23, no progress notes for signs or symptoms of an infection. Note of resident #20 returning from the hospital. - 10/27/23, Order received for Cephalexin 500 mg Bid x 5 days. - 10/28/23, no progress notes for antibiotic use monitoring. - 10/29/23, no progress notes for antibiotic use monitoring. - 10/30/23, Resident on antibiotic tx for UTI. NO adverse reaction noted. No urinary complaints. VSS. Continue to monitor. [sic] - 10/31/23, Resident on ABO TX for UTI. NO complaints of pain or urinary problems. VSS. NO adverse reaction noted. Continue to monitor. [sic] Also noted resident #20 was at the hospital. - 11/1/23, resident #20 returned from the hospital. Review of resident #20's October 2023 MAR showed: - Cephalexin Oral Tablet 500 MG, Give 1 tablet by mouth one time only for uti for 1 Day First dose now Start Date 10/27/23, and given at 5:34 p.m. - Cephalexin Oral Tablet 500 MG Give 1 tablet by mouth two times a day for UTI for 5 days, start date 10/28/23, D/C date 11/1/23. Given both times 10/28/23 through 10/30/23. Given in the morning only on 10/31/23 as resident was noted to be in the hospital. Review of the facility policy, Antimicrobial Stewardship (AMS) Program, last reviewed 3/23, was focused for the hospital system program and did not incorporate the required elements for the long term care antibiotic stewarship program.

Based on interview and record review, the facility failed to protect 1 (#77) of 5 sampled residents from physical and verbal abuse by a staff member. Findings include: Review of a State Survey Agency reportable incident, for resident #77, reported on 10/15/22, showed, Verbal and physical abuse was substantiated. Staff member [NF1] was witnessed yelling at resident (#77) to get him to listen; She tapped his chin to make him look up; She did this is an angry frustrated manner; In addition, she was witnessed roughly repositioning his leg in (on) the wheelchair foot rest; Resident (#77) has cognitive disability as well as dementia and is frequently yelling and lashing out but is unable to give statement; Three witnesses were interviewed; Other residents were assessed, and there no signs that the same behavior was exhibited towards them attempts were made multiple times to reach family to notify; No injuries to resident noted and not change noted in resident condition ie behavior or mood. Review of a facility document titled, Disciplinary Action Form, dated 10/18/22, showed, It was reported by two hospital staff that (NF1) was agrily yelling at a resident (#77), making threats about being sent away to another facility, and the staff member was physically touching the resident using angry abrupt movements i.e. sharply tapping his chin and roughly repositioning his leg while in the wheelchair. The document showed NF1 continued yelling at resident #77, even after being reprimanded by a staff member, and a provider. The document showed the facility substantiated the abuse, NF1's abusive behavior was addressed by facility policies and procedures, and the employee no longer held the position at the facility as of 10/18/22. During an interview on 3/1/23 at 8:48 a.m.,staff member B stated she conducted the resident interviews for the investigation into the incident. Staff member B said NF1 had been with them for a long time, and all the residents really liked her. Staff member B stated NF1 got frustrated with the resident. Staff member B said the resident (#77) had gotten to a point with his dementia the staff was having to take turns watching him one on one. Staff member B stated NF1 had taken resident #77 for a walk through the main hospital. The nurses from the clinic heard NF1 yelling at resident #77. Staff member B said NF1 told her she was speaking loudly because she didn't think he could hear what she was saying. The clinic nurses went to staff member E and reported the incident. Staff member B said staff member E came to her and explained what the clinic nurses had overheard and witnessed. Staff member B suspended NF1 during the investigation. Staff member B stated the incident did not seem to affect resident #77. During an interview on 3/1/23 at 10:00 a.m., staff member D stated the facility held an Ad Hoc QAPI meeting regarding the abuse on 10/18/22. Staff member C stated the facility educated all long-term care nursing staff on the abuse policy and the facility's no tolerance for abuse during the daily huddle after the incident. Staff member D stated NF1 was terminated on 10/18/22. The facility had taken the necessary action to identify and address the abuse event related to the staff member, and followed the facility policies and procedures, while ensuring future protection of the residents. A review of the State Survey Agency facility reported events showed the facility did not report or investigate any staff to residents abuse/neglect allegations after this event, up to the date of the survey, reflecting compliance in this regulatory area. Review of a facility policy titled, Abuse, Neglect, and Exploitation of Elderly and Disabled, dated 1/2023, showed: [Facility Name] prohibits the mistreatment, neglect, and abuse of its patients and the misappropriation of patient's property. Furthermore, the use of verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion is prohibited by [Facility Name].

