Every finding on record at Eastern Montana Veterans Home

Based on interview and record review, the facility failed to ensure staff members followed policies, procedures, and protocols to maintain resident safety by providing sufficient and necessary supervision on a secure care unit, for 4 residents (#s 6, 9, 10, and 12) of 6 residents sampled for injuries/abuse. This deficient practice contributed to resident altercations, and resident #10 sustained a hip fracture, which required hospitalization and surgical repair for the major injury; and resident #10 was not transferred properly and per the facility policies and procedures, after the fall, which may cause or contribute to an injury. Findings include:1. Review of a facility reported incident, dated 11/10/25, showed a resident-to-resident altercation occurred on the secure care unit between resident #10 and resident #12 on 11/9/25. The residents were sitting in the dining room together, and resident #12 pulled resident #10's wheelchair over, causing resident #10 to fall to the floor. Resident #12 was placed on one-to-one monitoring, and resident #10 had no injuries when assessed after the incident. The next day on 11/10/25, resident #10 was in pain and transferred to the ER for evaluation. Review of facility reported incident findings, submitted 11/18/25, showed resident #10 returned to the facility on [DATE] after surgery to repair his left hip fracture, sustained in the event with resident #12. The facility confirmed the incident did occur, with a plan to hold education with staff on the stages of dementia and behaviors, for those working on the secure care unit. During an interview on 12/10/25 at 2:08 p.m., NF2 stated staff called her the evening of 11/9/25 to inform her of a fall resident #10 had that day. NF2 stated staff informed her that resident #10 was doing ok and explained that resident #10 had been pushed over in his wheelchair by resident #12 and fell over onto the dining room floor. NF2 stated the next morning, 11/10/25, staff called to inform her of resident #10's noticeable pain level, with a plan to transfer him to the ER. NF2 stated resident #10 was admitted to the hospital and had surgery for a hip fracture. NF2 stated she was concerned that the incident could have caused a worse injury, like head trauma, and that would have been very serious. NF2 stated the facility had reviewed camera footage of the incident on 11/9/25 and apologized for the incident. NF2 stated the video footage showed that no staff were monitoring the dining room area, which was part of a large common room on the secure unit. NF2 stated, the staff member who should have been in the dining room area monitoring the residents should not have left them alone. NF2 stated she wondered why the staff member did not wait for others to be in the dining room before going into the kitchen area to put dishes away. NF2 stated the staff member should have immediately come back to the dining room to stop resident #12 from pushing resident #10 over. NF2 stated she was concerned about the lack of staff in the immediate area. During an interview on 12/10/25 at 10:15 a.m., staff member H stated she arrived on shift the morning of 12/10/25 and went to check on the residents in the secure unit. Staff member H stated she saw resident #10 moving around in bed and he looked like he was in pain. Staff member H stated she notified NF2 that resident #10 was going to transfer to the hospital for further evaluation. Staff member H stated staff on the secure unit were expected to be on the unit monitoring residents, and if a resident was identified to be a one-to-one monitoring status, the staff were to be within an arm's reach of the resident. Staff member H stated there are at least two CNAs on the unit for constant supervision of the residents. Staff member H stated that staff members have another staff member come replace them if they need to leave the unit, to go to break or lunch. During an interview on 12/10/25 at 11:28 a.m., staff member J stated she was working on the secure unit on 11/9/25 when resident #10 and resident #12 were in the dining room with staff member L. Staff member J stated she left to use the restroom on the unit since staff member L was with the residents. Staff member J stated staff member M left the unit to talk to the on duty nurse, and was not sure why staff member M did not use her radio or wait for another staff member to take her place. Staff member J stated she did not remember either resident #10 or resident #12's wheelchair wheels touching each other, or their wheels locked together. Staff member J stated staff member L went into the kitchen area, where the room divider was partially closed, out of the dining room area. Staff member J stated staff member L was speaking loudly to resident #12 since he was hard of hearing, saying, No, and so she ran out of the restroom to the dining room to help. Staff member J stated she went to get the nurse on duty and staff member M right away for assistance. Staff member J stated the nurse, another CNA on duty, and herself, transferred resident #10 from the floor to his wheelchair, manually, supporting him under both arms and holding the back of his pants. Staff member J stated that a gait belt was not used, but the gait belts were kept in the secure unit in a cabinet. Staff member J stated, We can do better about using gait belts, we don't have many residents on the unit who need assistance walking or moving around. Staff member J stated that staff in the secure unit all wear radios to communicate with each other. Staff member J stated there were usually three staff members on the secure unit to monitor residents. Review of resident #10's nursing progress notes, dated 11/9/25 at 12:45 p.m., showed: Event Type: Resident to resident, victimDate of Event: 11/9/25Time of event: 1245 (12:45 p.m.)Detailed description of event (how, when, where, vitals, symptoms) : Notified per CNA that this resident yanked another resident out of his w/c. Observed other resident lying on floor on his left side behind w/c & w/c was on it's side. Resident's have been separated & this resident stating He's just being stubborn.Patients description of event: unable d/t dementiaFull Range of Motion Assessment findings (i.e. wnl for resident, or describe abnormal findings): ROM as previously .Interventions (any Interventions what we can do as staff to prevent this event from happening again): residents separated, other resident on 1:1. [sic] Review of resident #10's nursing progress notes, dated 11/9/25 at 9:51 p.m., showed: Reason for alert charting: Victim of resident-to-resident physical altercation . Patients separated . Patient has no recollection of events that occurred, patient currently in bed, eyes closed, appears to be comfortable with even and unlabored respirations . Patient displays no S/S pain or discomfort . Patient remains at baseline [sic] Review of resident #10's nursing progress notes, dated 11/10/25 at 10:26 a.m., showed: LATE ENTRY Note Text: Called to resident's room by CNA. Resident was unable to sit up or move around due to severe pain. ROM to lower left extremity, resident grimacing and in pain. Notified ADON and DON that resident needed to be sent out to the ER. Resident sent to [Hospital Name] by ambulance. Notified family, wife and daughter. Report given to ER nurse.Review of a facility policy titled Safe Resident Handling/Transfers, revised 5/15/25, showed: . All residents require safe handling when transferred to prevent or minimize the risk for injury to themselves and the employees that assist them. While manual lifting techniques may be utilized dependent upon the resident's condition and mobility, the use of mechanical lifts are a safer alternative and should be used 3. Mechanical lifting equipment or other approved transferring aids will be used based on the resident's needs to prevent manual lifting except in medical emergencies 5. Handling aids may include gait belts, transfer boards, and other devices .Review of a facility policy titled Accidents and Supervision, revised 5/16/25, showed: . The resident environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents Policy Explanation and Compliance Guidelines . 5. Supervision- Supervision is an intervention and a means of mitigating accident risk. The facility will provide adequate supervision to prevent accidents. Adequacy of supervision:a. Defined by type and frequencyb. Based on the individual resident's assessed needs and identified hazards in the resident environment [sic]2. Review of a facility reported incident, dated 8/12/25, showed that a resident-to-resident altercation occurred on the secure care unit between residents #6 and #9. A physical exchange occurred between the two residents until staff came to the area and separated them. Assessments were then completed, and there was no physical injury or a negative psychosocial outcome apparent for either resident #6 or #9. Review of facility reported incident findings, submitted 8/20/25, showed residents #6 and #9 physical altercation was reviewed by camera footage. Resident #9 continued to receive one-to-one monitoring, psychosocial monitoring, and an appointment with the behavioral health provider following the incident. Staff education was completed on behavioral management and one-to-one monitoring expectations, and a dementia care training was scheduled for staff in September 2025. During an interview on 12/10/25 at 2:42 p.m., staff member A stated the previous Director of Nursing had educated staff member N in response to an incident involving a lack of staff supervision on the secure care unit in August 2025, and the formal Director of Nursing issued a formal disciplinary action since it involved a staff member and resident #6 and #9. Review of a facility document titled, Formal Written Warning, dated 8/13/25, showed staff member N received notification from the previous Director of Nursing that he failed to follow instructions. The facts of the incident showed, Failure to follow instruction for 1:1 supervision. Did not notify supervisor of lunch break and leaving facility without notice. This resulted in a resident to resident altercation. See page 13 of handbook #4 behaving in a way that may damage or injure any person or property; #19 Failure to meet acceptable quality and quantity work standards. [sic]

