Every finding on record at Dunseith Com Nursing Home

Based on observation, record review, review of facility policy, and staff interview, the facility failed to follow professional standards of infection control and prevention for 4 of 7 sampled residents (Resident #4, #5, #6, and #27) observed during cares. Failure to practice infection control standards related to hand hygiene, glove changes, wound care/dressing change, and catheter care has the potential to spread infection throughout the facility.Findings include: Review of the facility policy titled Hand Hygiene occurred on 07/23/26. This policy, dated 12/10/25, stated, All staff will perform hand hygiene procedure to prevent the spread of infection to other personnel, residents, and visitors. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. - Review of Resident #6's medical record occurred on all days of survey. Diagnosis included urinary tract infection. The current care plan stated, . Staff will keep catheter tubing properly positioned . Observations on all days of survey showed Resident #6's urinary catheter tubing dragging on the floor throughout the facility. - Review of Resident #5's medical record occurred on all days of survey. Diagnosis included non-pressure chronic ulcer of the right lower leg. The current care plan stated, . on Enhanced Barrier Precautions [EBP] . Perform wound care per provider orders. Observation on 07/21/26 at 2:18 p.m. showed an EBP sign on the door of Resident #5's room. Two nurses (#4 and #5) performed hand hygiene, applied a gown and gloves and entered the room to provide wound care. The nurse (#5) removed soiled dressings from Resident #5's right lower leg, removed the soiled gloves, performed hand hygiene, and applied clean gloves. Resident #5 removed an electrical plug from the wall, the nurse (#4) removed the electrical cord from the resident's hands and plugged it back into the wall. Without removing the soiled gloves and performing hand hygiene, the nurse (#4) prepared the clean dressings, removed the soiled gloves, performed hand hygiene and applied new gloves. The nurse (#5) removed the remaining soiled dressings, and without removing the soiled gloves and performing hand hygiene, cleansed the wound bed repositioned Resident #5's leg and the Xeroform (petroleum infused gauze) dressing to the calf fell onto the bed and folded. Rather than unfolding the dressing, the nurse reapplied it to the wound bed. - Observation on 07/21/26 at 8:14 a.m. showed Resident #27 in bed and two certified nurse aides (CNAs) (#6 and #7) completed a brief change. The CNA (#7) cleansed bowel movement (BM) using wipes, removed the gloves and applied the resident's brief. Both CNAs placed the Hoyer sling under the resident and used the mechanical lift to transfer Resident #27 into the wheelchair. The CNA (#7) failed to perform hand hygiene after removing soiled gloves. - Observation on 07/22/26 at 10:30 a.m. showed two CNAs (#7 and #8) assisted Resident #4 with toileting cares. The CNA (#8) applied gloves, used wipes to cleanse the resident's perineal area, removed the soiled gloves. As the resident stood with the walker, the CNA (#7) stood next to the resident while the CNA (#8) assisted the resident with the incontinence product and adjusted the resident's pants and shirt. The CNA (#8) failed to perform hand hygiene after removing soiled gloves. During an interview on 07/23/26 at 12:45 p.m. an administrative staff member (#10) stated she expected staff to complete hand hygiene after removing gloves.

Based on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.20.1), and staff interview, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 4 of 13 sampled residents (Residents #2, #4, #5, and #23). Failure to accurately complete the MDS does not allow each resident's assessment to reflect their current status and may affect the accurate development of a comprehensive care plan and the care provided to the residents. Findings include: SECTION A: IDENTIFICATION INFORMATION The Long-Term Care Facility RAI User's Manual, revised October 2025, pages A-30 to A-32, stated, . A1500: Preadmission Screening and Resident Review (PASRR) . Review the PASRR report provided by the State if Level II screening was required. Code 1, yes: if PASRR Level II screening determined that the resident has a serious mental illness . Review of Resident #23's medical record occurred on all days of survey and identified a PASRR Level II completed on 04/29/25. Diagnoses included schizophrenia and bipolar disorder. Review of the annual MDS, dated [DATE], showed the facility failed to code yes on Section A1500. SECTION I: ACTIVE DIAGNOSES The Long-Term Care Facility RAI User's Manual, revised October 2025, pages I-1 to I-12, stated, . Code diseases that have a documented diagnosis in the last 60 days and have a direct relationship to the resident's current functional status, cognitive status, mood or behavior status, medical treatments, nursing monitoring . I6100, post-traumatic stress disorder (PTSD) . Review of Resident #4's medical record occurred on all days of survey. Diagnoses included PTSD. The care plan, dated 04/06/26, stated, Resident is at risk for adverse side effects, mood instability, anxiety, and decreased quality of life related to . PTSD, cognitive impairment, and complex medical conditions evidenced by psychotropic medication management. Review of the quarterly MDS, dated [DATE], showed the facility failed to code I6100, PTSD. SECTION N: MEDICATIONS The Long-Term Care Facility RAI User's Manual, revised October 2025, pages N-4 to N-9, stated, . N0415: HIGH-RISK DRUG CLASSES: Uses and Indication . Code all high-risk drug class medications . Column 1: Check if the resident is taking any medications by pharmacological classification during the 7-day observation period . Code all high-risk drug class medications according to their pharmacological classification, not how they are being used. N0415I2. Antiplatelet: Check if there is an indication noted for all antiplatelet medications taken by the resident any time during the observation . N0415H1. Opioid: Check if an opioid medication was taken by the resident at any time during the 7-day look-back period . - Review of Resident #2's medical record occurred on all days of survey. A physician's order, dated 11/21/24, included aspirin, an antiplatelet medication. Review of the quarterly MDS, dated [DATE], showed the facility failed to code antiplatelet use. - Review of Resident #4's medical record occurred on all days of survey. The quarterly MDS, dated [DATE], showed the facility coded for opioid use. The medical record lacked a physician's order for an opioid medication. - Review of Resident #5's medical record occurred on all days of survey. The physician's orders included trazodone, an antidepressant medication, aspirin, and Lantus (insulin), a hypoglycemic medication. Review of the quarterly MDS, dated [DATE], showed the facility failed to code the use of an antiplatelet, antidepressant and hypoglycemic. During an interview on 07/23/26 at 11:09 a.m., an administrative nurse (#3) confirmed staff failed to code Resident #2, #4, #5, and 23's MDSs correctly.

Based on observation, record review, and staff interview, the facility failed to provide care in a manner that maintained, enhanced, and respected the resident's right to dignity and privacy for 1 of 6 sampled residents (Resident #14) observed during personal hygiene cares and 1 of 1 sampled resident (Resident #1) observed with confidential information posted on the resident's door. Failure to close the resident's blinds during personal hygiene cares and posting of confidential resident information does not preserve the resident's right to dignity, privacy and does not enhance the quality of life.Findings include: Review of the facility policy titled Personal Privacy and Confidentiality occurred on 07/23/26. This policy, dated February 2026, stated, . protect and promote each resident's right to personal privacy . Residents will be treated with dignity and respect while ensuring the confidentiality of personal, medical . information. Personal Privacy Respect for resident's physical body . The facility shall protect each resident's privacy during: a. personal care . d. toileting .-Review of Resident #14's medical records occurred on all days of survey. The current plan stated, . Urinary Incontinence . Observation on 07/20/26 at 4:16 p.m. showed two certified nurse aides (CNAs) (#7 and #9) transferred Resident #14 to the bed to check and change the brief. Without closing the window blinds, the CNAs pulled down the resident's pants, checked the resident's brief, determined no brief change needed, pulled up the resident's pants, and transferred Resident #14 back to the wheelchair. -Review of Resident #1's medical record occurred on all days of survey. A quarterly Minimum Data Set (MDS) dated [DATE] stated, . Highly impaired-absence of useful hearing . No speech-absence of spoken words . Observations on 07/20/26 - 07/22/26 showed a sign printed in bold red and black ink on Resident #1's outside door facing the hallway, which stated, Hearing and Speech Impaired.During an interview on 07/21/26 at 2:30 p.m., when asked (in written form) if he was ok with the sign on the door, Resident #1 indicated no by making horizontal hand gestures. When asked if this sign upset him, the resident indicated yes with a thumbs up gesture. During an interview on the afternoon 07/23/26, an administrative nurse (#1) confirmed she expected staff to close the resident's blinds during cares and agreed the sign violated Resident #1's privacy.

Based on record review and staff interview, the facility failed to develop a comprehensive care plan for 1 of 2 sampled resident (Resident #7) reviewed for post-traumatic stress disorder (PTSD). Failure to develop a comprehensive care plan limits staffs' ability to communicate, ensure the continuity of care, and avoid triggers that may result in re-traumatization.The facility failed to provide a policy related to PTSD.Review of Resident #7's medical record occurred on all days of survey. Diagnoses included post-traumatic stress disorder. The medical record failed to include an assessment addressing the history and triggers for PTSD.The current care plan failed to identify PTSD, known triggers, or personalized interventions to prevent re-traumatization. During an interview on 07/22/26 at 2:35 p.m., two administrative staff members (#1 and #3) stated, we knew she was coming in with a diagnosis of PTSD.

Based on record review, review of facility policy, and resident and staff interviews, the facility failed to revise the comprehensive person-centered care plan to reflect the resident's smoking status and related interventions for 1 of 2 residents (Resident #30) reviewed for smoking. Failure to address the resident's smoking status in the care plan may result in inconsistent care and compromised smoking safety. Findings include: Review of facility policy titled Smoke Free Facility Policy occurred on 07/23/26. This policy, dated 04/06/23, stated, . applies to all residents . both smokers and non-smokers. Smoking is prohibited in all areas of the facility. Residents with a history of smoking will be further assessed . If a resident does not abide by the smoking policy, care plan revisions shall be documented and implemented to promote safety. Review of Resident #30's medical record occurred on all days of survey. Review of Resident #30's smoking status identified light tobacco smoker. Review of the quarterly Minimum Data Set (MDS), dated [DATE], identified the resident as cognitively intact. The care plan failed to address Resident #30's smoking habits. A progress note, dated 11/29/25 at 11:44 a.m., stated, . observed resident outside smoking a cigarette. During an interview on 07/22/26 at 10:07 a.m., Resident #30 confirmed she smokes and stores the cigarettes and lighter in her purse. The resident stated, I smoke on the patio area outside in front of the building and only go to the sidewalk if another resident comes and asks me for a smoke. During an interview on the morning of 07/22/26, an administrative staff member (#1) confirmed Resident #30's smokes and her care plan failed to include smoking.

Based on observation, record review, review of facility policy, and resident and staff interview, the facility failed to ensure residents remain free from accident/hazards for 2 of 2 sampled residents (Resident #23, and #30) reviewed for smoking. Failure to safeguard fire starting devices from resident access placed all residents, staff, and visitors at risk for injury or fires. Findings include: Review of the facility policy titled Smoke Free Facility Policy occurred on 07/23/26. This policy, dated 04/06/23, stated, . applies to all residents . both smokers and non-smokers. Smoking is prohibited in all areas of the facility. to promote safety. - Review of Resident #23's medical record occurred on all days of survey. The care plan stated, . Resident exhibits nicotine dependence as evidence by choosing to smoke against facility policy. The record lacked a smoking assessment to identify safety issues/concerns related to Resident #23's smoking habit. Observations on all days of survey showed Resident #23 seated on a bench located outside on facility grounds multiple times each day smoking cigarettes. During an interview on 07/21/26 at 8:35 a.m., Resident #23 reported he smokes every few hours and keeps his cigarette lighter in his possession. During an interview on 07/22/26 at 3:00 p.m., two administrative staff members (#1 and #3) confirmed Resident #23 keeps his cigarette lighter in his possession. - Review of Resident #30's medical record occurred on all days of survey and identified the resident as light tobacco smoker. A behavior and mood event assessment, dated 07/17/26, stated, . observed smoking outside . offered . nicotine patch, resident refused. Review of the quarterly Minimum Data Set (MDS), dated [DATE], identified the resident as cognitively intact. Review of Resident #30's progress note, dated 11/29/25 at 11:44 a.m., stated, . observed resident outside smoking a cigarette. During an interview on 07/22/26 at 10:07 a.m., Resident #30 confirmed she smokes and stores the cigarettes and lighter in her purse. The resident stated, I smoke on the patio area outside in front of the building . During an interview on the morning of 07/22/26, an administrative staff member (#1) stated staff were unaware Resident #30 had a cigarette lighter in her possession. 2. Based on observation, record review, review of professional reference and staff interviews, the facility failed to ensure a safe environment for 1 of 1 sampled resident (Resident #5) observed during wound cares. Failure to ensure the safety of residents with access to electrical equipment places all residents at risk for adverse events and/or serious injury. Findings include: Kozier & Erb's Fundamentals of Nursing: Concepts, Process, and Practice, 11th ed., Pearson Education Inc., New Jersey, chapter 29, stated, . Alterations in mobility . place clients at risk for injury . Remove unsafe objects . Review of Resident #5's medical record occurred on all days of survey. Diagnoses included dementia with agitation, delirium, and unspecified psychosis. The current care plan stated, . Resident exhibits altered mood and emotional dysregulation related to dementia with agitation, psychosis, delirium . as evidenced by agitation . impaired reality perception. Observation on 07/21/26 at 2:23 p.m. two nurses (#4 and #5) entered Resident #5's room to provide wound care treatment. Resident #5 unplugged the bed's electrical cord from the wall outlet, handled the plug, and attempted to reinsert it into the outlet while his fingers were in contact with the metal prong. The surveyor asked the nurse (#4) whether the resident should be attempting to plug the bed back into the outlet. The nurse (#4) responded, no, he shouldn't, immediately removed the electrical cord from the resident's hands, and plugged the bed's cord into the wall outlet. Observation on 07/21/26 at 3:27 p.m. showed Resident #5 reached out and touched the wall outlet next to the head of the bed. During an interview on 07/21/26 at 5:15 p.m., an administrative nurse (#1) confirmed the resident should not have access to the electrical outlet. Observation on 07/22/26 at 8:00 a.m. showed outlet covers placed in the electrical outlet by the head of Resident #5's bed.