Based on interview, and record review the facility failed to ensure a resident received necessary pain management, specifically, was not given an as needed pain medication when requested by the resident, resulting in the resident experiencing pain and worry, for 1 (#1) of 8 sampled residents. Findings include: During an observation and interview on 8/12/2020 at 12:40 p.m., resident #1 stated There is a nurse named (staff member K) and she makes me beg for my pain medicine [MEDICATION NAME], and I know its every six hours. I know I can have it, and she tells me its too early, and she does not come back. I ask again later, and she will finally give it to me. Resident #1 stated Every time (staff member K) is here she does not ask me (about pain/medicine) I have to ask, and she always tells me I have to wait. Resident #1 stated There is a guy nurse named (staff member B) he is good about giving it. He sometimes asks me before I tell him if I need it. Resident #1 stated (Staff member K) acts like it's personally hers to give. My pain doesn't get any better when (staff member K) does that, and I just have to wait until she will agree to give it to me. I hurt until she finally gives it to me. I worry if (staff member K) is working because she is going to be here and I'm not going to get my pain medicine when I ask for it. I have a clock over there, and I know when six hours is up. She is the only one that does that. Resident #1 stated When I ask for them (pain medication) I do not have any problem with anyone but (staff member K). Resident #1 was able to sit up independently in bed to be interviewed. Resident #1 stated she always has some pain and expects that, but when she tells the nurse she needs her pain pill she really needs it. During an interview on 8/12/2020 at 1:24 p.m., staff member B stated My counterpart at night thinks (resident #1) is drug seeking. When resident #1 asks for her prn (as needed) pain medication staff member K does not tell her when she is due for her next dose and tells her it is not time. She refuses to let the CNAs know when she can have her next pain pill when they notify her that resident #1 is in pain and requesting her pain medicine. Staff member B stated, I have talked to the LTC manager about staff member K telling resident #1 if she takes her [MEDICATION NAME] then she can not have her prn [MEDICATION NAME] for six hours after that which is not the truth, and making her wait for her prn [MEDICATION NAME] and not letting her or the CNAs know when she can have her next dose. Review of resident #1's physician's orders [REDACTED]. Medications prescribed for pain included Tylenol 500 mg twice per day with meals, [MEDICATION NAME] 150 mg at bedtime, [MEDICATION NAME] 25 mcg apply a new patch every 72 hours, [MEDICATION NAME] 200 mg twice per day as needed, and [MEDICATION NAME] 5/325 mg every six hours as needed. A record review of resident #1's MAR for the months of May, June, July, and August 2020 showed an overall pattern that resident #1 would request her prn [MEDICATION NAME] late night and early morning with some doses around noon. Review of resident #1's Quarterly minimum data set, with an ARD of 6/15/2020, showed she had a BIMS score of 15, intact cognitive responses, and did not exhibit any behavioral symptoms or rejection of care. Review of resident #1's care plan, with a last edit date of 6/17/2020, showed a title area for Pain-Chronic. Interventions included .charge nurse to assess and evaluate comfort status as indicated. Medicate for pain as needed. O/A for effectiveness.Report any problems to Provider.Administer opioids and prn Tylenol as ordered by physician for pain management. Review of resident #1's Pain Summary, dated 6/18/2020, showed chronic pain to her back and joint with intermittent frequency and hours of duration. The summary showed resident #1's pain level had not changed in the past week/month/year. In the comment section was written, resident is on multiple pain medication. (sic) [MEDICATION NAME], [MEDICATION NAME], and [MEDICATION NAME] PRN. She has been to pain management and also received injections.The pain characteristics portion of the summary was blank. During an interview on 8/12/2020 at 1:24 p.m., staff member A stated she was aware of the concern brought by staff for staff member K not giving the resident her prn pain medication, which was [MEDICATION NAME], and stated she addressed it with staff member K in July 2020. Staff member A stated she was not aware the concern was continuing to occur. Review of a documented conversation, submitted by staff member A, showed a dated conversation of 6/25/20 that showed, Had a conversation with (staff member K) about how she determines when a resident can have pain medication. She stated that she assesses the resident if it is a PRN pain medication and what time it was last given, and if it is time I will give it to them. (Staff member K) was a little upset that she was being questioned about this. She said something like, I take my job very serious and giving pain medication at the right times.