Based on interview and record review, the facility failed to ensure a complete investigation of a facility reported incident was provided to the State Survey Agency, and failed to maintain and provide accurate documentation of investigative findings for 3 (#s 2, 4, and 7) of 12 sampled residents. Findings include:During an interview on 12/10/25 at 1:03 p.m., staff member A stated he could do better with documentation of facility reports of incidents. Staff member A stated that one of the incidents being looked at took place four weeks ago, and he could not provide more documentation for it. Staff member A stated it was busy in November (2025), and four incidents happened in one week, and all of them needed to be reported. Staff member A stated, I don't have anything else for that incident (between resident #4 and resident #7). The documentation provided included one paragraph of findings that would have been submitted to the State Survey Agency, and no other event forms, documents, or evidence related to the event. During an interview on 12/10/25 at 2:50 p.m., staff member A stated his desk had been full of papers, and this week he had the opportunity to review and go through them. Staff member A stated he started his position in August (2025), and in September (2025) was the main staff member to report incidents. Staff member A stated that staff member B could also report incidents. Staff member A stated that some incident findings were based on his own interview notes with staff. Staff member A stated that those were all written in the findings section for the investigation information. Staff member A stated he saved those as reports and considered the notes to be the investigation findings, and he did not keep separate interview templates or documents. A. Review of a facility reported incident, dated 11/23/25, showed a resident-to-resident altercation between resident #4 and resident #7, which took place in a dining room. The report noted there was a verbal disagreement which led to resident #7 pushing a table towards resident #4. Review of the facility reported incident findings, submitted 12/2/25, showed findings related to an incident with resident #2, and a former travel staff member, and the information did not mention resident #4 and #7. The facility did not conduct a complete and accurate investigation of the incident between residents #4 and #7. There was no evidence of interviews completed with residents, staff, or witnesses involved. There were no interventions taken to address the incident between resident #4 and #7, for analysis and prevention of a recurrence between the two residents. B. Review of a facility reported incident, dated 11/26/25, showed an allegation of staff to resident verbal abuse. A contracted staff member spoke to resident #2 in an inappropriate way. The staff member was suspended, and an investigation was started. Review of the facility reported incident findings, submitted 12/3/25, showed the administrator interviewed other residents in the hall where resident #2 resided. The facility confirmed that the verbal abuse occurred, and the contracted staff member did not return to work at the facility. The facility did not conduct a complete and thorough investigation of the incident between resident #2 and the contracted staff member. The findings provided were the same reports viewed by the State Survey Agency, and the evidence did not include which residents were interviewed and their responses. The findings did not include interviews with other staff members who witnessed the incident. Review of a facility document, titled Incidents and Accidents, dated 5/16/25, showed: It is the policy of this facility for staff to utilize the risk management section. to report, investigate, and review any accidents or incidents that occur or allegedly occur, on facility property and may involve or allegedly involve a resident. The purpose of incident reporting can include:- Assuring that appropriate and immediate interventions are implemented and corrective actions are taken to prevent recurrences and improve the management of resident care. Compliance Guidelines:. 3. Incidents or accidents involving employees or visitors will be documented per facility protocol. 5. The following incidents/accidents require an incident/accident report but are not limited to:- . Resident to resident altercations- Resident injuries due to staff handling. 13. Documentation should include the date, time, nature of the incident, location, initial findings, immediate interventions, notifications and orders obtained or follow-up interventions. 15. If an incident/accident was witnessed by other people, the supervisor or designee will obtain written documentation of the event by those that witnessed it and submit that documentation to the Director of Nursing and/or Administrator. Review of a facility policy titled, Abuse, Neglect and Exploitation, revised 7/6/25, showed: . V. Investigation of Alleged Abuse, Neglect and ExploitationA. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur.B. Written procedures for investigations include:. 4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations;. 6. Providing complete and thorough documentation of the investigation. VII. Reporting/Response. B. The Administrator will follow up with government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within 5 working days of the incident, as required by state agencies.

Based on record review, the facility staff assigned to a resident neglected to ensure he received necessary ADL care and was left in bed for an extended period of time without help. The resident experienced pain, distress, and skin abrasions from the event, for 1 (#4) of 5 sampled residents. Findings include: Review of a Facility Reported Incident, dated 3/6/25, showed resident #4 was left unattended in his room. The resident was residing on the special care unit, and he was not provided cares by CNAs (NF10 and NF11) working on the unit. Review of resident #4's nursing progress notes, dated 3/6/25 at 11:42 a.m., showed: CNA called this nurse to resident's room. Upon entering, this nurse noted resident lying on his side at the foot of the bed between the mattress and the footboard. Resident's Left arm was bent and caught between mattress and footboard, elbow touching the floor. Resident screaming and crying, very combative to all staff. Resident did not want to be touched or moved. Resident was covered in BM, as was the floor, bed, and floor mats. Bed was noted to be high, except the foot of the bed. Resident was assisted from bed to floor by this nurse and 3 CNAs. Skin tears noted to back of left hand by thumb, left wrist, and RFA. Dark purple bruising noted to back of left hand. Large dark-colored mark noted to Left hip with an indentation in the middle, likely from pressure. 2 other nurses came to assist with cleaning the resident up and dressing skin tears. Skin tears cleansed with soapy water. Adaptic applied, covered with silicone bordered gauze. Resident rolled onto a blanket and lifted x4 staff onto bed. Resident very combative during cares, hitting staff and kicking staff, nearly kicking staff in the face [sic] Review of NF10's witness statement, written by NF4, dated 3/6/25, showed: . Resident [#4] door was cracked all night so staff could check on him. ½ to 1 hr checks were done thru out night. Approximatly at 0200 (2:00 a.m.) the othe CNA stated she had HA + stopped working contined to do checks . Around 6am care were being done on 2 other residents + cleaning of a room needed done . at this time [resident #4] started to yell out. Did walk down the hall and see Resident on the floor on matt. It was asked to other CNA (NF11) what to do and aid stated 'I can't do anything the day shift will be in. Continued to get people up as another Resident needed to be changed + gotten up for day. Employee stated she didn't feel comfortable with resident because he would yell + call CNA names and belittle her. Didn't think to tell the nurse. [sic] Review of NF10's employee personnel file showed NF10 was terminated on 3/13/25. NF10 received abuse, neglect, and resident rights training on 2/3/25 from NF3. Review of NF11's witness statement, written by NF4, dated 3/6/25, showed: Resident was checked and changed at 2030 (8:30 p.m.) + linen change he was taking off pullup up and peeing everywhere . Resident 0145 (1:45 a.m.) checked was sleeping brief wet + again took brief off + was peeing on bed lining changed and care done . Did no cares from 0400 (4:00 a.m.) to 0700 (7:00 a.m.) . Did not hear Resident from 0400 (4:00 a.m.) - till 0630 (6:30 a.m.) . [sic] Review of NF11's employee personnel file showed NF11 was terminated on 3/11/25 due to neglect. NF11 had a previous performance review on 12/12/24 which showed, Ensures residents are well cared for and look good when working in the SCU. NF11 had a discipline note signed by NF4 which showed a termination date of 3/11/25 with supporting information which showed, Cameras reviewed and CNA did not do any cares from 0200 (2:00 a.m.) to 0700 (7:00 a.m.) causing neglect to residents. Review of a facility document titled, Abuse and Neglect - Clinical Protocol, dated Quarter 3, 2018, showed: . 2. 'Neglect,' as defined at Section 483.5, means the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress.' . 5. Along with staff and management, the physician will help identify situations that might constitute or could be construed as neglect; for example . inattention to . resident wishes, inappropriate management of problematic behavior, recurrent failure to provide incontinence care .

Based on interview and record review, the facility failed to prevent a resident with dementia from eloping from the facility through the front entrance doors, leaving the facility property without supervision and accessing a public road, for 1 (#1) of 6 subsampled residents at risk for elopement. The resident sustained lacerations to his forehead after falling during the elopement. Findings include: Review of a facility reported incident, submitted to the State Survey Agency, dated 5/3/25 at 1:45 p.m., showed resident #1 was found outside of the facility by the police and was transported to the hospital for an evaluation. During an interview on 6/16/25 at 4:18 p.m., NF2 stated she received a call from the facility on 5/3/25. NF2 stated resident #1 was found at an apartment complex, on the ground, by a passerby who called the police and ambulance. NF2 stated resident #1 sustained a head laceration and was admitted to the hospital for observation. A call was placed to the police department on 6/18/25 at 12:40 p.m., and the police chief stated NF5 was the only staff member who could release the report for resident #1, regarding the incident which occurred on 5/3/25. The police chief stated NF5 would not be in the office until 6/19/25. During an interview, on 6/18/25 at 12:55 p.m., staff member F stated on 5/3/25 at 11:30 a.m., he received a call from the police department stating a resident was located near an apartment complex. Staff member F stated the facility did a head count of all residents and realized resident #1 was missing from the facility. Staff member F stated he responded to the location where resident #1 was found and it appeared the resident had a laceration to his head. Staff member F stated the resident was transported by ambulance to the hospital for an evaluation. Staff member F stated NF6 responded to the front door alarm when resident #1 exited, but did not see any residents when he (NF6) scanned the outside perimeter of the facility. Staff member F stated he was not sure why NF6 did not do a head count of the residents in the facility after the alarm went off. During an interview, on 6/19/25 at 8:37 a.m., NF6 stated he responded to the front door alarm on 5/3/25 at 10:08 a.m. NF6 stated when he responded to the alarm, he exited the front door of the facility, and scanned the perimeter of the building. NF6 stated he did not see any residents outside. NF6 stated he received orientation when he started his employment, but never read the facility elopement policy. NF6 stated during his orientation, NF4 stated, You know all this, you can just sign the paper. Calls were placed to NF5 on 6/19/25 at 8:00 a.m. and 12:38 p.m., with voicemails left on both occasions requesting a return call regarding resident #1's incident on 5/3/25. No return call was received from NF5 by the end of the survey. Review of a facility document titled, Timeline for elopement of (resident #1), dated, 5/3/25, showed: - 10:06 a.m. (resident #1) exits the front doors and walks around the front of the building very quickly. - 10:08 a.m. staff member, (NF6), does exit the front doors, responding to the alarm, stands on the front patio and scans the immediate area and remains outside looking around the area for about 30 seconds and returns inside. - Camera footage reviewed by (NF3) 5/3/25 at noon. Review of resident #1's EHR showed resident #1 was admitted to the facility on [DATE] for skilled nursing services with a diagnosis of dementia. Review of resident #1's elopement risk assessment dated , 4/7/25, showed the resident was at risk for elopement with a score of 6. Review of resident #1's wander assessment dated , 4/7/25, showed the resident was at moderate risk for wandering with a score of 10. Review of resident #1's nursing progress notes showed the following: - On 4/7/25 at 5:45 p.m., resident #1 was found in another resident's bathroom. Resident #1 required redirection by the nurse back to his room. - On 4/7/25 at 8:00 p.m., a wander guard was placed on resident #1's right ankle. - On 4/16/25 at 12:40 p.m., resident #1 eloped from the front doors of the facility. The nurse responded to the alarm. Resident #1 resisted staff redirection and continued to walk away from the facility accompanied by the nurse. Resident #1 was eventually redirected by the nurse back into the facility. The resident was not unattended during the attempted elopement. - On 4/17/25 at 8:03 p.m., resident #1 was found on the service hallway setting off the door alarm. Resident #1 was redirected by staff back to the main part of the facility from the service hall to the D hall. - On 5/3/25 at 1:46 p.m., a call was received from the police department at 11:28 a.m. Resident #1 was found outside the facility at an apartment complex. Resident #1 was found by the nurse seated on a bench accompanied by two police. Resident #1 had an abrasion on his left forehead and appeared to guard his left arm. Emergency medical services were called, and the resident was taken to the emergency department for an evaluation. A written request for resident #1's 5/3/25 police report was made to the facility on 6/16/25 and 6/17/25. No documentation was received from the facility by the end of the survey. Review of the facility document titled, Process for triggered wanderguard alarm, undated, showed: 1. All staff will respond any door that is alarming. 2. Staff will immediately assess why the door is alarming. 3. Staff will walk the parameter of the area to identify if a resident has left the building. 4. If there is not an identified reason the door is alarming, a CODE GRAY must be announced on the overhead pager and all staff must respond to the C/D nurses station. 5. A full head count must be completed by staff. The A/B nurse will be responsible for assigning staff which residents to check on and/or locations to check. Staff will report completed assignments to the A/B nurse. 6. The administrator and Director of Nursing/on-call nurse, must be notified of any elopement. 7. If a head count has been completed and a resident is not located, law enforcement will be notified. [sic]