Based on record review, review of facility policy, and staff interview, the facility failed to ensure residents remained free from abuse for 4 of 6 sampled residents (Resident #1, #5, #16, #30) reviewed for resident-to-resident altercations. Failure to protect residents from verbal and/or physical abuse placed all resident at risk for physical harm, pain, mental anguish, and emotional distress. Findings include: Review of the facility's policy titled Abuse, Neglect and Exploitation occurred on 07/23/26. This policy, dated December 2025, stated, . Provide protection for the health, and welfare and rights of each resident by . implementing . policy and procedures that prohibit and prevent abuse . 'Abuse' willful infliction of injury . intimidation . resulting in physical harm, pain or mental anguish . which can include . resident to resident altercations. 'Physical Abuse' includes, but not limited to hitting, slapping, punching, biting, and kicking. 'Verbal Abuse' means the use of oral . communication or sounds that willfully include disparaging and derogatory terms to resident . within their hearing distance . Identification of Abuse, Neglect . Physical marks such as . patterned appearances . Verbal abuse of resident overheard . -Review of Resident #5's medical record occurred on all days of survey. Diagnoses included dementia with agitation, unspecified psychosis and delirium. The quarterly Minimum Data Set (MDS), dated [DATE], identified impaired cognition. The current care plan stated, . Resident is at risk for trauma-related behaviors due to history of resident altercation . Staff will provide a safe area . redirect resident away from triggering situations . provide a structured, low-stimulation environment to reduce confusion and agitation. A nurse's note, dated 04/18/26 at 4:35 p.m., stated, Resident was sitting at CNA station when they heard two other residents talking. This resident [Resident #5] then started to curse out in response to what they were saying. The other resident [Resident #30] came up to this resident and started cursing out at this resident. Both then started to swing out at each other. Then, other resident swung out and struck them on the left hand. This resident then put their hands up in response to being struck. The other resident then stated that this resident hit them when staff did not see this. The other resident then continued to curse out at staff until staff asked them to go to their room. The other resident left the CNA station. This resident was assessed for injuries and observed redness to left hand, first two knuckles with first knuckle observed to be swollen. -Review of Resident #30's medical record occurred on all days of survey. Diagnoses included altered mental status and major depressive disorder. The quarterly MDS, dated [DATE], identified intact cognition. The current care plan stated, . at risk for mood disturbances related to cognitive impairment, history of cerebrovascular disease (CVD), and altered coping abilities. approach resident in a calm . non-confrontational manner. exhibits impaired social interactions related to cognitive impairment as evidenced by inappropriate comments, irritability and history of altered mental status. redirect residents when inappropriate verbal comments occur, avoiding confrontation or argument. -Review of Resident #16's medical record occurred on all days of survey. Diagnoses included dementia with agitation, Alzheimer's disease, violent behavior with uncontrolled agitation and aggression, altered mental status, and anxiety disorder. The current care plan stated, . Resident exhibits impaired mood state related to cognitive impairment and anxiety as evidenced by emotional instability . Separate the resident from vulnerable residents during peak agitation periods and periods of distress .Resident #16's progress notes identified the following:*06/03/26 at 9:30 p.m., Client [Resident #16] was sitting by nurse's station trying to get up. Med [medication] nurse assisted client back into his wheelchair. Client attempted to hit nurse; swing out at staff. Another resident [Resident #1] attempted to get client to sit down and [Resident #16] hit other resident on the arm. Staff immediately intervened.*06/03/26 at 9:35 p.m., Notified [provider] client hit another resident. New orders to administer Haldol [antipsychotic medication] . now and if continues to be aggressive.-Review of Resident #1's medical record occurred on 07/23/26. A quarterly MDS, dated [DATE], identified intact cognition.Resident #1's progress notes identified the following:*06/03/26 at 9:30 p.m., CNA notified this writer that [Resident #1] has been hit by another resident. [Resident #1] was attempting to get the other resident to sit down in his wheelchair as he was trying to stand up. [Resident #1] reached towards [Resident #16] and [Resident #16] struck [Resident #1] on the right arm. During an interview on 07/23/26 at 1:00 p.m., an administrative nurse (#1) confirmed all residents have the right to a safe living space.

Based on observation, record review, review of professional reference, and staff interview, the facility failed to ensure a medication error rate of less than five percent for 2 of 7 residents (Resident #14 and #22) observed during medication administration. Five medication errors occurred during staff administration of 26 medications, resulting in a 19% error rate. Failure to properly prepare and administer medications may result in residents receiving an ineffective dose and experiencing adverse reactions.Findings include:The facility failed to provide a policy on medication administration, crushing medications, and obtaining/clarifying physician orders. Review of Mayo Clinic at https://www.mayoclinic.org/drugs-supplements/meloxicam-oral-route/description/drg-20066928, dated July 01, 2026, titled Meloxicam (oral route) stated, . Proper Use . Swallow the . tablet whole. Do not crush, break, or chew it.Observation on 07/22/26 at 8:01 a.m. showed a medication aide (MA) (#11) placed a crushed Tylenol and the contacts of a Gabapentin capsule in pudding and administered to Resident #14. The medical record lacked a physician's order to crush medication.Observation on 07/22/26 at 12:23 p.m. showed a MA (#11) placed crushed Tylenol, Meloxicam and Sertraline in pudding and administered to Resident #22. The medical record lacked a physician's order to crush medications.

Based on record review, review of facility reported incident s(FRI), review of facility policy, and staff interviews, the facility failed to ensure residents remained free from abuse for 2 of 2 sampled residents (Resident #1 and #6) intimidated and yelled at by staff members (Resident #6) and verbal outbursts/physical behaviors towards other residents (Resident #1). Failure to protect residents from abuse resulted in physical, verbal, and mental abuse, pain and has to potential to affect all residents. Findings include: Review of the facility's policy titled Abuse, Neglect, and Exploitation occurred on 12/22/25. This policy, revised 07/01/24, stated, . Abuse . the willful infliction of injury . intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and . resident to resident altercations. 'Mental Abuse' includes, but is not limited to . humiliation, harassment, threats of punishment or deprivation. 'Physical Abuse' includes, but is not limited to hitting, slapping, punching . 'Verbal Abuse' means the use of oral . or gestured that willfully includes disparaging and derogatory terms to residents . regardless of their age, ability to comprehend, or disability. - Review of Resident #6's medical record occurred on all days of survey. Diagnoses included anxiety, conduct disorder, and depression. Medications included Sertraline daily for depression. The quarterly Minimum Data Set (MDS), dated [DATE], identified moderate cognitive impairments and delusions. The current care plan stated, . Provide quiet, non-hurried environment, free of background noises and distractions. Staff will . redirect resident for any disruptive behaviors. Resident needs extensive assistance for toileting, R/T [related to] frequent episodes of incontinence. Resident is at risk for falls related to poor safety skills and with the use of a standard walker. Staff to assist resident with all cares . Assist x [times] 1 with personal hygiene, toileting, and dressing . transfer with assist of 2 with gait belt and FWW [front wheeled walker] . The initial FRI report, dated 12/10/25 at 5:43 p.m., stated, . Several CNAs [certified nurse aides] were involved in an incident with resident [Resident #6] during attempts to get her up for supper. Staff consistently reported that [Resident #6's] bed was wet, she was distressed, yelling, and at times refusing to get up or cooperate. Multiple CNAs . were in and out of the room. During attempts to move [Resident #6], she ended up naked on the bathroom floor. Conflicting accounts were given about how she got to the floor, though several reported she refused to stand or get herself up. A gait belt was applied directly to her bare skin, and staff lift [sic] her with it at least once. Several CNAs . were reported to have hollered at [Resident #6], pointing in her face, and insisted that she apologize, [another CNA] entered later, found [Resident #6] crying on the floor, and noted scratches on [Resident #6's] left arm. No staff could provide a clear explanation for the scratches. [The last CNA to enter the room] refused to leave [Resident #6] on the floor and ultimately calmed, cleaned, dressed, and brought her to supper. Charge Nurse . reported she was only told that [Resident #6] had a behavior and that the gait belt was used. She was not informed about [sic] yelling, the resident being on the floor naked, the number of staff involved, or any injuries. Overall, staff consistently note yelling towards the resident, difficulty during transfer, [Resident #6's] distress and that the full details were not reported to the charge nurse at the time. The final FRI investigation, received from the facility on 12/12/25, stated CNA (#5 and #6) removed and suspended. A Behavior/Mood Event report, dated 12/04/25 5:28 p.m., stated, . resident was yelling and refusing to get up and changed before supper. Three aides were needed in order to get her to cooperate. Gait belt was needed in order to get her toileted . Client did apologize to staff after . No further concerns at this time. [No] injuries noted. During an interview on 12/21/25 at 2:10 p.m., when asked about the incident on 12/04/25, a CNA (#3) reported hearing Resident #6 screaming from across the hall. When she entered Resident #6's room, she saw her naked on the bathroom floor. She indicated Resident #6 was crying and looked scared, while CNA (#6) was in her face, screaming 'Get up. Get up and apologize. Apologize right now.' The CNA (#3) also reported seeing three large, fresh scratches on the resident's upper arm and noticed CNA (#6) was not wearing gloves and had really long nails. Two of the CNAs (#5 and #6) denied scratching her, blaming the injury on her gait belt. The CNA (#6) told the others to Leave her. She can get up on her own. We need to feed the others. The CNA (#3) stayed with the resident, helped her get dressed, and assisted her to the dining room. During this time, Resident #6 alleged CNA (#5) threatened to withhold her snack, because she wasn't listening to them. The CNA (#3) admitted she reported her observations/concerns to the Director of Nursing a few days after the incident. During an interview on 12/22/25 at 10:47 a.m., when asked about the incident on 12/04/25, a CNA (#4) described Resident #6's clothing and bedding as soiled with urine and indicated the resident was able to walk pretty good with a walker. The CNA (#4) revealed she and another CNA (#5) assisted Resident #6 into the bathroom without utilizing a gait belt, assisted her to sit on the toilet, and removed her soiled clothing. The CNA (#4) stated, When we tried to put on her new clothes, she was uncooperative. I was trying to get her to stand up, so I offered her peanuts. The CNA (#5) told the resident she couldn't have any peanuts, cereal, or pop, because she wasn't cooperating. She then told CNA (#4) to find CNA (#6) to assist them. The CNA (#4) reported Resident #6 continued to resist cares and began screaming. She described CNA (#6) as pretty frustrated and talking loudly, loud enough for CNA (#3) to hear the commotion in the hall and enter the room. The CNA (#4) was unable to explain how the resident ended up on the floor. Then CNA (#3) pointed out fresh scratches on Resident #6's arm. The CNA (#4) confirmed, They weren't there before. She indicated the CNA (#6) wasn't wearing any gloves and had acrylic nails. The CNA (#4) stated, I've never seen [Resident #6] like that before. During an interview on 12/22/25 at 4:10 p.m., when asked about the incident on 12/04/25, an administrative nurse (#1) stated staff told her the resident sat herself on the floor. The administrative nurse (#1) did not observe the scratches to Resident #6's arm as staff failed to report the incident in a timely manner. The administrative nurse (#1) stated it is not acceptable for staff to holler at or threaten a resident or get in a resident's personal space or place a gait belt around bare skin. The administrative nurse (#1) expected staff to redirect residents who have behaviors, allow them a few minutes to calm down and reapproach, and/or have another staff member work the resident. The facility failed to protect Resident #6 from mental, verbal, and physical abuse and failed to report the abuse in a timely manner. - Review of Resident #1's medical record occurred on all days of survey. Diagnoses included dementia with agitation. The admission Minimum Data Set (MDS), dated [DATE], identified behaviors directed towards others that significantly disrupts care or living environment. The current care plan stated, . [Resident #1] at risk for agitation related to dementia . Staff will redirect resident when he becomes agitated.The FRI, dated 12/11/25, stated, . DON [director of nursing] heard hollering, she went to hallway to find [Resident #1] and [Resident #2] close to each other with their wheelchairs. Both residents were moving arms to get away from each other. [Resident #1] had [Resident #2]'s right arm and was holding it. DON and CNA [certified nurse aide] were able to separate residents, and [Resident #1] let [Resident #2] arm released [sic]. During the separation, [Resident #1] hit [Resident #2] on the right side of his face with his right fist closed. DON and CNA immediately separated residents. Vital signs take [sic] on both residents. Not sure how it initially started.The FRI, dated 12/22/25, stated, . Resident [#1] was involved in resident-to-resident altercation. Resident [#1] was sitting in the activity room with a few other residents watching television and socializing. During this time, nurse was alerted by loud shouting in the activity room among the residents. CNA and nurse went to assess concerns, staff was [sic] informed by residents present in the activity room [Resident #3] was hit in her mouth by resident's [Resident #1] closed fist. [Resident #3] confirms this occurred. She reports her mouth is sore. Vital signs taken, skin and mouth assessed, there is no indication of broken skin or bruise at this time.During an interview on 12/22/25 at 1:30 p.m., administrative staff members (#1 and #2) reported [Residents #1, #2 and #3] did not have any injuries following the incidents, care plans for all resident's involved were reviewed and updated, [Resident #1] is closely monitored by all staff, and staff education was completed. The facility failed to protect Resident #2 and #3 from verbal and physical abuse.