Based on observation, interview, and record review, the facility failed to provide supervision during mealtime; and failed to maintain a safe temperature of coffee for a resident while the resident was consuming hot liquids for 1 (#1) of 4 sampled residents, which resulted in the resident spilling coffee on her lap and sustaining 1st and 2nd [MEDICAL CONDITION] both lower, medial, thighs. During the survey, an Immediate Jeopardy situation was announced on 12/19/19 at 4:05 p.m., which included 1 (#1) resident who spilled coffee on herself, and sustaining 1st and 2nd [MEDICAL CONDITION] both lower, medial, thighs, when she was left unattended in the dining room by a staff member. It was found that the coffee machine, which the resident had just received the coffee from, had consistently brewed and maintained a holding temperature which was identified as unsafe. The facility failed to identify, investigate thoroughly, and carry out effective corrective actions for the prevention of future accidents and hazards for the resident, or any other resident at the facility. The Immediate Jeopardy was cited at the level of J, and upon the removal of immediacy, would be lowered to the level of [NAME] The Immediate Jeopardy was cited in the area of F689 - Accidents and Hazards. The facility provided a Plan to Remove Immediacy on 12/20/19 at 2:20 p.m., and at 3:21 p.m. had removed the immediacy for resident #1 and other residents who consumed coffee. Findings include: During an interview on 12/18/19 at 4:58 p.m., resident #1 stated her wound was almost healed. Resident #1 was unable to recall spilling coffee on herself. During an observation on 12/19/19 at 12:44 p.m., resident #1's burn on her right medial knee was light pink with some peeling noted around the wound's edges. The burn measured approximately six inches in length and 2.5 inches in width. The burn was not covered with a bandage. Supervision During an interview on 12/19/19 at 1:30 p.m., staff member F stated, recalling the incident on 12/4/19, she had placed resident #1's coffee on the table in front of her and walked away for a few minutes. Staff member F stated when she returned to resident #1, she saw that the coffee had spilled onto resident #1's lap. Staff member F explained staff immediately took resident #1 to her room and changed her, and noticed [MEDICAL CONDITION] her lower thighs. During an interview on 12/20/19 at 9:00 a.m., staff member A stated she thought resident #1 was supposed to be supervised because resident #1 tended to all of a sudden not eat during meals. Staff member A stated resident #1 was supervised during meals for prompting purposes; she did not need a one-person assist during meals. During an interview on 12/20/19 at 11:03 a.m., staff member F stated resident #1 was a set-up only, referring to staff providing assistance during meals. Staff member F stated resident #1 could feed herself, and if she needed anything, staff were present in the dining room to help. In other words, resident #1 did not need one-person assistance during meals. During an interview on 12/19/19 at 12:09 p.m., staff member G stated staff would make sure they watched while residents with dementia consumed hot drinks. During an interview on 12/19/19 at 1:19 p.m., staff member B stated she would stay with residents who had dementia while they drank coffee to ensure their safety. Review of resident #1's MDS, with an ARD of 10/25/19, under Activities of Daily Living showed resident #1 required supervision with a one person assist during eating and drinking. Setup help was not coded in this section. Review of resident #1's active diagnoses, dated 12/7/19, showed dementia without behavioral disturbance and generalized weakness. Safe temperature During an observation on 12/18/19 at 4:52 p.m., a cup was filled with coffee directly from the coffee machine in the dining