Based on interview and record review, the facility failed to ensure a system of communicable disease surveillance was maintained for tracking purposes and to protect residents from further transmission of infection, during an influenza outbreak in the facility, with 2 (#s 7 and 10) of 5 sampled residents, remaining in the same room after one tested positive for the flu and the other was not tested. Findings include: During an interview on [DATE] at 8:55 a.m., staff member L stated residents and staff members began to get sick very quickly during the influenza outbreak (week of [DATE]). Staff member L stated resident #7 and resident #10 were roommates who had been ill during that time. Staff member L stated NF4 was the infection preventionist. Staff member L stated both NF3 and NF4 were out of the facility during the time of the outbreak, so she coordinated the response between the facility and State health department. Staff member L stated there were discrepancies in NF4's data that had been documented, including dates of when residents were tested and when residents were deceased . During an interview on [DATE] at 4:56 p.m., NF3 stated staff and residents were sick during the time an influenza outbreak occurred (week of [DATE]). NF3 stated staff member L had email coordination with the State health department during the time she (NF3) and NF4 were out of the facility [DATE] through [DATE]. NF3 stated NF4 stated to her information for the influenza outbreak was kept in the facility infection control binder. NF3 stated NF4 communicated that she (NF4) had reported the outbreak to the State health department. NF3 stated NF4 reported the infection control binder would have a list of residents tested, and symptomatic residents. NF3 stated resident #10's roommate at the time (resident #7) was positive for the flu (week of [DATE]). NF3 stated resident #10 was not tested for flu. NF3 stated resident #7 remained in the same room as resident #10 after testing positive for flu. NF3 stated, We knew we should have moved people, but we didn't want to mix them with people who weren't symptomatic. During an interview on [DATE] at 11:32 a.m., NF4 stated that four residents had respiratory symptoms, and the facility began testing for influenza. NF4 stated she was out of the facility during the influenza outbreak. NF4 stated staff members helping with infection control coverage in her absence were the facility's previous ADON, and the MDS nurse. NF4 stated the previous ADON was supposed to keep a list and document residents for surveillance. NF4 stated when she returned to the facility, she was trying to backtrack to get everything done. NF4 stated she did not know where the list was of who was isolated or who was not. NF4 stated she documented dates incorrectly, when she was trying to work outside of the facility. NF4 stated she did not have the tracking and trending completed in the infection control binder for February (2025). NF4 stated she did not complete the infection mapping for February (2025), and did not receive the infection mapping from the previous ADON. 1. Review of resident #7's physician progress notes, dated [DATE], showed medical problems including, Debility, Atrial fibrillation . CHF, Cognitive impairment . There was not a documented date in resident #7's electronic medical record to show when he tested positive for influenza. There was no documentation showing the facility moved resident #7 to a different room when he tested positive for influenza. 2. Review of resident #10's medical diagnosis report, dated [DATE], showed a primary diagnosis of Chronic Obstructive Pulmonary Disease with (acute) Lower Respiratory Infection, a secondary diagnosis of Type 2 Diabetes Mellitus, and unspecified Atrial Fibrillation. Resident #10's primary diagnosis placed him at higher risk for respiratory complications. There was no documentation of testing resident #10 for influenza. There was no documentation of moving resident #10 when his roommate (resident #7) tested positive for influenza. Review of a facility infection control map dated, Feb/2025, showed no resident rooms with any identified cases for influenza. A written request was made to the facility on [DATE] for the February 2025 infection control log. No documentation was received by the end of the survey. Review of a facility document, untitled and undated, showed a list with the following: - Two residents testing positive on [DATE], - Nine residents testing positive on [DATE] and, - Four residents testing positive on [DATE]. The list did not show documentation of resident #7 and resident #10 being tested on 2/15, 2/16, or [DATE]. Review of a facility policy titled, Infection Prevention and Control Program, revised [DATE], showed: . 7. Surveillance . b. Surveillance tools are used for recognizing the occurrence of infections, recording their number and frequency, detecting outbreaks and epidemics . e. The medical staff will help the facility comply with pertinent state and local regulations concerning the reporting and management of those with reportable communicable diseases . Review of a facility policy titled, Isolation - Categories of Transmission-Based Precautions, last dated Quarter 3, 2018, showed: . Transmission-Based Precautions will be used whenever measures more stringent than Standard Precautions are needed to prevent or control the spread of infection . e. Influenza . 3. Resident Placement a. Place the resident in a private room if possible. b. When a private room is not available, residents with the same infection with the same microorganism but with no other infection may be cohorted .

Based on interview and record review, the facility failed to ensure nursing staff were adequately trained and had the knowledge necessary to fulfill the nursing role related to the facility's elopement policy. The failure resulted in a resident eloping from the facility unattended, for 1 (#1) of 6 subsampled residents at risk for elopement. Findings include: During an interview, on 6/18/25 at 12:55 p.m., staff member F stated on 5/3/25 at 11:30 a.m., he received a call from the police department stating a resident was located near an apartment complex. Staff member F stated the facility did a head count of all residents and realized resident #1 was missing from the facility. Staff member F stated he did not hear the alarm sound the day (5/3/25) resident #1 eloped. Staff member F stated NF6 responded to the door alarm, but did not see any residents when he scanned the outside perimeter of the facility. Staff member F stated he was not sure why NF6 did not do a head count of facility residents after the alarm sounded. During an interview, on 6/19/25 at 8:37 a.m., NF6 stated he responded to the front door alarm on 5/3/25 at 10:08 a.m., the day of #1's elopement. NF6 stated he was not aware he was to do a head count of residents in the facility when a door alarm sounded. NF6 stated he received orientation when he started his employment, but never read the facility elopement policy. Review of resident #1's nursing progress note, dated 5/3/25 at 1:46 p.m., a call was received from the police department on 5/3/25 at 11:28 a.m., resident #1 was found outside the facility at an apartment complex. Review of a facility document titled, Timeline for elopement of (resident #1), dated, 5/3/25, showed the resident exited the facility out the front doors and walked around the building quickly. In under two minutes, staff member NF6 exited the front doors to check why the alarm sounded. The employee scanned the area, and returned inside, not noticing the resident. Review of the facility document titled, Process for triggered wanderguard alarm, undated, showed: . 4. If there is not an identified reason the door is alarming, a CODE GRAY must be announced on the overhead pager and all staff must respond . 5. A full head count must be completed by staff . 7. If a head count has been completed and a resident is not located, law enforcement will be notified. [sic]

Based on interview and record review, the facility failed to have an RN working at least eight consecutive hours a day, per the twenty-four-hour period, seven days per week. This deficient practice had the potential to affect all residents who received nursing services and when an RN was needed, one was not immediately available. Findings include: Record review of the July and September 2024 schedule for licensed nursing, showed the following dates did not have eight consecutive hours of RN coverage documented in a twenty-four-hour period: - 7/6/24, 7/7/24, 7/13/24, 7/14/24, 07/20/24, and 9/1/24. During an interview on 2/13/25 at 11:30 a.m., staff member A reviewed and compared the facility's nursing schedule with the [NAME] payroll-based journal report for the period of July 2024 to September 2024. Staff member A stated on the [NAME] report there were no RN hours within a twenty-four-hour period on the dates triggered for No RN hours. Staff member A stated the facility had one RN out with short notice. Staff member A stated the director of nursing had been on call but did not work eight consecutive hours. Staff member A stated the facility had not applied for a staffing waiver.