Based on record review, review of the facility reported incident (FRI), and staff interview, the facility failed to report an incident of abuse to the administrator and the State Survey Agency (SSA) within the required time frames for 1 of 1 sampled resident (Resident #6) who experienced mental, verbal, and physical abuse from staff. Failure to ensure incidents of abuse are reported immediately, but not later than 2 hours after the allegation is made, may result in continued abuse, fear, anxiety, and psychosocial harm. Findings include:Review of Resident #6's medical record occurred on all days of survey. Diagnoses included anxiety and conduct disorder. The Minimum Data Set (MDS), dated [DATE], identified moderate cognitive impairments and delusions. A Behavior/Mood Event report, dated 12/04/25 at 5:28 pm., stated, . resident was yelling and refusing to get up and changed before supper. Three aides were needed in order to get her to cooperate. Gait belt was needed in order to get her toileted .Review of the initial FRI, received by the SSA on 12/10/25, stated the following, Date of allegation: 12/04/2025 . Several CNAs [certified nurse aides] were involved in an incident with resident [Resident #6] during attempts to get her up for supper. Staff consistently reported that [Resident #6's] bed was wet, she was distressed, yelling, and at times refusing to get up or cooperate. Multiple CNAs [names of CNAs] were in and out of the room. During attempts to move [Resident #6], she ended up naked on the bathroom floor. Conflicting accounts were given about how she got to the floor, though several reported she refused to stand or get herself up. A gait belt was applied directly to her bare skin, and staff lifted her with it at least once. Several CNAs mainly [two CNA's names] reported to have hollered at [Resident #6], pointing in her face, and insisted that she apologize. [CNA name] entered later, found [Resident #6] crying on the floor, and noted scratches on [Resident #6's] left arm. No staff could provide a clear explanation for the scratches. [CNA name] refused to leave [Resident #6] on the floor and ultimately calmed, cleaned, dressed, and brought her to supper. Charge Nurse [name] reported she was only told that [Resident #6] had a behavior and that a gait belt was used. She was not informed about yelling, the resident being on the floor naked, the number of staff involved, or any injuries. Overall, staff consistently note yelling toward the resident, difficulty during the transfer, [Resident #6's] distress, and that the full details were not reported to the charge nurse at the time. During an interview on 12/22/25 at 4:10 p.m. an administrative nurse (#1) stated facility staff failed to report the incident in a timely manner and it not acceptable for staff to holler at or threaten residents.

Based on record review and staff interview, the facility failed to review and revise care plans to reflect the resident's current status for 1 of 7 sampled residents (Resident #1). Failure to update/revise care plans limited the staff's ability to communicate residents needs and ensure continuity of care.Findings Include:- Review of Resident #1's medical record occurred on all days of survey. Diagnoses included chronic pain and dementia with agitation. The admission Minimum Data Set (MDS), dated [DATE], identified behaviors directed towards others that significantly disrupt care or living environment.Review of Resident #1's progress notes from 10/09/25 to 12/21/25 identified the following:* 21 occasions of pain and/or requested pain medication. * Two occasions of verbal and/or physical aggression with other residents. * 23 occasions of verbal and/or physical aggression with staff. Resident #1's current care plan lacked problems, goals, and interventions addressing pain and verbal/physical aggression towards others. During an interview on 12/22/25 at 1:30 p.m., two administrative staff members (#1 and #2) confirmed Resident #1's care plan required updates/revisions.

Based on observation, review of dishwasher temperature log, review of professional reference, and staff interview, the facility failed to ensure the high temperature dishwasher provided adequate heat sanitization for dishes and utensils washed in 1 of 1 kitchen (main kitchen). Failure to monitor the dish temperatures during the high temperature dishwash cycle may result in inadequate sanitation of dishware and foodborne illness. Findings include: The Food and Drug Administration (FDA) Food Code 2022, Annex 3 Public Health Reasons/Administrative Guidelines, page 169 states, 4-302.13 Temperature Measuring Devices . Water temperature is critical to sanitization in warewashing operations. This is particularly true if the sanitizer being used is hot water. mechanical hot water sanitization occurs when the surface temperatures of utensils passing through the warewashing machine meet or exceed the required . (160°F) [degress Fahrenheit]. Although the Food Code requires integral temperature measuring devices and a pressure gauge for hot water mechanical warewashers, the measurements displayed by these devices may not always be sufficient to determine that the surface temperatures of utensils are reaching 71°C [celsius] (160°F). The regular use of irreversible registering temperature indicators provides a simple method to verify that the hot water mechanical sanitizing operation is effective in achieving a utensil surface temperature of . (160ºF) . Observation in the main kitchen on 05/27/25 at 1:20 p.m. showed a high temperature dishwasher in use. Review of the May 2025 dishwasher temperature log showed dietary staff documented the morning and evening temperature readings of the external temperature gauge/dial for the dishwasher. When asked, dietary staff member (#5) placed the surveyor's dish thermometer in with the tray of plates to be washed. It took up to five wash/rinse cycles before the dish thermometer registered 160 degrees Fahrenheit (F) and above. The dietary manager (#1) reported the dietary staff do not check dishwash temperatures at the plate level during a wash/rinse cycle. When asked about the availability of a thermometer, the dietary manager retrieved the dish plate thermometer and stated it was not functioning and needed the battery replaced. The facility failed to have a process or a functioning dish thermometer to monitor adequate heat sanitization of dishware.

Based on staff interview, the facility failed to ensure 1 of 1 dietary manager (#1) obtained the proper qualifications to serve as the director of food and nutrition services. Failure to ensure the facility had a qualified dietary management to carry out the functions of food and nutrition services may result in foodborne illness to residents, staff, and visitors. Findings include: During an interview on the afternoon of 05/27/25, the dietary manager (#1) stated she had not completed the certified dietary manager course and received an extension to complete the course. The facility failed to ensure the dietary manager (#1) completed the required education for a certified dietary manager, certified food service manager, or a national certification for food service management and safety from a national certifying body.

Based on review of the facility's Quality Assurance Performance Improvement (QAPI) program committee minutes, review of facility policy, and staff interview, the facility failed to ensure the QAA (Quality Assessment and Assurance) Committee, and all the required members met at least quarterly for 2 of 5 quarters (June 2024 and September 2024) reviewed. Failure to meet quarterly and have the medical director participate in the facility's quality assurance activities may result in an ineffective QAPI program and deprives the committee of the physician's unique contributions for analysis of quality concerns and assisting with decision making based on identified concerns. Findings include: Review of the facility policy titled Quality Assurance and Performance Improvement (QAPI) occurred on 05/29/25. This policy, dated December 2024, stated, . The QAA Committee shall be interdisciplinary and shall . a. Consist at a minimum of: The Director of Nursing Services; The Medical Director or his/her designee . b. Meet at least quarterly and as needed to coordinate and evaluate activities under the QAPI program. Review of the QAA Committee meeting minutes from March 2024 to March 2025 showed the committee failed to meet in June and September of 2024. The medical director failed to attend any of the meetings. During an interview on 05/29/25 at 12:10 p.m., an administrative staff member (#7) confirmed the QAA committee had not met on a quarterly basis and failed to ensure the required quarterly attendance of the medical director.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to ensure staff followed professional standards of practice for 4 of 4 supplemental residents (Resident #8, #9, #10, and #17) observed during insulin preparation and 1 of 1 supplemental resident (Resident #10) reviewed for insulin use. Failure to properly prime an insulin pen and follow physician's orders regarding out-of-range blood sugar levels, may result in residents receiving an inaccurate dose of insulin and/or possible adverse events. Findings include: Review of the facility policy titled Insulin Pen occurred on 05/28/25. This policy, dated 07/14/23, stated, . screw the pen needle onto the insulin pen. Twist open and remove outer cover from the pen needle. With the needle pointing up, push the plunger, and watch to see that at least a drop of insulin appears on the tip of the needle. - Observation on 05/27/25 at 11:50 a.m. showed nurse (#3) primed Resident #9's insulin pen with the needle cap on. - Observation on 05/28/25 at 7:25 a.m. showed a nurse (#4) primed Resident #17's insulin pen holding the pen downward. - Observation on 05/28/25 at 7:38 a.m. showed a nurse (#4) primed Resident #8's insulin pen holding the pen downward. - Observation on 05/28/25 at 7:48 a.m. showed a nurse (#4) primed Resident #10's insulin pen holding the pen downward. During an interview on 05/28/25 at 2:08 p.m., an administrative nurse (#2) stated she expected staff to prime an insulin pen with the needle cap off and the needle pointing up. Review of the facility policy titled Blood Glucose Monitoring occurred on 05/29/25. This policy, dated 09/22/23, stated, . Report critical/out of range results to physician. Review of Resident #10's medical record occurred on 05/29/25. Diagnoses included Type 2 diabetes mellitus. A physician's order stated, Fiasp U-100 Insulin [long acting insulin] per Sliding Scale; If Blood Sugar is less than 100 milligrams per deciliter [mg/dl], call MD [physician]. If Blood Sugar is greater than 450 mg/dl, call MD. Review of the resident's blood sugar levels from March 1 through May 28, 2025 identified the following: * 03/05/2025 at 6:30 a.m.: 73mg/dL * 03/11/2025 07:20 a.m.: 72mg/dL. * 05/07/2025 11:57 a.m.: 492 mg/dL Resident #10's medical record lacked documentation staff notified the physician regarding out-of-range blood sugars. During an interview on 05/09/25 at 12:52 p.m., an administrative nurse (#2) confirmed staff failed to notify the physician regarding the out-of-range blood sugars.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to follow standards of infection control and prevention for 1 of 1 sampled resident (Resident #1) observed during wound care. Failure to practice infection control standards related to dressing changes has the potential to spread infection throughout the facility. Findings include: Review of the facility policy titled Clean Dressing Change occurred on 05/29/25. This policy, dated November 2024, stated, . Set up clean field on the overbed table with needed supplies for wound cleansing and dressing application: If the table is soiled, wipe clean. Place a disposable cloth or linen saver on the overbed table. Wash hands and put on clean gloves. Loosen the tape and remove the existing dressing . Discard into appropriate receptacle. Remove gloves . Wash hands and put on clean gloves. Cleanse the wound as ordered . pat dry with gauze. remove gloves and wash hands . put on clean gloves. Secure dressing. Discard disposable items and gloves into appropriate trash receptacle and wash hands. Findings include: Review of Resident #1's medical record occurred on all days of survey. A physician's order stated, Mepilex Transfer [a type of wound dressing] over open wound areas, apply ABD [dressing for wound drainage], and tape. Change daily and as needed. The current care plan stated, . Resident has impaired skin integrity r/t [related to] chronic posterior [back of] left thigh and bilateral [both] buttocks . Dressing changes as ordered by MD . Observation on 05/28/25 at 10:20 a.m. showed a nurse (#8) performed hand hygiene, applied a gown and gloves, and placed supplies for Resident #1's dressing change on the bedside table without sanitizing the table and placing a barrier between the suppleis and table. The nurse (#8) removed the soiled dressings, cleansed the wounds, and applied clean dressings without changing gloves or performing hand hygiene between steps. The nurse (#8) removed her gown and gloves, performed hand hygiene, and exited the room. During an interview on 05/29/25 at 10:20 a.m., an administrative nurse (#2) confirmed staff failed to follow infection control practices when completing Resident #1's dressing change.