room. An infrared thermometer showed the temperature was 154 degrees Fahrenheit. During an observation on 12/19/19 at 11:40 a.m., the coffee machine was noted to be in the dining room, to the right of the entry, on a counter, and next to a sink and ice machine. The coffee machine was accessible to all staff and residents. There were no holding pots next to the coffee machine. Brown mugs with handles were noted to the left of the ice machine. There were no lids or straws noted in the area. During an interview on 12/19/19 at 2:05 p.m., Staff member A stated 160 degrees Fahrenheit was the safe zone for coffee; bacteria would grow at a temperature lower than that. Staff member A stated the facility did not have a holding pot for the coffee; it just came straight out of the machine. During an interview on 12/19/19 at 2:40 p.m., staff member A stated the CNA assisting resident #1 on 12/4/19 (the day of the coffee spill) had provided resident #1 with a cup of coffee in the dining room. There was no lid on the cup at the time. Resident #1 grabbed for the cup and dropped it onto her lap. Staff member A stated staff member [NAME] checked the coffee temperature within an hour after resident #1 had spilled it, and it had read between 160.8 and 161 degrees Fahrenheit. Staff member A stated staff member [NAME] had told her that was in the normal temperature range. Staff member A stated she met with the CNAs, and recommended they add an ice cube or two in resident #1's coffee. Staff member A stated she was not sure if an ice cube would reduce the temperature of resident #1's coffee sufficiently, and she would have to stick a thermometer in it to be sure. Staff member A stated if residents were at risk (of injuring themselves), the facility would protect them, although no interventions related to the accident, to include the ice, were added to resident #1's care plan. Review of a temperature log for (MONTH) of 2019 showed coffee temperatures ranged from 158 to 170 degrees Fahrenheit. On 12/4/19, the day of resident #1's coffee spill, the coffee temperatures were 165 degrees Fahrenheit at breakfast; 166 degrees Fahrenheit at lunch, and 160 degrees Fahrenheit at dinner. The recommended temperature listed on the temperature log sheet was 160 degrees Fahrenheit. Record Review of Incident Review of a Nurse's Note, dated 12/4/19, showed: Resident spilled coffee in her lap, burning her right thigh close to knee and slight red burn to left thigh .Called provider, who came and saw resident. Review of a Nurse's Note, dated 12/7/19, showed: Burned area, measuring 7 inches by 2.5 inches is beefy red, wet, tissue layers are rolled back at edges, small areas of purulent exudate in wound bed - appears to be second degree burn .also has 2 smaller burns, approximately 1.5 inches to mid left thigh and a 2 inch area to lateral left thigh-red with skin intact, first degree. Review of a provider's note, dated 12/7/19, showed: (Approximately) 1% (of body surface area) right inner thigh with second degree burn .Wound cleaned with sterile saline and gently debrided significant amount of ruptured blister .Some eschar still in middle of burn .Macerated especially around the edges. Review of the facility's Incident Follow-up document, dated 12/11/19, showed: Action: RN manager had dietary check (temperature) of coffee coming out of coffee maker. The (temperature) was appropriate at 160.8 degrees. Moving forward we have educated staff to add a couple ice cubes to resident's coffee so it isn't as hot. The facility failed to identify the risks and hazards of the temperature of the coffee; failed to have safe equipment, such as cups and lids, available for the residents; failed to ensure an adequate investigation was done after the incident; and failed to implement interventions to ensure ongoing safety for resident #1 and all other residents who drink coffee.