Based on observation, interview, and record review, the facility failed to ensure staff prepared food in a sanitary manner; failed to ensure freezer equipment was maintained and that food items in the walk-in refrigerator and freezer were covered, labeled, and dated. This failure increased the risk of food borne illnesses, and may negatively affect all residents receiving services from the dietary department. Findings include: During an observation on 2/10/25 at 12:44 p.m., staff member H was working in a food preparation area, with a grown mustache and beard, which was not covered with a beard net. Staff member H failed to uphold infection control measures related to food safety. During an observation on 2/10/25 at 12:47 p.m., the walk-in freezer had a box with a plastic bag of omelets inside, which was left partially open, and not dated. There was an opened plastic bag holding the undated pork sausages. During an observation and interview, on 2/10/25 at 12:48 p.m., the walk-in freezer had large chunks of ice buildup under one of the compressor fans on the top shelf. There was a silver tray placed underneath the fan, to hold the ice chunks. The shelves below had boxes of food placed directly below the area with the tray holding the ice chunks. Two of the boxes of food had ice chunks stuck to the backs of the boxes. Staff member G stated there was a request put in for a new fan, and they were waiting for it to be purchased. Staff member G stated she would ask staff to chip the ice chunks away, and she usually had staff clear the tray area of the ice chunks. During an observation on 2/10/25 at 12:58 p.m., the walk-in refrigerator had two heads of lettuce, not covered, placed in a colander, which was in a box on the shelf. During an observation on 2/12/25 at 11:43 a.m., staff member H was cutting meat in the cold preparation food area, with a grown mustache and beard, which was not covered by a beard net. Staff member H had several skin tears on his right forearm, which weren't covered. Staff member H had several scabbed over skin tears on his left forearm which weren't covered. During an observation on 2/12/25 at 11:47 a.m., the walk-in freezer still had large chunks of ice buildup under one of the compressor fans, on the top shelf. A silver tray was directly underneath the fan on the shelf, to hold the ice chunks. The shelves below had boxes of food placed directly under the fan and tray holding the ice chunks. Two of the boxes of food had ice chunks stuck on the backs of the boxes. During an interview on 2/12/25 at 12:48 p.m., staff member H stated he completed ServSafe training three weeks ago. Staff member H stated someone called off that day, and said, So we are short-handed and scrambling. During an interview on 2/12/25 at 3:16 p.m., staff member G stated she thought the facility had a policy for staff to wear beard nets if they had facial hair that grew out longer than a half an inch. Staff member G stated she asked staff to chip away ice chunks that formed on the silver tray under one of the walk-in freezer's compressor fans. During an observation on 2/13/25 at 9:35 a.m., the walk-in refrigerator still had the two heads of lettuce, uncovered, placed in a colander, in a box on a shelf. Review of a facility policy titled, Dress Code and Personal Hygiene, dated May 2019, showed: . Arranging hair so that it does not interfere with work assignments . depending on . work area, an employee with long hair may require a hair net . Facial hair should be trimmed close to the face and kept clean . Review of a facility policy titled, Food Receiving and Storage, dated November 2022, showed: . Food services, or other designated staff, maintain clean and temperature/humidity appropriate food storage areas at all times . All foods stored in the refrigerator or freezer are covered, labeled and dated (use by date) . refrigerated foods are stored in such a way that promotes adequate air circulation around food storage containers . Wrappers of frozen foods must stay intact until thawing . [sic]

Based on interview and record review, the facility failed to assess a resident for safety with smoking, failed to monitor the resident's location when smoking and ensure the resident signed out of the facility when smoking, and failed to follow and adhere to the facility policy related to resident smoking. These failures occurred over an extended period of time, for multiple shifts and days, and multiple staff failed to adhere to the policy, for 1 (#39) of 17 sampled residents. Findings include: During an interview on 2/10/25 at 3:11 p.m., resident #39 said he goes outside to smoke four to five times a day. He said he must go off the facility property to smoke because there is a no smoking policy. Resident #39 said he had a warm coat and gloves for standing outside. Resident #39 said there is nowhere to go to be sheltered from the wind and cold weather when out smoking. Resident #39 said he knows that he is supposed to sign out when he goes out and smokes, however he said he doesn't sign out. Resident #39 was unable to explain why he did not sign out. Resident #39 said he had never gotten locked out after hours because of smoking. Resident #39 said there is a button, and when he rings for the staff, they come quickly and let him in. Review of facility document titled Smoking Policy - Residents, dated 10/2023, showed: . - Smoking is only permitted in designated resident smoking areas, which are located outside of the building. - The attending physician will be consulted with to determine if safety restrictions need placed on the resident's smoking privileges. - Residents who have independent smoking privileges are permitted to keep cigarettes, electronic-cigarettes, pipes, tobacco, and other smoking items in their possession. Only disposable lighters are permitted. All other forms of lighters, including matches, are prohibited. - If the facility policy changes to one that prohibits smoking (including electronic cigarettes, residents who are currently allowed to smoke will be provided an area to smoke which maintains the quality of life and safety for smoking residents, while considering the health and well-being of non-smoking residents. During an interview on 2/11/25 at 2:00 p.m., staff members A and B discussed the smoking policies and facility expectations. Staff member A said the facility went smoke free sometime in the summer of 2024. The residents that were smoking at that time were grand-fathered in. The residents are not allowed to keep their smoking paraphernalia with them. The facility had provided a metal container that is weatherproof, and the residents keep their cigarettes in there. Staff member A and B said the residents were expected to sign out when they go outside to smoke as they are going off the property. Staff member A said there was not a shelter of any kind for the residents. Staff member A said the facility didn't build anything for shelter as the smoking took place off the facility property. Review of the facility document titled, Release of Responsibility for Leave of Absence, for dates 1/27/25 through 2/10/25, showed resident #39 had not signed out at all to go smoke during that time, even though resident #39 stated he goes outside four or five times every day to smoke. During an interview on 2/13/25 at 8:14 a.m., staff member B said resident #39 knows to sign out when he goes out to smoke. Staff member B said she would not be surprised that resident #39 had not been signing out. Staff member B said resident #39 knows he is to sign out, he says he will, and then obviously he does not sign out. Staff member A said the smokers that are outside after dark were given reflectors to put on their coats for increased safety. Review of resident #39's, Smoking Evaluation, dated 9/03/24, completed at 5:57 p.m., showed, the assessment as incomplete, and resident #39's ability to safely smoke was not assessed. Resident #39 was not assessed for cognitive issues and confusion related to ability to smoke. Those cognition questions were left unanswered. Visual acuity and dexterity problems were not assessed and answered. Questions to resident #39's ability to light and extinguish his own cigarettes were not answered. Review of resident #39's Nurse Practitioner notes showed: - 12/18/24, resident #39 was an active smoker, however smoking safety had not been addressed. - 1/14/25, smoking was mentioned, but smoking safety was not addressed. - 1/21/25, #39 was a smoker and had no interest in smoking cessation, but smoking safety had not been addressed. - 1/28/25, the resident smoked but smoking safety had not been assessed. Review of resident #39 physician notes, dated 11/23/24, showed the physician identified resident #39 smoked. There was no documentation to show resident #39 was safe to smoke.

Based on interview and record review, the facility failed to ensure resident PASRRs (Pre-Admission Screening and Resident Reviews) were completed and accurate for 3 (#s 28, 35, and 38) of 17 sampled residents. Findings include: 1. Review of resident #28's EMR, accessed 2/12/25, showed the resident was admitted to the facility on [DATE]. The resident's diagnoses included, . Dementia other disease class with behavioral disturbance, anxiety disorder unspecified, mood disorder known psychological condition unspecified, major depressive disorder single episode unspecified, post-traumatic stress disorder chronic, and suicidal ideations . Review of resident #28's PASRR, dated 06/29/22, showed: Categorical approval - convalescent stay, if he (#28) stays past 29 days a new L 1 (level one) must be submitted . [sic] During an interview on 2/12/25 at 4:00 p.m., staff member A stated resident #28 had a PASRR completed on 6/29/22 and was not aware it was a categorical approval. Staff member A stated a new PASRR Level One would be completed on resident #28. 51111 2. a. Review of resident #35's medication administration record, dated January 2025, showed medical conditions including: .state of emotional shock and stress, unspecified; hallucinations, unspecified; mood disorder due to known physiological condition, unspecified; depression, unspecified; posttraumatic stress disorder, unspecified; cognitive communication deficit . b. Review of resident #38's electronic medical record showed diagnoses of cognitive communication deficit; major depressive disorder, recurrent, unspecified; other specified persistent mood disorders; violent behavior; post-traumatic stress disorder, chronic . A request was made to the facility on [DATE] at 9:50 a.m., for PASARR Level One forms for resident #35 and #38. No forms were provided from the facility by the end of the survey. During an interview on 2/13/25 at 11:19 a.m., staff member A stated she could not find PASARR Level One forms for resident #35 and #38. Staff member A stated she would have been the staff member to have a PASARR started for resident #35 and #38 due to their diagnoses. Staff member A stated she did not know why she did not do that for resident #35 or resident #38 to have them done. Review of pages 8 and 9 of a facility document titled, Facility Assessment, updated 7/23/24, showed: .1.3b Cognitive Disabilities: . PASSR completed to determine other accommodations. The appropriate assessments are completed to ensure resident is appropriately placed . [sic]

Based on interview and record review, the facility failed to ensure POLST forms were completed accurately in the electronic medical records, for 2 (#s 45 and 109) of 17 sampled residents. Findings include: A review of resident #45 and #109's electronic medical records, showed POLST forms with no date of the signature, which is required on the form for validity and the physician order. The dates should have been filled in next to the provider's signature. Resident #45's POLST form showed a checkmark next to, Yes CPR, and Full Treatment. Resident #109's POLST form showed a checkmark next to, No CPR, and Selective Treatment. During an interview on [DATE] at 8:29 a.m., staff member A stated POLST forms are reviewed by nursing staff members during a resident's admission. Staff member A stated POLST forms were reviewed annually during a resident's care conferences but not during all quarterly care conferences. Staff member A stated there is no specific nurse overseeing or reviewing POLST form completion for new admissions, it is usually the admitting nurse who reviews it. Staff member A stated the provider who completed the POLST form reviews the form. A request was made on [DATE] at 9:50 a.m., for a hard copy document of resident #45 and resident 109's POLST forms. The facility provided a hard copy document of resident #45's POLST form which still showed a missing date next to the provider's signature. Review of a facility document titled, Advance Directive Policy, included in the Admission Packet, showed: . If you do have an advance directive, we will ask for a copy to put in your medical record and give to your physician. . We will comply with the directions given in your advance directive in accordance with applicable laws, your physician's orders . Review of a facility policy, titled, Advance Directives, revised [DATE], showed: . Physician Orders for Life-Sustaining Treatment (or POLST) . form - a form designed to improve patient care by creating a portable medical order form that records patients treatment wishes so that emergency personnel know what treatments the patient wants in the event of a medical emergency . . Prior to or upon admission of a resident, the social services director or designee inquires . about the existence of any written advance directives . if the resident . has executed one or more advance directive(s) . copies of these are obtained and maintained in the same section of the residents medical record . . The director of nursing services (DNS) or designee notifies the attending physician of advance directives . so that appropriate orders can be documented in the residents medical record and plan of care . The residents wishes are communicated . in care planning meetings .