Based on review of facility policy and family and staff interviews, the facility failed to provide the resident's representative a copy of quarterly financial statements for 1 of 1 sampled resident (Resident #19) reviewed for personal fund accounts. Failure to provide quarterly statements to the individual designated by the resident to make financial decisions on their behalf prevented the representative from verifying transactions and fund balances. Findings include: Review of facility policy titled Resident Personal Funds occurred on 05/29/25. This policy, dated May 2024, stated, . The individual financial record must be available to the resident through quarterly statements . During an interview on 05/27/25 at 6:00 p.m., Resident #19's financial power of attorney (POA) stated she had not received any quarterly financial statements. During an interview on 05/29/25 at 8:50 a.m., a business office staff member (#6) confirmed staff failed to send quarterly statements to Resident #19's financial POA.

Based on observation, record review, review of resident council minutes, resident interview, and staff interview, the facility failed to provide appropriate dementia care and services for 1 of 1 sampled resident (Resident #23) with wandering behaviors and a history of inappropriate sexual behaviors. Failure to adequately assess for necessary care and services and implement effective behavior management interventions resulted in a decreased level of psychosocial well-being for Resident #23 and had a negative impact on other residents. Findings include: Review of Resident #23's medical record occurred on all days of survey. Diagnoses included dementia, agitation, and insomnia. A provider visit note, dated 02/29/24, stated, . Advanced dementia with history of behavioral issues including aggressive behaviors with other residents and sexually inappropriate behaviors. Resident #23's current medication orders included: * Seroquel (an antipsychotic) 100 milligrams (mg) at bedtime, start date 08/07/23. * Seroquel 50 mg once a day at 3:00 p.m., start date 10/26/23. * Trazodone (an antidepressant) 50 mg at bedtime, start date 11/30/23. * Melatonin (treats insomnia) 5 mg at bedtime, start date 08/02/23. Resident #23's current care plan included the following: Problem start date 08/09/23 . Behavioral Symptoms: Resident is at risk for elopement related to Hx [history] of elopement and diagnosis of Dementia as evidenced by exit-seeking behavior. Problem start date 12/03/23. Resident is at risk for harming others R/T [related to] diagnosis of severe dementia with agitation as evidenced by having a few incidents of hitting staff members and verbally threatening them. Problem start date 08/09/23 . Cognitive Loss / Dementia: Resident's cognition is impaired related to diagnosis of Dementia as evidenced by limited ability to make decisions and short/long-term memory deficits. Review of Resident #23's nursing progress notes showed the following: * 08/06/23 at 2:15 a.m., resident took apart call light and walked into another residents room and continued to argue with the other resident. resident than [sic] told staff [sic] quit touching him or he was going to poke out an eye. * 08/07/23 at 5:52 a.m., resident turned off bed alarm and went into another resident room. other resident reported that he was tickling his feet and then proceeded to sit in the other residents recliner. other resident yelled for nurse. went got [sic] the wheelchair and resident hit writer and kicked at writer. writer went got [sic] other staff to see if he would cooperate with them. resident hit and kicked at staff. other resident stated get him of my room. * 08/13/23 at 7:37 p.m., . Resident has been wondering [sic] into other resident rooms. * 08/17/23 at 9:25 p.m., Resident was beginning to wander into other resident's rooms and was trying to disrobe in front of other residents and staff. resident also argued with staff as they were redirecting them out of other resident's rooms and was telling staff they were 'out of their damn minds.' . * 08/30/23 at 8:45 p.m., Behavior: Staff notified Nurse that resident had wandered into room [ROOM NUMBER] and used the toilet while resident in this room was present and was watching them. Staff then redirected resident out of [sic] room as staff was [sic] going to perform HS [bedtime] cares on resident in room [ROOM NUMBER]. After a few minutes, resident then wandered into [sic] room and attempted to watch staff perform cares on resident in room [ROOM NUMBER]. Staff then asked resident repeatedly to leave the room. Resident became upset with staff and stated they 'just wanted to watch.' Staff asked resident to leave again, and resident did finally leave room. * 10/18/23 at 9:04 a.m., Last evening, Resident had become combative with staff and had grabbed the breast of a staff member. * 12/07/23 at 7:48 a.m., Resident up all night, using the bathroom or wanting to walk the hallways. Resident also had been sexually inappropriate with staff last evening and also during the night. * 02/11/24 at 6:04 p.m., Behavior: Resident started to swing his arms at another resident thinking she [the other resident] was in his room. Resident orientated to his own room . * 04/20/24 at 9:39 p.m., Resident became aggressive with an aide when asked to leave another resident room. The resident room he was in was upset he was in there. Resident hit [sic] CNA [certified nurse aide] 2 times when she asked to leave. Observations of Resident #23 showed the following: * 04/29/24 at 4:22 p.m., attempted to enter room [ROOM NUMBER], a room of another resident. * 04/30/24 at 9:28 a.m., attempted to exit the south doors of the building. The doors locked and unable to exit. * 04/30/24 at 1:23 p.m., exited room [ROOM NUMBER], a room of another resident located in a different hallway. During a resident interview on all days of survey, Resident #6 reported Resident #23 wanders into his/her room and Sometimes I find him laying in my bed. The resident stated he/she asked for a lock on their room door or some safety thing. I don't feel safe with him here. He walks into my room all the time. He lays on my bed all sprawled out. He even said 'come lay with me' and 'starts playing with himself. I told him to get the [explicit] out of my room. I mean he's a real nice guy. I'm afraid of him now. During an interview on 05/01/24 at 10:55 a.m., when asked about Resident #23's behaviors, a CNA (#7) confirmed the resident wanders into other resident rooms and can be difficult to redirect If he is laying in a bed and is asleep. The CNA (#7) confirmed Resident #23's behaviors affect other residents, including Resident #6. Review of the Resident Council Minutes, dated 12/28/23, identified Resident #6 attended the meeting and brought up another resident who wanders. During an interview on 05/01/24 at 11:00 a.m. with a social service member (#13), when asked if she was aware of Resident #6's concerns of Resident #23 entering his/her room and/or laying in his/her bed, the staff member (#13) stated, Only once in Resident Council. When asked about corrective actions implemented, the staff (#13) stated, We put a picture of him [Resident #23] on his door so he can locate his room more easily and further stated, [Resident #6] said it got better. When asked if she was aware Resident #23 displayed sexual behaviors towards residents, the staff member (#13) stated she was not aware. The facility failed to assess and monitor patterns/trends of Resident #23's behaviors, develop an effective behavior management program, implement a person-centered care plan to include interventions to address the resident's wandering into other resident rooms and sexual behaviors. The facility failed to modify the physical environment within the facility to ensure the dignity, privacy, and safety of Resident #6 and other residents. This failure resulted in Resident #23's inability to achieve the highest level of functioning and infringed upon the rights of other residents affected by the behaviors to achieve their highest level of physical, mental, and psychosocial well-being.

Based on observation, review of facility policy, review of professional reference, and staff interview, the facility failed to ensure food is stored in accordance with professional standards for food service sanitation in 1 of 1 kitchen (main kitchen). Failure to ensure food is safe from contamination from ice/condensation, dirt, and rust has the potential to result in a foodborne illness or adverse effects for patients, visitors, and staff. Findings include: Review of the policy titled, Sanitation Inspection occurred on 05/02/24. This policy, dated 03/01/24 stated, Policy: It is the policy of the [NAME] Community Nursing Home (DCNH), as part of the department's sanitation program, to conduct inspections to ensure food service areas are clean, sanitary and in compliance with applicable state and federal regulations. Policy Explanation and Compliance Guidelines: . 4. Sanitation inspections will be conducted in the following manner: a. Daily: Food service staff shall inspect refrigerators/coolers, freezers . daily. b. Weekly: The dietary manager shall inspect all food service areas weekly to ensure the areas are clean and comply with sanitation and food service regulations. The 2022 Food and Drug Administration (FDA) Food Code, Annex 3 page 100 states, . Preventing contamination from the premises . 3-305.11 Food Storage. 3-305.12 Food Storage, Prohibited Areas. Pathogens can contaminate and/or grow in food that is not stored properly. Drips of condensate . can be sources of microbial contamination for stored food. . (page155) Chapter 4 Equipment . 4-101.11 Characteristics . equipment is subject to deterioration because of its nature, i.e., intended use over an extended period of time. Surfaces that are unable to be routinely cleaned and sanitized because of the materials used could harbor foodborne pathogens. Deterioration of the surfaces of equipment such as pitting may inhibit adequate cleaning of the surfaces of equipment . Inability to effectively wash, rinse and sanitize the surfaces of food equipment may lead to the buildup of pathogenic organisms transmissible through food. Observation of the kitchen on 04/29/24 at 12:30 p.m. showed the following: - Walk-in Cooler: Food storage racks with several rusty areas and rough surfaces. When asked about cleaning the racks, a dietary staff member (#10) stated they are hard to get clean. Observation also showed a build-up of black debris on the grate of the fan on the ceiling.- Walk-in Freezer: Large amount of ice build-up on a pipe, on the back north wall, back east wall, and on the ceiling. Observation showed ice build-up in an open box of sherbet cups, on packages of coffee, and ice build-up on the ceiling above a bag of garlic toast and other boxes of food. Observation of the kitchen on 05/02/24 at 10:00 a.m. showed the same conditions as observed above, except the open box of sherbet had been removed.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to follow standards of infection control for 5 of 15 sampled residents (#1, #9, #15, #18, and #22) observed during medication administration and resident cares. Failure to follow infection control standards related to hand hygiene and glove use has the potential to transmit infections to residents, staff, and visitors. Findings include: Review of the facility policy titled Personal Protective Equipment occurred on 05/02/24. This policy, dated 02/19/23, stated, . Gloves . Perform hand hygiene before donning gloves and after removal. Gloves are not a substitute for hand hygiene. Change gloves and perform hand hygiene between clean and dirty tasks, when moving from one body part to another . The outside of gloves are contaminated. Do not reuse gloves. - Observation on 04/29/24 at 4:17 p.m. showed a nurse (#2) performed hand hygiene, donned gloves, entered Resident #22's room, and performed a blood sugar check. Without removing her gloves, the nurse exited Resident #22's room, disinfected the accucheck machine (used to check blood sugar levels), placed the supplies back into the medication cart, and typed on the computer. The nurse (#2) failed to remove her gloves and perform hand hygiene prior to exiting Resident #22's room. - Observation on 04/29/24 at 4:29 p.m. showed a nurse (#2) performed hand hygiene, donned gloves, entered Resident #15's room, and performed a blood sugar check. Without removing her gloves, the nurse exited Resident #15's room, disinfected the accucheck machine, placed the supplies back into the medication cart, and typed on the computer. With the same gloves on, the nurse (#2) gathered supplies for Resident #15's insulin administration from the medication cart, entered the resident's room, and administered the insulin. The nurse exited Resident #15's room, placed the insulin supplies back into the medication cart, and typed on the computer. The nurse (#2) failed to remove her gloves and perform hand hygiene prior to exiting Resident #15's room and in between the blood sugar check and insulin administration. - Observation on 04/29/24 at 4:43 p.m. showed a nurse (#2) performed hand hygiene, donned gloves, entered Resident #9's room, and performed a blood sugar check. Without removing her gloves, the nurse exited Resident #9's room, disinfected the accucheck machine, placed the supplies back into the medication cart, and typed on the computer. The nurse (#2) failed to remove her gloves and perform hand hygiene prior to exiting Resident #9's room. - Observation on 04/29/24 at 4:50 p.m. showed a nurse (#2) performed hand hygiene, donned gloves, entered Resident #18's room, and administered insulin. The nurse exited Resident #18's room, placed the insulin supplies back into the medication cart, and typed on the computer. The nurse (#2) failed to remove her gloves and perform hand hygiene prior to exiting Resident #18's room. - Review of Resident #1's medical record occurred on all days of survey. The record identified diagnoses of chronic ulcers to both upper back of legs and sacral/coccyx areas and a history of Methicillin-resistant Staphylococcus aureus (MRSA) and Vancomycin-resistant enterococci (VRE) infections (infections resistant to many antibiotics). The record also identified the resident on enhanced barrier precautions (EBP). Observation on 04/30/24 at 1:55 p.m. showed a nurse (#11) put on a gown, donned gloves, donned a second pair of gloves over the first pair of gloves (double gloved) and applied a pain-relieving cream to the resident's upper back. The nurse doffed the soiled outer pair of gloves, donned a clean second pair of gloves, and cleansed the resident's wounds. The nurse doffed the soiled outer pair of gloves, donned a clean pair of second gloves, applied the wound medications, and dressed the wounds. The nurse then removed both pairs of gloves and completed hand hygiene. The nurse (#11) failed to remove gloves and perform hand hygiene before and after the wound cleansed and the medications applied. During an interview on the afternoon of 04/30/24, and administrative nurse (#12) confirmed double gloving is not the practice of the facility. 40488