Based on observation, interview, and record review, facility staff neglected to stay with a resident who required a one-person assist with eating and drinking; neglected to adjust the temperature of a coffee machine to prevent burns; and neglected to implement interventions after 1 (#1) of 4 sampled residents sustained 1st and 2nd [MEDICAL CONDITION] her legs. The facility had system failures identified related to the provision of goods and services to promote the residents' well-being. Findings include: 1. During an interview on 12/19/19 at 1:30 p.m., staff member F stated, recalling the incident on 12/4/19, she had placed resident #1's coffee on the table in front of her and walked away for a few minutes. Staff member F stated when she returned to resident #1, she saw that the coffee had spilled in resident #1's lap. Staff member F explained staff immediately took resident #1 to her room and changed her, and noticed she had sustained a burn. Review of a Nurse's Note, dated 12/7/19, showed: the resident had a burned area, measuring 7 inches by 2.5 inches that was beefy red, wet, with tissue layers that were rolled back at edges, small areas of purulent exudate in wound bed, and it appeared to be a second degree burn. Two smaller burns, approximately 1.5 inches to mid left thigh, and a 2 inch area to the lateral left thigh was red with skin intact, and identified to be a first degree burn from the coffee spill. Review of a provider's note, dated 12/7/19, showed: (Approximately) 1% (of body surface area) right inner thigh with second degree burn .Wound cleaned with sterile saline and gently debrided significant amount of ruptured blister .Some eschar still in middle of burn .Macerated especially around the edges. Review of resident #1's MDS, with an ARD of 10/25/19, under Activities of Daily Living, showed she required supervision with one-person physical assistance during eating and drinking. 2. During an observation on 12/18/19 at 4:52 p.m., a cup was filled with coffee directly from the machine in the dining room. An infrared thermometer showed the temperature was 154 degrees Fahrenheit. During an interview on 12/19/19 at 12:26 p.m., staff member [NAME] stated he checked the coffee temperatures three times daily. Staff member [NAME] stated he knew 170 degrees Fahrenheit was too hot, and if the machine reached that temperature, he would ask the manufacturer to come in and adjust the machine. Staff member [NAME] stated he did not call the manufacturer on 12/4/19, the day resident #1 was burned by the coffee, because the coffee was at an acceptable temperature. During an interview on 12/19/19 at 2:40 p.m., staff member A stated staff member [NAME] checked the coffee temperature within an hour after resident #1 had spilled it, and it had read between 160.8 and 161 degrees Fahrenheit. Staff member A stated staff member [NAME] had told her that was in the normal temperature range. Review of a temperature log for (MONTH) of 2019 showed coffee temperatures ranged from 158 to 170 degrees Fahrenheit. Staff neglected to adjust and monitor the coffee machine to ensure safe temperatures for their residents. 3. During an interview on 12/19/19 at 2:40 p.m., staff member A stated she met with the CNAs following the incident with resident #1, and recommended they add an ice cube or two in resident #1's coffee. Staff member A stated she was not sure if an ice cube would reduce the temperature of resident #1's coffee sufficiently, and she would have to stick a thermometer in it to be sure. Staff member A stated if residents were at risk (of injuring themselves), the facility would protect them, although staff neglected to update resident #1's care plan following the incident. Staff member A stated no other safety precautions were put in place for resident #1 or other residents who drink coffee (e.g. lids, separate containers to cool the coffee outside of the machine, etc.) Review of resident #1's care plan, dated 12/10/19, showed resident #1 required assistance during meals for set-up only. No supervision or one-person assist recommendations were noted, as per resident #1's MDS. There was no intervention within resident #1's care plan that showed staff should add ice to her coffee, or take any other preventive measures to lower the temperature of the coffee. The combined concerns, showed an overall system failure for the resident's event, but also individual failures related to identifying and addressing neglect, protecting the resident(s), implementing safety interventions, and ensuring equipment, such as the coffee pot, was safe for resident use.