Based on observation, interview, and record review, the facility failed to provide a clean, sanitary, and homelike environment for 2 (#s 45 and 109) of 17 sampled residents. Findings include: During an observation on 2/11/25 at 9:35 a.m., resident #45's bathroom floor had color stains around the edges of the toilet, towards the wall, behind the toilet. There was dark brown crusted debris along the linings of the walls to the left of, in front of, and behind the toilet. The bathroom had caked and dried dark yellow substance on the floor which appeared to be urine, and there was a strong odor of urine. During an observation on 2/11/25 at 2:29 p.m., resident #45's bathroom floor still had colored stains around the edges of the toilet, towards the wall, behind the toilet. There was dark brown crusted debris along the linings of the walls to the left of, in front of, and behind the toilet. There was still a strong odor of urine. During an observation on 2/11/25 at 2:59 p.m., along the bottom of resident #109's wall below the heater, close to the sink area, was a peeling hole in the wall with paint cracking and lifting up from the edges of the hole. During an interview on 2/12/25 at 3:29 p.m., staff member G stated housekeeping staff had assignments to clean resident rooms daily, which included cleaning in the bathrooms. Staff member G stated housekeeping completes a deep cleaning of resident rooms and bathrooms when a resident is discharged and before a new admission arrives. During an observation on 2/13/25 at 9:12 a.m., resident #45's bathroom had a caked and crusted dark yellow urine stain along the floor on the right side of the toilet. A strong odor of urine was present in the bathroom. There was dark brown crusted debris along the linings of the walls to the left of, in front of, and behind the toilet. During an interview on 2/13/25 at 9:15 a.m., staff member K stated, I think I know which bathroom you want to look at. Staff member K stated she had been working in the facility for three weeks. Staff member K stated she had not deep cleaned resident #45's bathroom and had not gone in there to clean that day. Staff member K stated the crust along the edges of the wall to the floor had been there since she started. Staff member K stated she cleans resident rooms and bathrooms everyday as an assignment. During an interview on 2/13/25 at 9:25 a.m., resident #109 stated he was not told what happened to make the hole in the wall below the heater. He stated it was like that since he got to the facility about two weeks ago. He stated he thought it's gotten bigger since he first arrived. He stated no staff from the facility had tried to cover or fix the hole since he had been in the room. Review of a facility policy titled, Cleaning and Disinfecting Resident' Rooms, dated April 2013, showed: . Housekeeping surfaces (e.g., floors, tabletops) will be cleaned on a regular basis, when spills occur, and when these surfaces are visibly soiled . Clean spills of . body fluids as outlined .

Based on observation, interview, and record review, the facility failed to create a baseline care plan with pertinent condition specific information to address resident needs, within the 48-hour timeline following a resident's admission, for 1 (#109) of 17 sampled residents. Findings include: During an observation on 2/11/25 at 4:34 p.m., resident #109 was sleeping in bed and wearing a nasal cannula, connected to an oxygen concentrator, turned on to two liters of oxygen. During an observation on 2/12/25 at 9:59 a.m., resident #109 was sleeping in his bed and wearing a nasal cannula, connected to an oxygen concentrator, turned on to two liters of oxygen. Review of resident #109's electronic medical record showed resident #109 was admitted to the facility on [DATE]. Review of resident #109's treatment administration record, dated February 2025, showed the oxygen at 2 liters per nasal cannula was ordered to start on 1/25/25 at 6:00 a.m. Review of resident #109's care plan, showed an initiation date of 2/1/25 for resident #109 to receive supplemental oxygen for [NAME]/pulmonary health/respiratory condition r/t COPD Oxygen per nasal cannula at 2 Liters/Min . [sic] During an interview on 2/13/25 at 12:02 p.m., staff member C stated a resident's baseline care plan is started when the UDA (user defined assessment) is completed by the admitting nurse. Staff member C stated some parts of documentation from the electronic medical record, which are pulled into the baseline care plan, included information on medications, physical functioning, pain, and skin. Staff member C stated she did not know if oxygen treatment pulled over into the baseline care plan. Staff member C stated she was not sure how to find out where the baseline care plan is done and she is not sure how to tell what is on the baseline care plan. Review of a facility policy titled, Care Planning - Interdisciplinary Team, revised March 2022, showed: The interdisciplinary team is responsible for the development of resident care plans. 1. Resident care plans are developed according to the time frames and criteria established by S483.21. Review of a facility policy titled, Care Plans - Baseline, revised March 2022, showed: . A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission . includes instructions needed to provide effective, person-centered care of the resident . and must include the minimum healthcare information necessary to properly care for the resident . The baseline care plan is updated as needed to meet the resident's needs until the comprehensive care plan is developed .

Based on observation, interview, and record review, the facility failed to update resident care plans in a timely manner for 1 (#33) of 17 sampled residents. Findings include: Review of resident #33's weight report, dated 9/11/24 and 10/7/24, showed resident #33's weight went from 143 pounds down to 131 pounds. This was a 12 pound or 8.39 percent weight loss in 26 days. During an observation on 2/11/25 at 10:42 a.m., resident #33 was observed to rapidly get out of the chair and pacing in his room on three occasions during the 10-minute interview. Resident #33 said his skin condition burned, itched, and bothered him. Resident #33 said he can't sit still because of his skin irritation. Resident #33 said he had lost weight, but he had atrial fibrillation and shouldn't gain any weight. Review of resident #33's comprehensive care plan, updated on 9/20/24 showed, a potential for the presence of altered nutrition needs. The facility did not identify or update the care plan to include interventions to stop the weight loss that occurred in October 2024. Review of residents #33's Nurse Practitioner note, written 10/21/24, showed, resident #33 had been focusing on his rash and had not been eating or drinking well. Review of resident #33's physician orders, dated 1/10/25, showed, Med Pass 2.0 was ordered for the resident to receive 120 milliliters twice a day. Review of resident #33's comprehensive care plan showed, the care plan was not updated with weight loss interventions until 1/26/24. Review of resident #33's comprehensive care plan showed, no dietary interventions for increasing food intake when the resident was hyper focused on his skin, pacing, and was not eating well. During an interview on 2/13/25 at 11:01 a.m., staff member C said each discipline is responsible for updating their own care plans. Dietary would update nutrition, the MDS nurse would update the nursing section. Staff member C said the care plans got updated after the MDS (minimum data set) is opened and the assessment reference date is added. For changes and updates that need added to the care plan, staff member C said the team hears different stuff at the interdisciplinary team meeting. The areas of concern are discussed, and the care plans are updated as needed.

Based on interview and record review, the facility failed to ensure an as needed (PRN) psychotropic medication was limited to 14 days, for 1 (#26) of 17 sampled residents. Findings include: During an interview on 2/12/25 at 3:30 p.m., staff member A and B stated they were not sure why the PRN lorazepam did not have a stop date. Staff member A stated the facility medical providers were aware to only write a PRN antianxiety medication order for 14 days, and they were aware of the need to re-evaluate the resident(s) for continued use. Staff member B stated, I will get an order to discontinue the medication. Staff member B stated resident #26 had not received lorazepam in the last couple of weeks as the medication was not necessary to treat any medical symptoms. Review of resident #26's physician order, written on 1/7/25, for lorazepam concentrate, showed, 2 mg/ml, give 1 mg every two hours, prn. There was no stop date noted. Resident #26's MARs for January 2025 and February 2025, showed he received PRN lorazepam on five occasions in January 2025, and no doses used in February 2025. The order for PRN lorazepam remained active as of 2/12/25. The review of resident #26's medical record showed lorazepam was ordered to be used on a PRN basis, continuing over a one-month period, with no 14-day stop date, which was not in accordance with federal regulations.