Based on record review, review of facility policy, and staff interview, the facility failed to ensure acceptable parameters of nutritional status for 1 of 3 sampled resident (Resident #18) with significant weight loss. Failure to implement interventions, adequately assess the effectiveness of existing interventions, ensure consistent implementation, and re-evaluate the need for updated or additional interventions resulted in a significant weight loss. Findings include: Review of the facility policy titled DCNH ([NAME] Community nursing Home) Weight Monitoring occurred on 03/23/23. This policy, dated 09/22/22, stated, . 1. The facility will utilize a systemic approach to optimize a resident's nutritional status. This process includes: a. Identifying and assessing each resident's nutritional status and risk factors. b. Evaluating/analyzing the assessment information. c. Developing and consistently implementing pertinent approaches. d. Monitoring the effectiveness of interventions and revising them as necessary . 6. A significant change in weight is defined as: a. 5% [percent] change is weight in 1 month (30 days) b. 7.5% change in weight in 3 months (90 days) c. 10% change in weight in 6 months (180 days) . Review of Resident #18's medical record occurred on all days of survey. The care plan stated, . Resident is risk for impaired nutrition . as evidence as resident has involuntary movements causing his food to miss his mouth . Staff to weigh me per DCNH policy and monitor for stability of my weight. Implement interventions as needed. Resident will maintain a healthy weight. Physician orders included the following: * 01/06/21 Mighty Shake Special Instructions: 6 times a day, 1 each with meals and snacks * 02/02/23 Nectar Thickened Liquids Three Times A Day * 03/20/23 Pureed diet A quarterly Minimum Data Set (MDS), dated [DATE], identified Resident #18 had a significant weight loss that was not physician prescribed. The record identified the following weights: * 07/08/22 - 175.6 pounds (lbs) * 12/07/22 - 177.2 lbs * 01/04/23 - 163.6 lbs (7.67 % weight loss in 1 month) * 03/14/23 - 160.4 lbs (9.48% weight loss in 3 months) Meal intake records included percentages of all fluids consumed by Resident #18, but did not show specifically the percentage of the mighty shakes he consumed. Resident #18's progress notes stated the following: * 01/08/23 3:15 p.m., Dietary: Resident eats ruffly [sic] 26-50% of his meals when he does eat. Has had a weight change, talk with nurse. Current weight is 163.6 lbs. BMI [body mass index] 23.47. Will continue to monitor. * 01/08/2023 5:59 p.m., Nursing: Sat with resident and tried to assist with feeding. Allowed a couple spoons of potatoes . Dietary manager assured me he is getting enough calories via mighty shakes, and ice creams, etc. * 02/20/23 4:16 p.m., Nursing: Discussed with Dietary Supervisor her concerns with resident having a hard time swallowing his liquids lately. Phone call to [Dr's name] to discuss. New order: Nectar Thickened liquids. Will further discuss on DCNH Rounds 02/28/23. * 03/10/23 2:30 p.m., Nursing: Resident did have a choking episode this afternoon. Was given a banana for snack and choked on a piece. Was able to dislodge per self. No adverse side effects noted. * 03/11/23 7:44 p.m., Nursing; did feed resident this morning. Noted when taking bites of pureed eggs and sausage, resident was not able to swallow without liquids. When giving a bite of oatmeal with milk, resident was able to swallow on his own. Will continue to monitor. No further concerns. * 03/20/2023 7:04 p.m., Nursing: This writer fed resident all meals on 7am-7pm shift. Resident has not been able to eat finger food or chopped foods without having hard time swallowing. Resident has been tolerating pureed foods well. Resident refuses to grab his food per self. Discussed with [name of doctor]. New order: Pureed Diet at all times. Resident is tolerating thickened liquids well. No further concerns at this time. * 03/23/23 8:53 a.m., Dietician: Spoke with food service manger 03/20/23 regarding (Resident #18's name) increasing difficulty tolerating current diet consistency. Continue with previous nutrition plan of mighty shake supplements at all meals and snacks for calories, protein, vitamins & minerals due to previous weight change. Calorie needs higher due to constant uncontrolled movements. Weight 3/14/23 160.4#, 3/8/23 162.4# without significant change over 2-3 months. Note the resident had a significant weight loss in the past three months. The last dietary assessment was completed on 03/24/21, two years ago. During an interview on 03/23/23 at 10:30 a.m., an administrative nurse (#1) confirmed the facility failed to re-assess interventions put in place, document intake of supplements (mighty shake), care plan previous and/or current weight loss interventions, and recognize continued weight loss for Resident #18. The facility failed to: * Complete a nutritional assessment by the dietician routinely or in a timely manner related to weight loss. * Document and assess supplement intake of supplements * Recognize continued weight loss despite receiving supplements and initiate/monitor additional interventions * Care plan the various interventions they had attempted, identifying if they were successful or needed to be modified.

Based on record review, review of facility policy, and staff interview, the facility failed to ensure each resident received adequate supervision and assistance devices for 1 of 1 sampled resident (Resident #2) who experienced a fall from a mechanical lift. Failure to follow the plan of care resulted in Resident #2 experiencing back pain secondary to a fall from a full body lift. Findings include: Review of the facility policy, Lift Transfers occurred on 02/07/19. This policy, dated 01/18/14, stated, . Transport Slings: 1. Two assist with all lifting and transferring procedures. Review of the Hoyer Lift Instruction Sheet occurred on 02/07/19. This instruction sheet, dated (MONTH) 2001, stated Always have 2 people to assist. Never leave resident unattended. - Review of Resident #2's medical record occurred on all days of survey. Resident #2's current care plan identified the following: . Hoyer lift with sling with all transfers with assist x (times) 2. I have . Left sided paralysis unable to ambulate. Assistance required with transfers, poor sitting balance . Potential for falls and injuries, history of [MEDICAL CONDITION] activity . I have a history of falls and am at risk for injury related to falls. The Certified Nurse Aide (CNA) Care Card for Resident #2 identified, . Transfers: A 2 (assist of 2) Hoyer lift . Review of Nurses Notes identified the following: *01/30/19 at 6:00 p.m. CNA notified charge nurse that resident had slipped out of lift during transfer and landed on floor. Nurse observed resident laying on back on floor with lift machine above resident. CNA stated that lift strap became undone causing resident to fall out. Charge nurse performed ROM (range of motion) finding normal results. Full body assessment completed with no visual injuries. Resident c/o (complained of) back pain . Tylenol 500 mg (milligrams) PRN (as needed) given for back pain. 01/30/19 at 8:00 p.m. c/o back pain. 01/31/19 11 p.m. - 7:00 a.m . Tylenol ES (extra strength) 500 mg (milligrams) given @ (at) 3 a.m. for c/o back pain. (No) visible injuries noted. Staff placed warm blankets under client to help relieve pain. 01/31/19 at 9:00 a.m. Resident continues to c/o back pain. But unable to specify pain level. given PRN pain medications with no relief. He has been agitated, complaining of pain during movement. 01/31/19 at 9:15 a.m. (Physician) notified of residents complaints. (Physician) in agreement to send resident to ER (emergency room ). 01/31/19 at 12:17 p.m. Nurse . from ER called facility regarding resident. She stated that resident will be discharged . the X-ray results came back negative. 01/31/19 at 12:50 p.m. Resident returned . New orders were sent back to give [MEDICATION NAME] (a muscle relaxant), (and) [MEDICATION NAME] (pain medication) Patch. [MEDICATION NAME] to start 12 hrs (hours) after injection of Toradal (pain medication) he received. 02/01/19 at 6:00 a.m. Client c/o back pain. [MEDICATION NAME] 800 mg given for back pain . 02/01/19 at 6:00 p.m. Resident was having pain before supper. Staff attempted to get resident out of bed and it was observed that he was in extreme pain as he was stiffening up his body and yelling at staff, 'stop it, that hurts. You are killing me.' . Nurse gave PRN [MEDICATION NAME] 800 mg at 4:25 p.m. By 5:45 p.m., there was no relief observed. Nurse was able to contact physician and he gave new orders for pain relief. 02/02/19 at 8:00 a.m. TO (telephone order) from (physician) to increase [MEDICATION NAME] to 5 mg due to increased pain. Resident complains of pain to back. He is unable to specify location but will holler out 'My back hurts.' 02/02/19 at 1:00 p.m. during transfer, resident continued to c/o pain to his back. 02/03/19 7:00 a.m. - 3:00 p.m. Resident continues to c/o pain to back during transfers (and) turning. PRN's given for pain. Review of Resident #2's Medication Administration Record [REDACTED] [MEDICATION NAME] 400 mg: 2/02/19, 2/03/19 (twice), 2/04/19, 2/05/19, 2/06/19 (twice), and 2/07/19. [MEDICATION NAME] 800 mg: 2/01/19 (twice). [MEDICATION NAME] 2.5 mg: 2/01/19 and 2/02/19. [MEDICATION NAME] 5 mg: 2/02/19 (twice), 2/03/19 (twice), 2/04/19 (twice), 2/05/19 (twice), 2/06/19 (twice), and 2/07/19 (twice). [MEDICATION NAME] 10 mg: 2/02/19, 2/03/19, 2/06/19 (twice). In addition, the physician ordered a [MEDICATION NAME] (pain medication) 5% (percent) patch for low back pain daily for 30 days. Review of the facility's investigation of the fall, dated 01/31/19, stated, Staff member (#7) used a hoyer lift with the assist x 1, resulting in . a fall on 01/30/19 at 6pm. did not follow care plan, which states all transfers per hoyer lift x 2 assist. (Staff member #7) . states . did not know that staff needed 2 assist with all hoyer lifts.did not intentionally try to hurt (resident). The sling was not properly positioned right and sling came undone from the hoyer lift. (staff member) was educated on facility policy, care plan, care card, and all hoyer and stand lift proper procedures for usage on 01/31/19. All nursing staff will be educated on the proper use of hoyer lifts and stand up lifts per owners manual and facility policy. Observation on 02/05/19 at 9:18 a.m. showed two certified nurse assistants (CNAs) (#8 and #9) utilized a hoyer lift to transfer Resident #2 from the bed to the wheelchair. Resident #2 identified back pain during the transfer. Review of the staff member's (#7) personnel file identified the staff member completed inservice education on lifting, transfers and positioning on 10/02/18. Review of the nursing in-service records, dated (MONTH) 1 and 2, 2019 identified six CNAs and four nurses viewed the video and read the facility policy and manufacturer's instructions on lift transfers. Review of the list of current employees identified 14 CNA's and seven nurses have not yet viewed the video and read the policy regarding lift transfers. During an interview on the morning of 02/07/19, a supervisory nurse (#1) confirmed staff should follow the care plan/care card when transferring residents. This staff member (#1) also confirmed there are nursing and CNA staff who have not completed the in-service training and stated the facility has not monitored staff during resident transfers to ensure they are following the care plan/care card. Failure to provide the necessary assistance when transferring Resident #2 as directed on the plan of care resulted in the resident experiencing pain secondary to a fall from the mechanical lift and requiring PRN pain medications three or more times a day since the fall.