Based on observation, interview, and record review, the facility failed to provide supervision for 1 (#1) of 4 sampled residents. Resident #1 had a dementia diagnosis, and was left unsupervised in the dining room with an open cup of hot coffee, and she spilled the coffee in her lap, suffering 1st and 2nd [MEDICAL CONDITION] her legs; and the facility failed to assess, develop, and implement interventions within resident #1's care plan following the incident. Findings include: During an observation on 12/19/19 at 11:40 a.m., a coffee machine was noted in the dining room, to the right of the entry, on a counter and next to a sink and ice machine. The coffee machine was accessible to all staff and residents. There were no holding pots next to the coffee machine. There were no lids or straws noted next to the coffee machine. Four residents were sitting at a table next to the counter. During an interview on 12/19/19 at 1:30 p.m., staff member F stated, recalling the incident on 12/4/19, she had placed resident #1's coffee on the table in front of her and walked away for a few minutes. Staff member F stated when she returned to resident #1, she saw that the coffee had spilled in the resident's lap. Staff member F explained staff immediately took resident #1 to her room and changed her, and noticed the burns, but resident #1 did not exhibit any signs of distress. During an interview on 12/19/19 at 2:40 p.m., staff member A stated the CNA assisting resident #1 on 12/4/19 had provided resident #1 with a cup of coffee in the dining room. There was no lid on the cup. Staff member A stated she met with the CNAs after the incident, and recommended they add an ice cube or two in resident #1's coffee. Staff member A stated there were no other interventions implemented at the time of the incident or following. During an interview on 12/20/19 at 11:22 a.m., staff member B stated the facility did not offer any additional training for residents with dementia. During an interview on 12/20/19 at 3:05 p.m., staff member A stated the facility had not offered any formal training on dementia care. New CNAs are mentored by more experienced CNAs so that they know the individualized care to provide the residents, such as cooling a resident's coffee. Review of resident #1's active diagnoses, dated 12/7/19, showed dementia without behavioral disturbance. Review of resident #1's MDS, with an ARD of 10/25/19, under Activities of Daily Living, showed she required supervision with one-person physical assistance during eating and drinking. Review of resident #1's care plan, dated 12/10/19, showed resident #1 required assistance during meals for set-up only. No supervision or one-person assist recommendations were noted, as per resident #1's MDS. There was no mention of interventions to prevent resident #1 from spilling her coffee or cooling hot liquids. Review of a Nurse's Note, dated 12/7/19, showed: Burned area, measuring 7 inches by 2.5 inches is beefy red, wet, tissue layers are rolled back at edges, small areas of purulent exudate in wound bed - appears to be second degree burn .also has 2 smaller burns, approximately 1.5 inches to mid left thigh and a 2 inch area to lateral left thigh-red with skin intact, first degree. Review of a provider's note, dated 12/7/19, showed: (Approximately) 1% (of body surface area) right inner thigh with second degree burn .Wound cleaned with sterile saline and gently debrided significant amount of ruptured blister .Some eschar still in middle of burn .Macerated especially around the edges.

Based on observation, interview, and record review, the facility failed to provide coffee at a safe temperature, which led to 1 (#1) of 4 sampled residents sustaining 1st and 2nd [MEDICAL CONDITION] her legs. During an observation on 12/18/19 at 4:52 p.m., a cup was filled with coffee directly from the coffee machine in the dining room. An infrared thermometer showed the temperature was 154 degrees Fahrenheit. This was the identified machine which was used the day resident #1 sustained a coffee burn, and the coffee was provided to resident #1 by a staff person, who then left the resident unattended. During an interview on 12/19/19 at 12:26 p.m., staff member [NAME] stated he checked the coffee temperatures three times every day. Staff member [NAME] stated the manufacturer of the coffee machine never provided a safe drinking temperature for the coffee; however, he knew the standard temperature was 160 degrees Fahrenheit. Staff member [NAME] stated he knew 170 degrees Fahrenheit was too hot, and if the machine reached that temperature, he would ask the manufacturer to come in and adjust the machine. Staff member [NAME] stated he did not call the manufacturer on 12/4/19, the day resident #1 was burned by the coffee, because the coffee was at an acceptable temperature. During an interview on 12/19/19 at 2:40 p.m., Staff member A stated she had called staff member [NAME] immediately to check the temperature of the coffee. Staff member A stated staff member [NAME] checked the coffee temperature within an hour after resident #1 had spilled it, and it had read between 160.8 and 161 degrees Fahrenheit. Staff member A stated staff member [NAME] had told her that was in the normal temperature range. Review of a temperature log for (MONTH) of 2019 showed coffee temperatures ranged from 158 to 170 degrees Fahrenheit. On 12/4/19, the day resident #1 spilled the coffee, the coffee temperatures were 165 degrees Fahrenheit at breakfast; 166 degrees Fahrenheit at lunch, and 160 degrees Fahrenheit at dinner. The recommended temperature listed on the temperature log sheet was 160 degrees Fahrenheit. A 3rd degree burn can occur within one second at 155 degrees Fahrenheit. The facility failed to identify that the temperatures that were recorded in (MONTH) 2019 were hazardous for the residents; failed to adjust the temperature after resident #1 sustained first and second degree burns; and failed to develop an accurate monitoring system to address the issue of unsafe hot liquid temperatures.