Based on observations, interviews, and record review, the facility failed to protect a resident's right to be free from physical and psychosocial abuse by facility staff for 1 (#7) of 13 sampled residents, causing resident #1 skin injuries, ongoing fear, and inability to sleep, fearing the specific staff involved would return to the facility. Findings include: During an observation and interview on 10/22/24 at 9:07 a.m., resident #7 was sitting in her wheelchair in her room. Resident #7 began to transfer herself from her wheelchair to her reclining chair. Resident #7 stated seven or eight weeks ago, one CNA, and one nurse, entered her room and woke her from a sound sleep and said, Get up, get up. You're going to the dining room. Resident #7 stated she told the nurse and CNA she did not eat in the dining room, and the nurse replied, You will today. Resident #7 stated the nurse and CNA then proceeded to undress her. Resident #7 stated the staff were, Tearing off my nightgown. Resident #7 stated she told the nurse and CNA to, Stop it as she was resisting care. Resident #7 said the CNA that was in the room called another CNA by radio for help. Resident #7 said the second CNA entered the room and helped transfer the resident to her wheelchair and then left her room. Resident #7 stated she was then transported by wheelchair down to the dining room, but she resisted by putting her feet down to the floor to try and stop the wheelchair from moving. Resident #7 said she really did not remember much else after that because she was in such a state of shock. Resident #7 said it took her three or four nights to settle down because she thought the staff would come back and harm her. During an interview on 10/23/24, at 4:17 p.m., staff member I reported on 8/22/24 the night shift nurse mentioned resident #7 had fallen out of her reclining chair on 8/21/24. Staff member I decided it would be best for the resident to go to the dining room for breakfast, so the resident could be monitored more closely. Staff member I asked staff member N to help get the resident ready and bring her to the dining room. Staff member I explained that as the CNA was helping the resident dress, she was called by staff member N back into the resident's room a few more times because the resident was resisting. Staff member I and N tried explaining to the resident that she couldn't stay in her room alone because no one would be able to assist her if she needed help. Staff member I stated resident #7 reacted with resistance, but staff were accustomed to this and maintained a firm approach to get her ready for breakfast. Once in the dining room, resident #7 was served her meal but tried to stand up unsteadily. Staff member I stated she then moved resident #7 to a regular chair instead of her wheelchair to keep her seated. Due to this, the resident would be unable to leave the dining room area as she was not in her wheelchair. During an interview on 10/24/24 at 2:30 p.m., staff member E stated on 8/22/24, resident #7 was sitting in her wheelchair crying at a desk located in the front office. Staff member E stated she stopped and spoke to resident #7 to make sure she was okay. Staff member E stated while speaking with the resident, staff member A approached her and resident #7 and asked if she would complete a skin assessment on resident #7. After resident #7 agreed to the assessment, staff member E transported resident #7 in her wheelchair to the bathroom located in the administration office. During the skin assessment of resident #7, staff member E found one bruise on the back mid right shoulder described as a dime in size and purple in color and one bruise on the outer right groin described as a quarter to nickel in size and purple in color. Staff member E stated resident #7 had scratch abrasions on her right forearm. Staff member E stated resident #7's skin assessment was completed on 8/22/24 shortly after the incident occurred and no medical treatment was required. A review of the facility surveillance footage received on 10/24/24 from law enforcement, dated 8/22/24, showed staff member N pushed resident #7 in her wheelchair into the dining room. Eight other residents were observed seated at dining room tables, each in their own wheelchair. Resident #7 appeared [NAME] sitting in her wheelchair with her hands resting in her lap. Resident #7 was left in her wheelchair in the dining room between two dining tables by staff member N. Staff member N then exited the dining room. Resident #7 was seen moving her wheelchair with her feet, heading toward the dining room exit. Staff member N re-entered the dining room and grabbed the handles on the back of resident #7's wheelchair. Staff member I entered the dining room and directed staff member N and resident #7 over to a dining table in the middle of the room. Staff member N pushed resident #7's wheelchair to the dining table. Staff member N placed resident #7's wheelchair brakes on and attempted to transfer the resident to a stationary chair. Resident #7 was seen resisting the transfer by pushing the staff members hands away from her body. Staff member N and I then placed their forearms under resident #7's upper arms. Resident #7 was seen attempting to resist the transfer by lifting her head and turning it to the right as she pushed staff member N and I's hands and arms away from her. Surveillance video did not show resident #7's meal at the dining table or resident #7 attempt to stand on her own prior to being transferred to a stationary chair. Review of resident #7's medical provider noted dated 8/22/24 at 4:53 p.m., showed: Assessment & Plan Offerred ED transfer after being transferred in rough fashion this AM by staff Staff have been suspended they transferred her rouhgly and are being investigated No ecchymosis today Pain seems more chronic than anything No further changes today [sic] Review of resident #7's Weekly Head to Toe Skin Check, dated 8/22/24, showed, . 3. Wound documentation and notes: bruise to right shoulder scratch to right forearm small bruise to right upper thigh. [sic] Review of resident #7's EMR medical provider note, dated 8/28/24 at 1:30 p.m., showed, . Patient was physically assaulted by three individuals at her nursing home, resulting in multiple bruises and emotional distress. She is fearful, especially at night, and is having difficulty sleeping. The incident has left [Resident #7] in a state of heightened fear and anxiety, particularly at night. She is constantly on edge, reacting to every sound and expressing fear that the perpetrators might return. This emotional distress has also affected her sleep; she has difficulty falling asleep and staying asleep due to her heightened fear and anxiety. She stated that she hears every footstep in her hallway she is constantly worried about the return of the perpetrators. [Resident #7]'s [family member] is also upset about the incident, which has caused [Resident #7] feelings of guilt and sadness. She expressed regret that despite moving to the nursing home for safety reasons, she does not feel safe. In terms of medication changes, [Resident #7] would like her quetiapine dosage to be increased at night to help with her sleep issues. Review of resident #7's care plan, with a revision date of 9/20/24 showed: Focus: [Resident #7] has a physical functioning deficit related to osteoarthritis pain. Goal: [Resident #7] will maintain current level of physical functioning through next review target date of 11/11/24. Interventions: Dressing assistance of one, able to stand to transfer independent or with assist x one. Not able to walk. Is independent in eating. Chooses to remain in room for meals. Focus: [Resident #7] has a behavioral complex care plan due to behavioral presentations as evidenced by periods of verbal behaviors towards others and tearful episodes with emotional dysregulation. Goal: [Resident #7] will not exhibit a behavioral decline through next review target date 11/11/2024. Intervention: If [Resident #7] cannot be redirected or calmed, and if safe to do so, staff to attempt to perform cares at a later time after [Resident #7] is calmer. [sic] Review of Resident #7's MDS with an ARD of 7/14/24, showed the following: . Section C, BIMS score 15; cognitively intact. . Section GG, Functional Abilities and Goals: - eating; independent. - upper body dressing; set up or clean up assistance. - lower body dressing; independent. - putting on or taking off footwear; independent. - personal hygiene; independent. - wheel 50 feet with two turns; independent. - wheel 150 feet; independent. A review of a Facility Reported Incident, sent to the State Survey Agency, showed a staff to resident abuse report was submited for the interaction resident #7 had with facility staff on 8/22/24. The report showed the facility identified the abuse after it occurred, suspended the staff for resident protection, made the initial report of abuse to the State Survey Agency, investigated the event, and put corrective measures in place. The facility investigation failed to address root causes, and the fact multiple staff were involved, but all failed to intervene or stop the abuse from occurring at the time of the event, or report it as alleged abuse immediately after, in an attempt to prevent future recurrences.

Based on observation, interview, and record review, the facility failed to honor dining preferences for 1 (#7) of 13 sampled residents. The deficient practice had the potential to impact the resident's health and well-being. Findings include: During an observation and interview on 10/22/24 at 9:07 a.m., resident #7 was sitting in her wheelchair in her room. Resident #7 began to transfer herself from her wheelchair to her reclining chair. Resident #7 stated she had just finished her morning breakfast. Resident #7 stated seven or eight weeks ago, one CNA and one nurse entered her room and woke her from a sound sleep, and said, Get up, get up. You're going to the dining room. Resident #7 stated she told the nurse and CNA she did not eat in the dining room, and the nurse replied, You will today. Resident #7 stated, I never go to the dining room because my husband was here for about seven years, and I watched him truly die of Parkinson's. Resident #7 stated towards the end of her husband's life she couldn't watch facility staff feed him. Resident #7 stated when she first moved into the facility she would go to the dining room for meals, but over a short period of time, resident #7 stated, All I could see was that circle of (residents) that they feed, and I just didn't like it, so I don't go to the dining room anymore for my meals. I eat in my room and that's the way I like it. During an interview on 10/22/24 at 3:05 p.m., Staff member L stated she was called on her radio on 8/22/24 by staff member N to come and assist her in resident #7's room. Staff member L entered resident #7's room and noticed the resident was upset. Staff member L stated resident #7 said she did not want to get up. Staff member L stated she tried to comfort the resident while staff member N was providing coping skills to the resident. Staff member L stated she was aware of resident #7's personal reasons as to why the resident did not eat meals in the dining room. Staff member L stated staff member N was also aware because staff member N stated to resident #7, Just don't look at the residents that need help and focus on your food. Staff member L stated staff member I was present in resident #7's room and told staff members L and N the resident needed to be taken to the dining room for breakfast. During an interview on 10/23/24, at 4:17 p.m., staff member I reported on 8/22/24, the night shift nurse mentioned resident #7 had fallen out of her chair. Staff member I decided it would be best for resident #7 to go to the dining room for breakfast, to be monitored more closely. Staff member I asked staff member N to help get the resident ready and bring her to the dining room. Staff member I explained that as staff member N was helping the resident dress, staff member N had to call staff member I back into the room a few times because the resident resisted care. Staff member I and N tried explaining to the resident that she couldn't stay in her room alone because no one would be able to assist her if she needed help. Staff member I stated resident #7 reacted with resistance, but staff were accustomed to this and maintained a firm approach to get her ready for breakfast. Staff member I stated it was resident #7's preference to eat meals in her room. Staff member I stated, With [Resident #7] falling, I thought, oh she's confused somebody needs to help her. Staff member I stated she thought she was keeping resident #7 safe taking her to the dining room for her meal. Staff member I stated once resident #7 was served her meal in the dining room the resident tried to stand up unsteadily. Staff member I stated she then moved resident #7 to a regular chair instead of her wheelchair to keep her seated. During an interview on 10/24/24, at 9:45 a.m., staff member K stated two CNA's report to the dining room for resident meals, and one CNA is required to stay on the residential unit to pass meals to residents who want to eat in their room. A review of the facility surveillance footage, received on 10/24/24 from law enforcement, dated 8/22/24, showed staff member N pushed resident #7 in her wheelchair into the dining room for resident #7's morning meal. Resident #7 was seen moving her wheelchair with her feet, heading toward the dining room exit. Staff member N re-entered the dining room and grabbed the handles on the back of resident #7's wheelchair. Staff member I entered the dining room and directed staff member N and resident #7 over to a dining table in the middle of the room. Staff member N pushed resident #7's wheelchair to the dining table. Staff member N placed resident #7's wheelchair brakes on and attempted to transfer the resident to a stationary chair. Resident #7 was seen resisting the transfer by pushing the staff members hands away from her body. Staff member N and I then place their forearms under resident #7's upper arms. Resident #7 was seen attempting to resist the transfer by lifting her head and turning it to the right as she pushed staff member N and I's hands and arms away from her. Surveillance video did not show resident #7 attempting to stand on her own prior to being transferred to a stationary chair. Review of Resident #7's MDS with an ARD of 7/14/24, showed, the following: . Section C, BIMS score 15; cognitively intact. . Section GG, Functional Abilities and Goals: - eating; independent. Review of resident #7's care plan, with a revision date of 9/20/24, showed: Focus: [Resident #7] has a physical functioning deficit related to osteoarthritis pain. Goal: [Resident #7] will maintain current level of physical functioning through next review. Date Initiated: 10/10/24.Interventions: Is independent in eating. Chooses to remain in room for meals. Date Initiated: 1/22/24. Focus: [Resident #7] has adjustment issues related to decline in level of independence, recent changes in environment and situation. Date Initiated: 02/17/24. Goal: [Resident name] will express needs/preferences. Date Initiated: 02/17/24. Intervention: Allow [Resident #7] to make daily decisions and allow independence as much as possible. Date Initiated: 02/17/24. [sic]