During the complaint survey on (MONTH) 14-15, (YEAR), the team determined a potential Immediate Jeopardy (IJ) situation existed. The IJ potential resulted from review of Resident #5, #6, #7, #8's medical records which showed the residents were placed in avoidable dangerous situations after they eloped from the facility. After record review and interview with facility staff, the survey team met at 1:30 p.m. on 06/15/18 and determined corrective action needed to occur. At 1:40 p.m., the team contacted the managerial staff at the State Survey Agency (SSA) to report the findings and to discuss a potential IJ situation. At 2:00 p.m., the survey team notified facility administration of the IJ and that they must develop a plan for removal of the immediate jeopardy situation. At 3:15 p.m., the facility provided a written plan to remove the IJ. The team reviewed and accepted the written plan which included checks every 15 minutes, updates to the care plan, additional staffing, and staff education. At 3:25 p.m., the team determined the IJ situation removed, reduced the scope and severity level to E, and informed the facility administration of this action. Based on information provided by the complainant, record review, review of facility's policy, and staff interview, the facility failed to ensure residents received adequate supervision and/or monitoring to prevent safety elopements from the facility for 1 of 1 sampled resident (Resident #5) and 3 residents who were discharged from the facility (Resident #6, #7, and #8). Failure to acknowledge the high-risk behaviors of the residents upon admission, identify each resident's risk of elopement, implement, monitor, and modify individualized resident-centered interventions when necessary, and demonstrate a commitment to the residents' overall safety, resulted in Resident #5, #6, #7, and #8 being placed in avoidable dangerous situations after they eloped from the facility. Findings include: Information provided by the complainant indicated residents were repeatedly eloping from the nursing home, and in many instances police intervention was required in locating them. Review of facility policy titled Elopements and Wandering Residents occurred on 06/15/18. This policy, revised 01/17/18, stated, . 'Elopement' occurs when a resident leaves the premises or a safe area without authorization . or . (the) necessary supervision to do so . The facility is equipped with door locks/alarms to help avoid elopements . Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner . The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary . Interventions to increase staff awareness of the resident's risk, modify the resident's behavior, or to minimize risks associated with hazards will be . communicated to appropriate staff . Adequate supervision will be provided to help prevent accidents or elopements . The effectiveness of interventions will be evaluated, and changes will be made as needed. Any changes or new interventions will be communicated to relevant staff . Charge nurse will complete the Elopement Incident Report . A social service worker will set up a care plan meeting to address approaches, modifications and goals that are appropriate for the resident . Staff may be educated on the reasons for elopement and possible strategies for avoiding such behavior. - Review of Resident #5's medical record occurred on all days of the survey. [DIAGNOSES REDACTED]. An elopement risk assessment, dated 05/08/17, stated, . Client returned from (family leave) now has elopement bracelet to right ankle per guardians request-client only able to sign out with certain family members- due to [MEDICAL CONDITION]. The most recent care plan identified the following: * 05/09/18, History of alcohol/drug abuse . I have a history of leaving facility and coming back intoxicated. I have a history of elopement . I have a history of having bottles of different alcohols in my room . staff to monitor my whereabouts frequently. Wanderguard bracelet applied per guardian request. * 05/09/18, Behavioral symptoms . I often want to leave without safe transportation . I am only able to sign out of facility with certain people. The care plan failed to identify interventions necessary to prevent Resident #5 from interacting in an aggressive manner towards other residents. The interdisciplinary team's progress notes identified the following: * 05/23/18 at 9:15 p.m., . client fell outside . lying on his back on the ground just outside the doors . client is under the influence of alcohol . speech slurred . client became physical. Client grabbed CNA (cupped her breast) . client swung at her . grabbing writers shirt pulling it down-almost ripping it off . at 10:25 p.m., (nearby town) ambulance called per (physician) to take client to emergency room (ER) to detox . and at 10:45 p.m., . ambulance arrived . client combative-swinging at staff, kicking and grabbing staff in inappropriate places . speech still slurred. Client very intoxicated. * 05/24/18 at 3:30 p.m., . (late entry) on 05/23/18 at approximately 8:00 p.m., resident was seen getting into a pick-up . police visited our facility . Police were notified that resident was unauthorized to leave . after about 35 to 40 minutes resident returned . he and fell ow resident passed around a Gatorade bottle which contained alcohol . shortly after is when resident fell . * 05/25/18 at 1:45 p.m., resident returned from hospital. * 05/30/18 at 9:45 p.m., resident was sitting outside with another resident . 5 minutes later noticed they were not sitting there . resident found one block over. * 05/31/18 at 11:20 a.m., care conference held to discuss recent elopements. Discussed concerns and interventions to put in place . Care plan reviewed/revised as needed. * 06/06/18 at 8:30 p.m., CNA smelled alcohol on client . CNA went into resident's room . A water bottle resident had in his hand and when asked what was in it client said water and drank the remaining liquid left in bottle. CNA smelled an empty water bottle and it smelled of alcohol . at 10:00 p.m., client trying to leave facility . client pushed on door until it went off track and he went outside . Client wanted a cigarette became angry and yelled I don't give a (explicative) what time it is I want to smoke . client was slurring his speech . found an empty Grande Canadian bottle . in client's closet . and at 11:56 p.m., client in room with another resident. Client is yelling and swearing . being disruptive of other residents . client appears to be intoxicated . 'he doesn't have to go anywhere this is my (explicative) house' Attempted to take dirty cups out of room. Client said 'leave my (explicative) cup.' . police called. * 06/09/18 at 11:45 p.m., Client in room with another resident. Client is yelling and swearing . client appears to be intoxicated . (he doesn't have to go anywhere this is my (explicative) house . attempted to take dirty cups out of room client said (leave my (explicative) cup) police called. * 6/10/18 at 12:55 a.m., client was on floor . hit head on bed side dresser causing a laceration 4 cm x 0.1 cm and an abrasion to right shoulder 8 cm x 5 cm . Empty vodka bottle found in bottom of garbage. Facility staff completed Incident Reports/Post Elopement Forms following three of Resident #5's three related incidents/elopements (one with a fall). Following the elopement on 05/23/18, they identified closer supervision as an intervention to keep Resident #5 from eloping. - Review of Resident #8's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS), dated [DATE], identified moderate cognitive deficits, independence with locomotion on/off the unit, and wanders; significantly intruding on the privacy/activities of others. The most recent care plan identified the following: * 04/03/18, Risk of elopement . Wanderguard placed. Removed. Resolved. Staff to monitor whereabouts frequently. Staff to try to redirect (Resident #8), be non-judgmental, keep environment calm, frequent reminders as (Resident #8) has limited memory. * 05/24/18, (Resident #8) may not leave facility (without) assistance. He has lost his privilege to check in (and) out on his own because of his behavior on 05/23/18 per (guardian). This is for his own safety. Wanderguard placed. Staff to accompany when outdoors . A physician's progress note, dated 04/03/18, identified, . He has guardian and no etoh (alcohol) intake since incarceration. NH (nursing home) placement to ensure safety and continued abstinence . The interdisciplinary team's progress notes identified the following: * 04/03/18 at 3:00 p.m., Resident was admitted to facility. and at 9:00 p.m., wanderguard placed on ankle to alert staff of his whereabouts; may be forgetful at times . * 04/05/18 at 12:15 p.m., Resident left facility without approval . returned with a bag of food . was told by nurse that he cannot leave facility . Nurse stated that law enforcement will be called if he continues to not follow policy. Resident voiced understanding. A social service progress note, dated 04/11/18, identified, . moderately impaired (cognition) . Resident went to the store after being told that he could not. Wandering did not endanger anyone . The interdisciplinary team's progress notes identified the following: * 04/19/18 at 3:40 p.m., . resident will sign in (and) out of facility . and at 8:40 p.m., New wanderguard placed on right wrist. * 05/08/18 (time not identified), Resident has been compliant with cares and facility policies due to elopements. Wanderguard has been removed. Guardian has approved to take wanderguard off. * 05/23/18 at 9:15 p.m., . Client's words were slurred. Writer noticed client had a (sic) off yellow drink in a Gatorade (sic) bottle that smelled strong of alcohol. Client seemed very intoxicated unsteady gait when trying to walk . * 05/24/18 at 9:15 a.m., Called (guardian) . Resident is not to leave facility (without) assistance, he has lost that privilege because of his behavior . A social service progress note, dated 05/24/18, identified, . Informed (guardian) of recent incident and that the local bar reports that (Resident #8) has been buying alcohol on other occasions . The interdisciplinary team's progress notes identified the following: * 05/30/18 at 9:56 p.m., (Resident #8) was sitting outside with another resident . 5 minutes later . noticed they were not sitting there . CNA (certified nursing assistant) found (Resident #8) one block over. (Resident #8) refused to come back to (nursing home). CNA kept encouraging client to return. Client . walked back to nursing home . * 05/31/18 at 2:30 p.m., Notified (guardian) regarding resident's elopement yesterday. No concerns at this time. * 06/07/18 at 11:20 p.m., Care conference held for elopement. Care plan reviewed and revised as indicated. Guardian aware and involved in planning care to prevent further elopements. Interventions in place to prevent elopement . Record review showed no further updates were made to Resident #8's care plan after 05/24/18. * 06/09/18 at 2:35 p.m., Received phone call from community member stating that resident was observed walking east of Dunseith . at 3:00 p.m. (25 minutes later), Resident was escorted back to facility by (deputy) . at 4:25 p.m., Resident has left again . Returned (at) 5:00 p.m. (35 minutes later) (with) alcohol on breath. Had been found drinking at (local bar/cafe). Readily admitted such to sheriff. Sheriff strongly advised that if this happens again stronger measures would be taken . at 9:00 p.m., Resident again attempted to leave the facility, but CNA spotted him walking down street to the north . When CNA got to him, he said, 'I almost got free.' Will lock front door to discourage further leaving . at 9:30 p.m., Citizen called and said she saw resident race out of kitchen door to the east and take off at a fast pace going south. Apparently he ended up at (local bar/cafe) and police were called. Showed up at 10:00 p.m. (30 minutes later) Door locked (no further escapes . at 11:45 p.m., Client in another clients room . very intoxicated, yelling, making noise, swearing, being very disruptive to other clients . Client and other client continue to yell and swear. Writer asked them to keep it down. Police called . (During an interview on 06/15/18 at 11:45 a.m., when asked questions pertaining to the Resident #8's behaviors, an administrative nurse (#1) reported, We had a resident who was dying next door. (We) called the police to get him to go (back to his room).) . and at 12:15 a.m., . Police officer entered and told (Resident #8) he needed to go to his own room. Police officer told client, 'This is ridiculous to have to be called how many times today because of you. Let's go to your room or your (sic) going to jail . Before leaving police officer told writer, 'Client belongs somewhere else - a locked down unit or his (sic) going to end up going to jail.' (Resident #8) had left the facility earlier and was picked up at (bar/cafe) where he purchased the vodka. The interdisciplinary team's progress notes identified the following: * 06/10/18 at 10:20 a.m., Resident came out of room and started digging through the housekeeping cart . stating, 'Where the (explicative) is my jug?' . Resident started hollering at nurse saying 'You better watch yourself.' . Resident pushed cart towards nurse, causing water to spill on floor. Nurse hollered for housekeeper (male) to assist with calming down resident. Resident continued to holler. Prior to incident CNA and nurse confiscated a powerade bottle with clear liquids inside. Nurse smelled bottle finding a strong smell of alcohol . at 10:30 a.m., Resident would walk by nurses' station and hold his fists up at charge nurse. Charge nurse had locked herself in nurses' station due to resident verbally threatening, stating to nurse, 'You better watch it.' . at 10:35 a.m., Resident was standing by his door and started slamming door. He slammed door 3 times causing staff at the nurses station to hear sound. Immediately the housekeeper got up and attempted to calm resident down. Resident was hollering loudly, stating, 'I'll fight you, where's my jug?' . Resident continued to holler loudly (sic). Resident did go into his room. Charge nurse (and) other staff members observed this incident . at 10:36 a.m., (Guardian was) notified . (Guardian was) in agreement for charge nurse to call authorities . at 10:50 a.m., Two police officers arrived at facility. Resident was very resistant with the officers. Officers had to use extreme force with tazing approx (approximately) 3 times. The 2 officers escorted resident out of building and transported resident to police station . and at 11:25 a.m., . (Physician) was in agreement to call authorities due to the safety of staff (and) residents. * 06/11/18 at 9:30 a.m., Received phone call from . officer . She then explained that they are unable to care for someone (with) his medical condition. Writer asked officer what about the safety of the other residents (and) staff at (nursing home)? She again stated they cannot pick him up or arrest him. Resident returned to (nursing home) around 9:30 p.m. on 06/10/18. Resident is currently pacing hallways going outside without permission and has a scowl on his face. Staff is frightened to communicate (with) resident as unknown how he will react . * 06/12/18 at 10:00 a.m., Resident was found missing . at 10:20 a.m., Resident was still missing and charge nurse called 911 . at 10:50 a.m., (Guardian) was notified and they said to attempt to keep resident in facility . at 2:30 p.m. (4 hours 30 minutes later), Resident has been found by local residents of Belcourt and the police have been notified to pick up resident (approximately six miles from the nursing home) . and at 3:00 p.m., Resident has been . sent to a facility in (name of another town). During an interview on 06/15/18 at 10:00 a.m., when asked questions pertaining to the elopements, an administrative nurse (#1) reported Resident #8's physician directed staff to let (Resident #8) leave (the facility), because of his aggression. He was a large guy. Staff (were) afraid of him, afraid (they'd) get hit. Facility staff completed Incident Reports/Post Elopement Forms following three of Resident #8's eight elopements. Following the elopement on 06/12/18, they identified one-on-one's as an intervention staff should use to keep Resident #8 from eloping. According to the administrative nurse (#1) one-on-one's had been in place since the first week of May. - Resident #7's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. The admission MDS, dated [DATE], identified severe cognitive deficits and independence with locomotion on/off the unit. An admission nursing assessment, dated 04/19/18, identified, . Family report that resident was living at retirement home (and) would elope numerous times . Resident will walk from door to door and set off alarms at times. The most recent care plan identified the following: * 04/20/18, . I am at risk of elopement . Wanderguard, staff to monitor whereabouts frequently . Listen to my concerns in a calm, non-judgmental (sic) manner . Staff to supervise me if I go outside. If I try to leave (without) supervision try to redirect me to come indoors, if not successful - call law enforcement for assistance while keeping me within staff's field of vision . * (undated), hx (history) of Elopement on 05/01/18. An interdisciplinary team's progress note, dated 04/19/18 at 1:00 p.m., identified, Resident admitted to the facility . Resident is an elopement risk, wanderguard was placed to resident's right wrist. A social service progress note, dated 04/29/18, identified, . He has had a long history of wandering, which necessitated Nursing Home placement. (Resident #7) has delusions. Misconceptions and beliefs that are firmly held contrary to reality. He has been returned to his previous address several times by the police in the middle of winter and still thinks he can walk outdoors by himself. The interdisciplinary team's progress notes identified the following: * 05/01/18 at 7:45 p.m. Phone call from community alerting staff that (Resident #7) was out in community trying to get a ride to (nearby town). Good samaratin brought (him) back to facility. Missing approx 7:25 p. (sic) Found (at) 7:45 p. (sic) (20 minutes). He stated that his car was broken and he had to fix it. * 05/02/18 at 7:00 p.m., CNA was supervising resident outdoors . (Resident #7) was refusing to come in . At 7:10 she told me (Resident #7) was refusing to come in. By this time (Resident #7) was behind the nursing home (and) I ran to catch up to bring him back. I told him to stop and he only increased his pace. I followed him and he would not stop. At one point I touched his arm to turn him around and he hit me with a closed fist. He then kept walking. CNA was trying to raise the police to come help and they never came. Resident kept walking at a quick pace out to (road) and turned east. Trying to keep him out of center of road was a challenge as he was determined to do exactly what he wanted to do. All CNA and I could do was follow and attempt to warn cars of his presence. Several more calls made to police who assured us they were coming to our rescue. Time (and) passed (and) no police. Frustrated to the maximum I dialed 911 and emphatically stated that they send help 'NOW' as I was in a situation that was critical. Three or so miles down the road the police finally came and police calmly directed resident into the car. Police returned resident . Resident crying as he didn't want to be brought back . Front door locked to prevent any further problems. Family notified of plans to set up a psych appt (appointment) in Belcourt for tomorrow . Throughout this ordeal Resident told this nurse to '[***] off.' When I told him to stop. He was defiant, resistive, and unmanagable (sic). * 05/04/18 at 1:30 p.m., (Physician) notified facility regarding resident (and) new orders. (Physician) ordered Risperadone 1 mg (milligram) po (by mouth) BID (twice daily) . * 05/05/18 at 11:38 a.m., Resident kicked open front doors of facility knocking door off track. Resident eloped facility. In route walking north on Main Street . Charge nurse notified 911 regarding resident's elopement . at 11:15 a.m., . (son) called. Charge nurse informed him of resident's elopement (and) being sent to ER (emergency room ) . at 12:29 p.m. (31 minutes later), Officer stated she located resident on (name of road) and would be bringing resident back to facility. The emergency room progress note, dated 05/05/18, identified, . male presents via ambulance after eloping from the (nursing home) . Discharge in stable condition. The interdisciplinary team's progress notes identified the following: * 05/07/18 at 1:35 p.m., Wander guard placed to resident's right ankle. * 05/08/18 at 11:10 a.m., Resident had walked out of front doors of facility at 10:50 a.m. and proceeded south of building and was approached by 3 staff members. Resident would not reply to staff . started heading north of facility. Charge nurse then called police to assist with getting resident back to the facility. Staff continued to walk north with resident until reaching Highway 21. Staff then attempted to . (redirect) him back to facility and resident struck CNA in the face and then charge nurse in the face as well. A bystander then pulled up on scene and also helped to redirect resident back to facility . The social service progress notes, dated 05/08/18 at 10:40 a.m., identified, Care Conference . Assurance was given to (sons) that we will work on these problems (anger and elopements). That transfer and discharge is the last option . and at 11:05 a.m., . Reviewed checklist for meetings on physical aggression concerns. Concluded that protocol is being followed. The interdisciplinary team's progress note, dated 05/10/18, identified, . (Hospital) . suggested to start medications that were previously ordered . If medications don't help, they suggested to have him transferred to a lock down unit since most behaviors are related to elopements. A physician's progress note, dated 05/24/18, identified, . He has a history of severe dementia . He . was outside in the winter without proper clothing, decision was made to have him . placed in the nursing home . He eloped from the facility in spite of having a wander guard, likes to walk a lot, staff doing their best to try to keep an eye on him, keep him from leaving the facility. The interdisciplinary team's progress notes identified the following: * 05/25/18 at 7:28 a.m., Client eloped. Another resident informed writer that he seen (Resident #7) walking towards main street . Writer checked front doors and they were locked . Writer went and told CNA to go and look for (Resident #7). CNA located (Resident #7) by (local bar/cafe). (Resident #7) would not get in CNA's vehicle. CNA seen a Border Patrol officer sitting by (local bar/cafe) and asked for his help . (Resident #7) proceeded to walk down the road . Border Patrol officer followed (Resident #7) until police arrived . (Administrator) was also present. (Administrator) stated (Resident #7) fell x 2 . (Resident #7) told writer 'to get the (explicative) away from him. * 05/28/18 at 11:45 a.m., At 11:15 a.m., CNA was having difficulty with resident returning into the building . Nurse went outside to talk to the resident . when asked resident to come back in resident said, 'Can you just leave me alone? You just like to run your (explicative) mouth don't you?' Nurse . softly put their hand on his shoulder and resident stood up and pushed nurse back and said, '. Get away from me or I'll hit you' . and proceeds into facility . * 05/29/18 at 8:25 a.m., Resident was found outside walking around the block. Charge nurse asked resident if he could come back into the building and resident said,'I'm going to walk if I want to walk. Why don't you get out of my (explicative) way?' . Nurse walked with resident around the building . asked resident to return into building and resident said, 'Don't tell me what to do, get the (explicative) out of my face before I (explicative) hit your big head.' . at 8:40 a.m. (15 minutes later), Resident . came back into facility . and at 12:00 p.m., . At 11:20 a.m. CNA reminded resident again that it was time for dinner and resident said, Get the (explicative) out of my face and leave me the (explicative) alone.' Resident then went outside and did not want to be disturbed. Resident came back into the facility at 11:50 a.m. (30 minutes later) . * 05/30/18 at 12:20 p.m., Community member called (nursing home) stating resident walk (sic) walking north of Dunseith by (store) . at 12:30 p.m., Police (911) authorities were notified of resident's elopement . at 12:35 p.m. (15 minutes later), Resident walked back into facility . * 06/07/18 at 11:15 a.m., . Resident is continually walking away from facility (without) any concerns for his own safety. He walks in middle to road unaware of on-coming traffic . Interventions in place to try (and) prevent elopement. Family aware of situation (and) working (with) (nursing home) to come (with) a plan that is best for resident's safety. Facility staff completed Incident Reports/Post Elopement Forms following each of Resident #7's five elopements. Following the elopements on 05/01/18 and 06/12/18, they identified do not allow outdoors without close supervision and one-on-one's as interventions staff should use to keep Resident #7 from eloping. - Review of Resident # 6's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. The most recent care plan identified the following, 04/23/18, Elopement . wear wanderguard. The interdisciplinary team's progress notes identified the following: * 04/15/18 at 9:00 p.m., I'm feeling anxious and suicidal. * 04/23/18 at 3:15 a.m., . anxious, can't sleep, . out of his room several times, worried about a cig (cigarette) . at 8:00 a.m., . I need a taxi. I can't stay here . resident had left the facility and proceeded to walk towards the street . redirected inside . at 12: 40 p.m., resident left facility at 11:50 a.m. nurse followed the resident into a grocery story . nurse walked around town with resident to make sure he would not get hurt . resident walked into a bar and bought cigarettes . two police officers then assisted resident back to nursing home . at 1:30 p.m., resident attempted to leave facility again . at 3:45 p.m., Police notified (facility) staff resident was at the (bar) . and at 4:00 p.m., Resident once again left facility. Police notified us (facility staff) of the elopement. During two interviews on 06/15/18 at 10:00 a.m. and 11:45 a.m., when asked questions pertaining to wanderguards, an administrative nurse (#1) reported, The wanderguards were not working. This is not a locked facility. If you push (on the front door), it goes right off the track. When asked questions pertaining to monitoring expectations, the nurse (#1) reported hiring an additional staff member the first weekend in May. The staff member was hired to sit with residents who wanted to be outside between the hours of 3:00 p.m. and 9:00 p.m., the time period most of the elopements were occurring. She (#1) did not respond when it was pointed out that a number of the elopements occurred between 3:00 p.m. and 9:00 p.m. when the additional staff member was present, and the remainder of the elopements occurred outside the newly hired staff member's scheduled hours. When asked questions regarding how frequently residents were being monitored, the administrative nurse (#1) stated, Just frequently. (Staff) fill out a form if (there is a) doctor's order. When asked questions pertaining to staff education, the nurse (#1) reported, We had training on elopement in April, and a drill. (Review of CNA education rosters showed the inservice took place in (MONTH) (YEAR).) When asked questions pertaining to admitting high-risk residents to their facility, she (#1) stated, We were forced by the board to take these residents. (We had a) low census. When asked questions pertaining to the the facility's abuse/neglect policy, the administrative nurse (#1) indicated she wasn't aware (they) were supposed to notify the State agency. The facility failed to demonstrate a commitment to Resident # 7 and #8's overall safety, when they failed to: * Acknowledge the high-risk behaviors of Resident #5 (history of [MEDICAL CONDITION]), Resident #7 (history of elopements), and Resident #8 (history of [MEDICAL CONDITION] and recent incarceration) upon admission, * Provide the necessary supervision/monitoring to prevent Resident #5 and #6 from eloping and accessing alcohol on two occasion, Resident #7 from eloping on five separate occasions (whereabouts unknown for 31 minutes), and Resident #8 from eloping on eight separate occasions (whereabouts unknown for 4 hours 30 minutes, found 6 miles from the facility) and accessing alcohol on at least two occasions, * Determine if Resident #5, #6, #7, and #8 were able to elope as a result of insufficient supervision and/or monitoring (wanderguard/staff observation), * Restrict Resident #5, #7, and #8's access to other residents after they had consumed alcohol and/or became verbally/physically aggressive towards other residents and/or staff between (MONTH) 2-June 11, (YEAR), * Implement, monitor, and modify Resident #5, #6, #7, and #8's individualized interventions when necessary, and * Educate nursing staff regarding Resident #5, #6, #7, and #8's elopements and possible strategies for avoiding such behavior in the future per facility policy.