Based on interview, record review, and observation, the facility failed to identify a significant weight loss, and failed to implement interventions to prevent further weight loss for 1 (#10) of 19 sampled and supplement residents. Findings include: Review of resident #10's weight record showed she weighed 180 pounds on 1/1/18, and 168 pounds on 2/5/18. The resident had a six percent significant weight loss in one month. Review of resident #10's monthly summary, dated 1/3/18, showed the resident had lost 6.4 pounds in six months, and 17.8 pounds in the last year. Supercereal was tried in (MONTH) (YEAR) due to weight loss, which (resident) refused to eat. Review of resident #10's medical record showed the weight loss for (MONTH) (YEAR) was documented in the record, but the loss was not identified as a concern to be addressed by other interdisciplinary team members. Review of resident #10's nutrition note, dated 3/5/18, showed Weight loss. Resident showing persistent weight loss. Although not significant in the past six months, she had lost 25 pounds over the past year. She has been sick over the past few months and has not been eating very well. Will see if she will accept supplements or milkshakes. During an interview on 3/8/18 at 1:10 p.m., staff member D stated she would need to review her notes to describe why she did not note resident #10's significant weight loss. During an observation on 3/6/18 at 8:09 a.m., resident #10 received hot cereal and pureed pears for breakfast. The menu for breakfast on 3/6/18 showed fresh fruit, egg, and cinnamon toast. During an observation on 3/6/18 at 11:47 a.m., resident #10 received pureed soup and ice cream. The menu for lunch on 3/6/18 showed turkey, bread dressing and butternut squash. During an observation on 3/7/18 at 8:19 a.m., resident #10 received hot cereal and pureed fruit for breakfast. The breakfast menu showed fresh fruit, egg, sausage, and an English muffin. During an interview on 3/7/18 at 8:19 a.m., staff member J stated resident #10 sometimes received the entree on the menu. She was unable to explain how the decision was made to provide only soup, or the pureed meal, as specified on the menu. During an interview on 3/7/18 at 12:48 p.m., staff member C stated he believed resident #10 only wanted soup, although it was not documented, and she was unable to make her choices known. Review of resident #10's Care Plan, dated 1/16/18, showed the resident was ordered a Regular, pureed diet, and to assess food like/dislikes. The Care Plan did not show the resident's meals should be limited to soup and cereal, or how those food limits were decided by staff. During an interview on 3/8/18 at 10:45 a.m., staff member A stated resident #10's weight loss may not have been identified because there was a period of time when the dietitian was not available.