Based on observation, interview, and record review, the facility failed to provide social services for a resident who suffered with grief and loss of a spouse, for 1 (#8) of 13 sampled residents. Findings include: During an observation and interview on 10/24/24 at 1:01 p.m., resident #8 was in her room sitting in a recliner with her legs elevated, and a blanket on her lap. Resident #8 said she shared the room with her husband, but was fearful another resident would be moving in. Resident #8 said her husband passed away recently and she really missed him. Resident #8's nose turned red as tears ran down her face. With her voice trembling she stated, It was really hard on him. Resident #8 then glanced over to a table stand which held a digital picture frame. Resident #8 looked at the pictures pass by as she wiped away her tears with a tissue in her hand. Resident #8 said facility staff had not spoken to her about her fear of a new roommate moving into resident #8's room. Resident #8 said the facility had not provided any grief support since the passing of her husband. During an interview on 10/24/24 at 2:53 p.m., staff member A said she had visited with, and provided emotional support to resident #8 following the death of her husband. Staff member A said she did not document in the EMR her interactions when talking with resident #8. Staff member A said resident #8's family is very involved with her care and she would reach out to resident #8's [family member] to see what services would be best for the resident. Review of resident #8's care plan with a revision date of 8/21/24, showed resident #8's care plan was not updated addressing the recent loss of her husband, and no interventions were put in place to help the resident cope with grief and loneliness. The emotional distress concerns were not identified timely and addressed thoroughly by the facility or social services. A record review showed resident #8's spouse passed away in September 2024.

Based on observation, interview, and record review, the facility failed to review and update a comprehensive care plan for 1 (#8) of 13 sampled residents. The resident experienced grief and sorrow from the recent death of her husband. Findings include: During an observation and interview on 10/24/24 at 1:01 p.m., resident #8 was in her room sitting in a recliner with her legs elevated and a blanket on her lap. Resident #8 said she shared the room with her husband, but was fearful another resident would be moving in. Resident #8 said her husband passed away recently, and she really missed him. Resident #8's nose turned red as tears ran down her face. With her voice trembling she stated, It was really hard on him. Resident #8 then glanced over to a table stand which held a digital picture frame. Resident #8 looked at the pictures pass by as she wiped away her tears with a tissue in her hand. Resident #8 said facility staff had not spoken to her about her grief or her fear of a new roommate moving into resident #8's room. During an interview on 10/24/24 at 2:53 p.m., staff member A said she had visited with, and provided emotional support to resident #8 following the death of her husband. Staff member A said she was not aware resident #8's care plan had not been updated. Staff member A stated the facility's social services director had recently ended her employment, and the position has not been filled. Staff member A stated it was her responsibility to fulfill that position until a new employee was hired. Review of resident #8's care plan, with revision date of 8/21/24, failed to show a focus area related to grief due to the death of resident #8's husband. No interventions were found in resident #8's care plan related to coping with loss, grief, or loneliness.

Based on interview and record review, the facility failed to identify and address a resident acted out in willful abusive manner, when the resident (#2) had dementia, and the resident attacked another resident (#1), and could have inflicted harm, of 5 sampled residents; and, and failed to ensure a confused resident who displayed elopement behaviors was assessed and managed for safety, specifically when the facility attempted to use a wanderguard for the resident which increased his agitation and anxiety, for 1 (#3) of 5 sampled residents. Findings include: 1. Review of a facility reported incident, dated 4/29/23, showed resident #2 entered resident #1's room through an adjoining bathroom. Resident #1 asked resident #2 what she (resident #2) was doing. Resident #2 proceeded to attack resident #1 with her walker, and grabbed resident #1's breast. The residents were separated by staff. The facility determined resident #2 was confused and only showed they were separated, but not how the willful behavior was addressed for future resident protection. Review of resident #2's Significant Change MDS, with an ARD of 1/10/23, showed the resident was severely cognitively impaired. Review of the facility's policy, titled Abuse, Neglect, Exploitation, and Misappropriation Prevention Program, revised April 2021, showed: - 1. Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to: . b. other residents; . Review of the facility's policy, titled Abuse and Neglect - Clinical Protocol, revised March 2018, showed: - Definitions . 4. Willful as defined at 483.5 and as used in the definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. 2. Review of a facility reported incident, dated 8/30/23, showed resident #3 was found outside the facility next to the parking lot. The resident told staff he was getting the hell of here. During an interview on 10/11/23 at 2:48 p.m., NF2 said resident #3 was pretty mad about the wanderguard. NF2 said resident #3 was a bachelor all his life, and he was very set in his ways. NF2 said it was very hard for resident #3 to give up his independence, and that made him angry. Review of resident #3's nursing progress notes, dated 8/30/23 to 9/6/23, failed to show facility staff tried alternate interventions with resident #3 prior to the placement of the wanderguard on the resident. During an interview on 10/11/23 at 3:36 p.m., staff member A said the facility did not get a physician's order for resident #3's wanderguard, because he only wore it for like a hot minute. Staff member A said resident #3 would not leave the wanderguard on, and at 4:15 p.m., staff member A was not aware the facility needed to have a physician's order with an appropriate medical diagnosis for the placement of a wanderguard. Review of resident #3's medical record, dated 8/30/23 to 9/5/23, failed to show the facility had obtained a physician's order, including a medical diagnosis, for the use of a wanderguard for the resident. Review of resident #3's medical record showed the facility had started a Wandering Assessment, dated 8/30/23, but had not completed the assessment. Review of resident #3's nursing progress notes, dated 9/6/23, showed: Resident will not leave wander guard on he continues to take it off to the point where he will get out of his scooter and do what it takes to take wander guard off. Resident took arm off the scooter this last time to get wander guard off. Review of resident #3's Alert charting note, dated 9/6/23, showed: resident refuses to have wanderguard and stated he will take it off and throw it in the trash. Review of a facility policy, titled Wandering, Wanderguards/ROAM alert/etc, not dated, showed: . 3. Physician order will be obtained for placement of wanderguard or alert system. The facility failed to appropriately identify and utilize the least restrictive intervention for a resident who wanted to leave, and the wanderguard caused him more agitation and he kept removing it, and failed failed to thoroughly assess the resident for the use of the wanderguard to meet the resident's needs, nor ensure a physician's order was in place for the device.

Based on observation, interview, and record review, the facility failed to maintain an effective system for tracking resident weights, identifying weight loss, and implementing nutritional interventions for 2 (#s 12 and 49) of 2 sampled residents. Resident #49 had a severe weight loss, and #12 had a significant weight loss. Findings include: 1. During an observation on 2/14/23 at 9:50 a.m., resident #49 was lying in a low bed on his side. Resident #49 had his eyes closed and did not rouse to his name being spoken in a normal voice. Resident #49 had hollow cheeks with temporal wasting. The resident was left undisturbed. During an interview on 2/15/23 at 9:44 a.m., staff member I stated resident #49 had begun declining before Christmas. Staff member I stated she had discussed resident #49's care with his POA and agreed to give the resident what he wanted to eat and drink, and not to force him to get out of bed if the resident did not want to get up. Staff member I stated the resident was sleeping more but would take food and fluids when awake. The staff fed him as much as possible when he was awake. Staff member I stated the facility had identified an issue with inaccurate resident weights and had provided education to the CNAs regarding the correct procedure for weighing residents. Staff member I could not remember exactly when the education had occurred, but believed it was late December of 2022 or January of 2023. Staff member I stated if she identified an inaccurate weight, she asked the CNA to re-weigh the resident. Staff member I was not able to explain why the inaccurate weights obtained on 1/15/23 and 1/19/23 were not corrected. Review of resident #49's nursing progress notes, dated between 12/5/22 and 2/13/23, showed a gradual decline in the resident's mobility and oral intake of food and fluids. None of the nursing progress notes noted the resident's weight loss from 154 pounds (12/26/22) down to 117.6 pounds on 2/13/23, issues with the outlier weights documented on 1/15/23 and 1/19/23, or notification of the resident's physician or the dietician regarding his weight loss. Review of resident #49's weights, dated between 12/11/22 and 2/13/23, showed the following weight changes: - 12/11/22 - 148 pounds, - 12/26/22 - 154 pounds, - 12/29/22 - 140 pounds, - 1/1/23 - 142 pounds, - 1/8/23 - 136 pounds, - 1/12/23 - 129 pounds, - 1/15/23 - 171 pounds - Incorrect - 1/19/23 - 170 pounds - Incorrect - 2/5/23 - 126 pounds, and - 2/13/23 - 117.6 pounds. Review of resident #49's physician progress note, dated 12/8/22, failed to include anything about the resident's weight loss, despite a weight loss of 11 pounds in the previous two months (158 pounds on 10/3/22 and 147 pounds on 12/1/22). There were no changes in the resident's treatment documented on the note. Review of resident #49's nutrition note, dated 1/25/23, and completed by staff member H, failed to show the resident's weight loss after 1/1/23. There were no changes in the resident's plan of care documented on the note. Review of resident #49's physician progress note, dated 2/4/23, showed a 20-pound weight loss with refusal to eat. The physician progress note showed a feeding tube was not recommended and contradicted the nutrition note from 1/25/23 which showed the resident's weight was stable. There were no changes in the resident's treatment documented on the note. During an interview on 2/15/23 at 4:30 p.m., staff member H stated she was responsible for performing nutritional assessments for residents, and she visited the facility monthly if the weather was cooperative. Otherwise, she did video visits if she was unable to get to the facility. When asked why she used resident #49's weight from 1/1/23, rather than a more current weight, staff member H stated she was not sure why she had not used the most current weight. Staff member H stated she had not been notified of any problems with resident #49, despite his severe weight loss, and had not notified resident #49's provider regarding his severe weight loss. 32997 2. During an observation on 2/14/23 at 9:17 a.m., resident #12 was seated in the day room of the secure care unit. His hair was messy, he had facial whiskers, and his pants were cinched up. Resident #12 had a Danish on a plate in front of him. It was cut into small pieces. Staff member I would stop by resident #12's table, get a piece of Danish on a fork, and coax resident #12 to eat it. During an interview on 2/14/23 at 9:20 a.m., staff member I said resident #12 did not eat much most days. Staff member I said resident #12 got four to five health shakes every day. She said some days the health shakes were the only thing resident #12 would have. Review of resident #12's Weights and Heights Report, dated 8/2/22 to 2/13/23, showed resident #12 weighed 150 pounds on 1/10/23. On 2/13/23 resident #12 weighed 139 pounds for a weight loss of 11 pounds or 7.33%. That was a significant weight loss in 30 days. Review of resident #12's Nutrition Assessment, dated 2/13/23, identified a weight loss of 6% in 30 days from 1/3/23 (148 pounds) to 2/13/23 (139 pounds). Review of resident #12's Nutrition Care Plan, last edited on 6/14/22, failed to identify a significant weight loss, what the weight loss was related to, or show a reason for his weight loss. The only interventions the facility had in place were [Brand Name] Plus at meals, 1:00 p.m., to encourage resident #12 to have two to three snacks a day, and to provide him with a regular diet. Review of the facility's menu showed the facility provided five meals per day to the residents. These meals consisted of a continental breakfast from 7 a.m. to 9 a.m., brunch at 10 a.m., a substantial snack at 1 p.m., dinner at 4 p.m., and another substantial snack at 7 p.m During an interview on 2/15/23 at 4:41 p.m., staff member H said resident #12's appetite waxes and wanes due to his disease process. Staff member H said she had never thought about using three meals a day as an intervention to prevent weight loss.