Based on observation, record review, review of facility policy and procedure, and staff and confidential individual interview, the facility failed to ensure staff safely transported and monitored 1 of 1 resident (Resident #6) who experienced an unavoidable fall with injuries while transported by wheelchair. Failure of staff to act in a safe manner resulted in Resident #6's fall with injuries. Findings include: Review of the facility policy, "Falls/Falls Prevention and Management," occurred on 11/20/14. This policy, revised June 2009, stated, "Policy: 1. All residents experiencing a fall will be assessed and treated for [REDACTED]. All falls will be completely and accurately documented and reported . . . Purpose: 1. To ensure proper documentation and reporting of all resident falls and resultant injuries . . . Procedure: . . . 5. Do vital signs and assessment at time of fall, every hour x (times) 2, and for the next 2 shifts. If the resident has sustained a head injury or suspected head trauma, crani (neurological) checks must be included with the vital signs . . . 8. Complete the Post Fall Assessment Form . . . and the Post-Fall Investigation Form . . . Chart 'see Post Fall Assessment' in the Nurses Notes . . . D. Investigation and Monitoring of Falls . . . 2. The DON (director of nursing) or designee will review documentation and interventions implemented after the fall for appropriateness. . . ." Review of Resident #6's medical record occurred on all days of survey. Medical [DIAGNOSES REDACTED]. The current care plan stated, "He uses a w/c (wheelchair) for almost all . . . mobility. . . " Observations during all days of survey identified staff pushed Resident #6 in his wheelchair for mobility. Review of the "Post Fall Assessment" form identified a fall on 10/31/14 at 12:30 p.m. and stated, "Resident slipped out of wheelchair at KDU (kidney dialysis unit) . . . Bit lip - KDU nurse assessed and treated Abrasion to upper R (right) eye Bleeding tooth Abrasion at left nostril. . . ." The form identified staff notified the family by phone and the physician by fax. The documentation lacked any orders or instructions received from the physician. The form included a post fall assessment started by staff when the resident returned to the facility that afternoon and included assessments for 11/01/14 and 11/03/14. The "Injury Follow-up" column did not address the lip, tooth, or nostril injury for the three days. Staff documented an upper right eye abrasion one day and an upper left eye abrasion the next day. The initial report noted an upper right eye abrasion. Staff documented "denies pain" for all three days and lacked documentation under "falls prevention strategies." Resident #6's Nurse's Notes identified the following: * "10/31/14 1 pm Reported by nurse (name) at KDU that (resident's name) fell out of wheelchair just prior to KDU. Will begin post fall tonight. (Family name) was called." * "11-1-14 5:30 am Resident slept all noc (night) . . . voices no pain and has no concerns. . . ." * "11-3-14 Post fall complete - denies injury - abrasion to lt (left) eye. . . ." * "11-18-14 Noon: Have called (family) . . . (resident) lost . . . front tooth yesterday. No pain reported. . . ." During a confidential interview on 11/19/14 at 3:45 p.m., the individual (A) indicated staff reported Resident #6 fell forward from his wheelchair after staff, pushing the wheelchair too fast, hit a curb on the way into the KDU. This individual verified staff reported Resident #6's tooth bleeding after the fall, and on 11/18/14 staff reported the tooth had fallen out. During an interview on 11/20/14 at 11:00 a.m. and 12:30 p.m., an administrative nurse (#1) verified a post-fall investigation started on 10/31/14 identified a facility staff member pushed Resident #6 in his wheelchair from the facility's van to the KDU. The nurse (#1) indicated the staff member hurried too fast while also looking for the resident's missing glasses. The resident "slipped out" of the wheelchair before reaching the KDU door. The nurse (#1) agreed the investigation did not include: * Specific details to identify how the fall and facial injuries occurred * A report from the KDU regarding the resident's injuries, treatment, or evidence KDU staff monitored the resident's neurological status while at the KDU * Neurological checks by the facility after the resident's return * Accurate and complete documentation and monitoring regarding the fall and injuries * A follow-up to the initial investigation Failure of staff to safely transport Resident #6 in his wheelchair resulted in his fall with injuries. Incomplete documentation and failure to monitor and follow-up may have contributed to Resident #6's tooth falling out 18 days later.