Based on record review and interview, the facility failed to ensure residents received the necessary services to prevent fecal impaction and failed to follow an established individualized bowel protocol, resulting in constipation and a need for manual disimpaction for 3 (#s 1, 6, and 7) of 10 sampled residents. Findings include: 1. Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the October, 2015 MAR indicated [REDACTED] Review of the October 2015 MAR, reflected the following: 10/14/15 at 12:00 p.m., MOM 30 ml po constipation BM after disimpaction. Ducolax 10 mg supp (sic) stool impaction BM after disimpaction. Review of the MDS, with an ARD of 12/5/14, under H600, reflected constipation was present. Review of the EHR bowel report showed the last bowel movement resident #6 had was on 10/11/15. Review of the nurse charting by staff member B on 10/14/15 at 5:52 p.m. showed, Resident earlier today was disimpacted of round hard stool followed by liquid stool after [MEDICATION NAME] suppository given. MOM was also given. During an interview on 11/17/15 at 4:10 p.m., staff member A stated We do not have a standard bowel protocol, each person has an individualized bowel protocol and it should be in the resident care plan. During an interview on 11/18/15 at 9:50 a.m., staff member C stated, Each resident has an individualized bowel protocol. We meet with the physician to determine the protocol. The protocol is documented in the nurses' notes and the physician should document in the progress notes. If a resident is impacted, we would not get a physician order [REDACTED]. The physicians are very busy and they can look at the notes in computer because they have access. During an interview on 11/18/15 at 11:00 a.m., staff member D stated he would not expect to be notified if a resident needed to be disimpacted as he would not provide a physician order [REDACTED]. Review of the nursing procedures approved on 6/19/15, reflected the Lippincott Nursing Procedures Manual will be used as the procedure guidance in performance of nursing procedures. Review of the Lippincott Nursing Procedures Manual under Fecal Impaction Removal, Digital. Implementation; Verify the doctor's order. 2. Review of resident #1's November MAR indicated [REDACTED] Review of resident #1's bowel records indicated that leading up to the disimpaction, the last previous bowel movement the resident had was on 11/5/15. The November MAR indicated [REDACTED]. Resident #1 was prescribed PRN [MEDICATION NAME] and Milk of Magnesia. Review of the resident's bowel record also showed the resident had no BM from 10/28/15 to 11/3/15, with no interventions, and no documentation of refusing bowel medications until 11/2/15, when the resident was given a dose of PRN Milk of Magnesia. The resident had a BM on 11/3/15. Review of the resident's bowel record between 10/13/15 and 10/21/15 showed no BM. On 10/16/15, the resident refused Senna. A nursing chart note dated 10/16/15, showed the resident was four days without a BM and refused her meds. The resident stated she had a BM by herself and no one saw her. The note reflected the resident is not capable of using the toilet by herself. Two more days passed with no BM and no other interventions and no documentation of refusal of bowel meds. On 10/19/15, resident #1 was given MOM, and on 10/20/15 a small BM was noted. During an interview on 11/17/15 at 4:10 p.m., staff member A stated We do not have a standard bowel protocol, each person has an individualized bowel protocol and it should be in the resident care plan. Review of resident #1's care plan did not indicate any specific bowel protocol, and review of the resident's charting notes did not indicate any nurse charting on the resident's constipation nor the manual disimpaction. In an interview on 11/18/15 at 9:46 a.m., staff member A stated there was no documentation between the nurse and the physician regarding an order for [REDACTED].>3. Review of resident #7's MAR for July, 2015, reflected she was on scheduled doses of [MEDICATION NAME] and Senna, and also prescribed PRN doses of [MEDICATION NAME], and Milk of Magnesia, which was ordered if no BM in three days. Review of resident #7's bowel record for the month of July, 2015 reflected two instances where the resident went 7 days between BMs. The resident went from 7/13/15 - 7/18/15 without having a BM and did not receive the ordered MOM after three days. The resident was given MOM on 7/18/15, 7/19/15, and then on 7/20/15 before having a BM. Review of resident #7's bowel record for July, 2015 reflected a second interruption in a normal time for having a BM. The resident went from 7/23/15 - 7/25/15 with no BM, then was given a PRN dose of MOM on 7/26/15. The resident went two more days without a BM and without any further interventions for lack of a BM, until 7/29/15 when the PRN dose of MOM was given, and then again on 7/30/15, when the resident had a BM. Review of the nursing chart notes for resident #7 on 7/15/15, showed the resident was discussed in a RICC meeting and was noted to be More uncomfortable lately and is participating less in activities. There were no other chart notes regarding documentation of the resident's lack of BM, no documentation the physician was notified of the lack of BMs on these two occasions in July, 2015, and no care plan specific protocol for this resident when the initial dose of PRN MOM did not result in a BM.