Based on observation, review of facility policy and procedure, record review, resident interview and staff interview, the facility failed to re-evaluate the appropriateness of the assistive devices when 2 of 3 sampled residents (Resident #2 and #7) voiced pain with the use of stand lift during transfers, and 1 of 2 residents (Resident #5) transferred with the assistance of a gait belt. Failure to provide for safe transfers resulted in injury and/or increased pain, and may affect patient safety through falls. Findings include: Review of the facility "Pro Assist Lift Operator Instructions" occurred on 12/19/13. The policy, updated April 2001, stated, "The Pro-Assist lift is designed for semi-ambulatory residents/patients (Patients/Residents that have adequate upper body strength) . . . 1. First choose the proper size sling . . . The sling fits across the back just above the waist line with the safety restraint strap buckled very snugly (without pinching) across the chest. . . . To adjust for snugness easily, grasp the sling under the resident's right arm and pull strap to the right until snug. To adjust bottom strap slings, grasp the sling at the waist on the left side, and pull strap to left until snug. . . . 5. Attach both sling couplings and adjust evenly. Encourage patient/resident to grasp handgrips (any of three positions) and use as much arm strength and leg strength as possible during transfer. . . ." Review of the facility policy titled, "Mandatory use of GAIT BELT" occurred on 12/19/13. This policy, dated 2005, stated, " . . . Procedure: . . . 5. To use a gait belt: . . . b. Grasp gait belt with an underhand grasp to provide support for the resident. c. Assist resident to transfer or ambulate. . . ." - During interview on the afternoon of 12/17/13, Resident #2 (identified as interviewable by the facility) stated he reported to an administrative staff member that the stand lift "messed up" his left shoulder and was told "that's the only thing (stand lift device) they can use." Resident #2 stated he heard "popping noises" in his shoulder when staff first started using the lift for transfers. Resident #2 demonstrated he could not raise his left arm above shoulder level while able to lift his right arm above his head. Resident #2 stated he uses a topical pain reliever medication and pain medications due to his shoulder pain. Resident #2 stated he sleeps two to three hours per night as the pain medications are not strong enough. Review of Resident #2's medical record identified an impairment in motor or sensory function of the lower extremities. Review of Resident #2's Minimum Data Set (MDS), dated [DATE], and annual MDS, dated [DATE] both identified the resident: cognitively intact; required extensive assistance of two or more persons for transfers, and with a functional limitation in range of motion of the lower extremities on both sides. Both MDSs identified Resident #2 received a scheduled and as needed (prn) pain medications, frequent pain, pain affecting sleep and activities, and an intensity of severe (11/30/13) and horrible (09/02/13). Resident #2's current care plan identified the following problems: * "Risk for falls. Uses w/c (wheelchair). Is using the stand up lift to transfer." Approaches included: ". . . Staff make sure . . . that resident has good footwear for using the lift. Use stand-up lift when transferring. Educate him to the benefits of using the lift for transfers." * "Resident has complaints of back, left shoulder and right wrist pain" with approaches including "Monitor pain . . . Administer . . . pain medications as ordered. . . . Notify GNP/MD (nurse practitioner or medical doctor) if adequate pain control is not achieved. Encourage rest periods and comfortable positioning. Observe care when transferring/repositioning. . . ." Review of an annual physical therapy evaluation, dated 12/18/12, identified Resident #2 "states his legs are very weak now and his shoulders are painful. . . . Uses bedrail, but no longer able to stand to transfer . . . Would benefit from LE (lower extremity) strengthening/ROM (range of motion) exercises to try to get back to standing transfers, however, resident states he is not interested in RA (restorative therapy) program at this time." Review of a physician progress notes [REDACTED]. . . He says that his shoulders hurt all the time because of the nurses using the lift and that when the hoist goes under his arms, his shoulders start hurting, especially at night. He says that the tramadol (mild pain reliever) does not work for him. Lidoderm patch (topical pain patch) does not work. He says that he cannot take oxycodone (pain medication used for moderate to severe pain) but he has not tried hydrocodone (pain medication used for moderate to severe pain; similar to oxycodone). He says that it would be helpful, especially at night. . . . We will increase the dose of Tylenol and put him on hydrocodone as needed and at night. . . ." Review of nurse's notes identified the following: * 06/28/13: ". . . (Resident) remarked that the standing lift caused his neck pain, as he was left to hang there. He always has an excuse." Review of a nursing assessment form, dated 11/29/13, stated ". . . complaints of back & shoulder pain. Legs very weak as are hands & arms." On 12/17/13 at 2:10 p.m., two certified nursing assistants (CNAs) (#3 and #4) transferred Resident #2 from the bed to the toilet using a stand lift. Observation showed the harness moved into the resident's right and left axilla (armpit) during the transfer. When the CNAs began to raise Resident #2 to the standing position, Resident #2 removed his left hand from the handgrip and rested the arm across the top edge of the harness. He stated he does this because the transfer hurts his shoulder. The two CNAs (#3 and #4) voiced awareness and stated Resident #2 does this quite often, and they have made the nurses aware. Facility staff continued to transfer even after the resident complained of increased pain to his shoulders. A physician progress notes [REDACTED]. The last PT evaluation, approximately one year ago identified the resident's legs as "very weak now and his shoulders are painful . . . no longer able to stand to transfer." Continued use of the sit-to-stand lift in consideration of these factors placed the resident at risk of falls, further strain on his shoulders and resulted in increased pain. - Review of Resident #7's medical record occurred on 12/19/13. Resident #7's [DIAGNOSES REDACTED]. Observation of Resident #7 at 8:10 a.m. on 12/19/13 showed her seated in a wheelchair with an arm rest supporting her right arm. Resident #7 stated her right shoulder hurt. On 12/19/13 at 8:50 a.m. and 10:10 a.m., two CNAs (#5 and #6) transferred Resident #7 with a stand lift from her wheelchair, positioned just outside of her bathroom, to a toilet in the resident's bathroom. During both observations, Resident #7's right arm dangled at her side unsupported. During both transfers the harness of the lift sling slid up into the resident's right and left axillary region. Resident #7's current care plan identified the problem of "Resident needs assistance with all her ADL (activities of daily living) needs" with interventions of: "Staff will assist her with all her ADL needs. . . ." The care plan did not address the manner in which staff should transfer Resident #7. Review of physical therapy notes identified the following: * 05/07/13: ". . . Sit to stand lift is appropriate for transfers. Other recommendations: . . . Shoulder brace to prevent subluxation." * 10/09/13: ". . . Her (right) shoulder is limited in ROM (range of motion) due to pain. X-ray in June was not very conclusive other than showing degenerative changes and possible rotator cuff injury. Resident has not had AROM (active range of motion - i.e. self initiated) in her (right) shoulder since her stroke. . . ." Record review identified through physical therapy (PT) notes to transfer Resident #7 with a sit to stand lift and shoulder brace. The PT notes also identified xray report results. Nursing staff failed to ensure proper transfer with the sit to stand lift and utilize a shoulder brace in recognition of Resident #7's impairment in motor or sensory function of the right arm due to her [DIAGNOSES REDACTED]; functional limitation in ROM of the right arm; and with regard of the PT evaluation. Sit-to-stand lift transfers for Resident #7 in consideration of these factors placed the resident at risk of falls, further strain and increased pain in her right shoulder. Resident #2's and Resident #7's records lacked current transfer assessments. The facility failed to ensure the completion of a transfer assessment which included an evaluation for safe transfers while pain issues were identified. This resulted in the residents continuing to have pain during transfers and the potential for an accident from the stand lift due to the residents limited assistance with the transfers considering their medical condition and pain. - Review of Resident #5's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. Resident #5's current quarterly MDS identified the resident required limited assistance with transfers. Resident #5's care plan identified the resident had chronic right shoulder pain. Observation on 12/17/13 at 10:15 a.m. showed a CNA (#2) assisted Resident #5 to stand after using the toilet. The CNA lifted the resident under his right arm. The CNA (#2) failed to use the gait belt that was around the resident's waist.