Based on interview and record review, the facility failed to ensure the dietitian, and the dietary manager, accurately assessed and communicated the nutritional needs of 1 (#49) of 1 sampled resident. This deficient practice resulted in the failure to intervene for a resident with a severe weight loss. Findings include: During an interview on 2/15/23 at 4:30 p.m., staff member H stated she was responsible for performing nutritional assessments for residents. Staff member H stated she visited the facility monthly, either in person or via video conference. Staff member H stated she depended on staff member G to notify her if there were any nutritional issues with the residents. Staff member H stated she had not been notified by staff member G of any nutritional issues with resident #49, and was not aware of his severe weight loss. When asked why she had used resident #49's weight from 1/1/23 in the 1/25/23 nutrition note, rather than a more current weight, staff member H stated she was not sure why she had not used the most current weight. Staff member H stated she may have questioned the accuracy of the weights, but was not able to specifically explain why the resident's current weight was not used or why she had not identified resident #49's severe weight loss. Staff member H stated she depended on staff member G to notify her of specific resident nutritional concerns. Staff member H stated if staff member G did not notify her, she had no reason to further investigate a resident's nutritional needs. Staff member H was not at the facility full time, per the interview. This surveyor attempted to interview staff member G during the survey. The staff member was not available for interview. A review of staff member G's educational information showed staff member G held the necessary certification to carry out the functions of the food and nutrition services, taking into consideration resident assessments, individual plans of care, the number, acuity, and diagnosis of the facility population, in the absence of staff member H, who was not at the facility full time. Review of the facility's policy titled, Nourishment At Risk, not dated, showed: RD regularly tracks and identifies weights that show a gain or loss. RD will initiate interventions and inform the interdisciplinary team. The policy showed the dietitian assessed the nutritional needs of the residents and developed an individualized plan of care for the resident. Refer to F692 Nutrition/hydration Status Maintenance, F657 Care Plan Timing and Revision for additional details related to resident #49's severe weight loss.

Based on observation, interview, and record review, the facility failed to accurately assess and provide supervision for the safety of 1 (#18) of 4 sampled residents for smoking; failed to implement effective fall interventions for a resident who had significant fall history and risk factors for more falls for 1 (#12) of 5 sampled residents for falls; failed to provide supervision for residents in the secured nursing unit while residents were in common areas for 4 (#s 11, 12, 13, and 16) of 4 sampled residents. Findings include: 1. Smoking During an observation and interview on 11/3/22 at 10:00 a.m., resident #18 stated he had a lighter explode in his face when he tried to light a cigarette. Resident #18 said he did not remember if he was outside or in his room at the time it occurred. Resident #18 said he did not remember if he was wearing his oxygen at the time of the incident, and he did not remember ever having a lighter explode prior to the incident. Resident #18 was seated in his recliner, covered with a blanket, and had his oxygen via nasal cannula in place. The burns on his face appeared to be healed. During an interview on 11/3/22 at 10:30 a.m., staff member C said the facility had no specific answers for where resident #18 acquired the lighter. Staff member D said they believed the lighter was purchased for resident #18 by another resident that was able to leave the facility and shop independently. However, the resident denied purchasing the lighter for resident #18. Staff member A said resident #18 was found to have a lighter prior to the incident and had given the lighter to facility staff, and it was added to the smoking container. Staff member A said resident #18 was told he could not have a lighter and understood. Staff member A said resident #18 was provided the smoking policy to read and a verbal agreement to follow the facility smoking policy was obtained from the resident. Staff member A said resident #18 was observed by other residents digging thru the fire suppression trash can between smoke breaks when staff were not supervising him outside. The fire suppression trash cans did not have a lock that prevented residents from accessing the contents. Staff member C said the facility believes resident #18 acquired the butts found in his room from the fire suppression trash can. Staff member C said, We were aware of the incident that occurred at his prior facility and believed it was because they (residents) were not supervised while smoking at that facility. The resident was not in a controlled environment. We believed that it would not occur if he was in a controlled environment at our facility. Review of resident #18's progress note, dated 10/13/22 at 4:15 p.m., showed resident #18 was short on funds to purchase cigarettes, and the cigarettes he had were all he had left, but the facility would work on getting him more soon. It was explained to resident #18 that borrowing cigarettes from other residents was not allowed. Review of resident #18's progress note, dated 10/13/22 at 6:12 p.m., showed resident #18 was noted to have a cigarette hidden in his hat. Review of resident #18's progress note, dated 10/14/22 at 7:03 p.m., showed a CNA was called to resident #18's room for assistance. Resident #18 had a lighter and had tried to light a cigarette with his oxygen on. It had exploded in his face causing burns to his face. Review of resident #18's progress note, dated 10/15/22 at 12:23 p.m., showed: Late entry: prior to resident being sent out to hospital for treatment of his burns, on the evening of 10/14/22, resident did allow this RN to look in coat pockets. Resident did state that he didn't have any cigarettes in his coat pockets. One broken cigarette and one broken short cigar were found in pocket. Also was found two butts in pocket, one to a cigar and one to a cigarette. nurse did also find a cigarette butt in garbage can in room after resident left for medical treatment. Review of a resident #18's Smoking Assessment, dated 9/22/22 showed: . (Resident #18) has dementia and hx of TBI and he is safety aware. Review of a facility document, Type of Event, dated 10/14/22 showed: . An incident report was completed on September 28 2022. Resident (#18) was out on the smokers patio digging through the ashtray, found a cigarette butt and lit it. Resident had a lighter in his pocket per incident report. Investigation noted that social service spoke to the resident, reviewed the policy and resident agreed to turn the lighter into social services it was unsure if the resident had signed the resident smoking agreement at the time the incident occurred. As per nursing conversation with resident daughter the daughter stated that this incident of the residence sustaining burns while attempting to light a cigarette with oxygen was not the first time prior to this event [sic]. Review of a facility document, Root Cause Analysis, not dated, showed: . Questions surrounding direct supervision - whether they are being supervised adequately -smoking box outside of eyesight of CNA? -Another resident reported seeing (resident #18) sneak cigarettes out of the smoking box when CNA's back is turned . 2. Falls During and interview and observation on 11/3/22 at 8:23 a.m., staff member G said resident #12 likes to walk and can not see. Resident #12 tends to fall and was difficult to redirect because he became agitated if people got too close to him. Resident #12's vision was bad, and he would walk into things and trip over things because he could not see them. He would reach out and grab other residents trying to navigate, and the other residents would strike out, not understanding he was grabbing them to steady himself. Staff member G said she did not know what more to do for resident #12's falls. If staff made an attempt to help him, he became agitated and would strike out, so staff would keep him in sight and attempt to anticipate his behaviors and falls. Staff tried to balance his behaviors and falls. Resident #12 was observed wandering throughout the secured unit with a staff member following at a distance. The day room was long and narrow, lined with recliners and chairs on both sides of the room. When residents were seated in the recliners and not reclined, their feet would extend out into the walkway through the room, becoming a tripping hazard. Residents were asked to move their legs so other residents could pass and they would become agitated with staff. During an interview on 11/3/22 at 10:30 a.m., staff member C said the aides stay with resident #12 as much as possible. Resident #12 does not see well and will not wear his glasses; he startles and then gets combative and falls. Staff member C said resident #12 will go up to other residents and grab them, trying to orient himself, and it will cause an altercation. He will also run up and down the secured unit hallway. Staff member C said the facility is focused on keeping resident #12 from injury when he falls. Staff member C said the facility was aware of the issue with falls and had started a process improvement plan a year ago. Record review of a facility document, Report of Falls, dated for the month of September and October 2022, showed resident #12 had three falls in September (9/3/22, 9/9/22, and 9/13/22) and more in October (10/1/22, 10/8/22 x2, 10/15/22, 10/24/22 x2, and 10/26/22). Record review of resident #12's care plan, not dated, showed: Title: Increased Risk for Falls . Evidenced by: History of falls - Needs supervision and cueing w/transfers and ambulation at times - Poor Vision - Resistive to assist-aggressive behaviors Goal: (Resident #12) will be free from falls through next review. (Resident #12) will be free from injury if he does fall thru next review. . Approaches: - Offer toileting when rounding or when (resident#12) is restless and wandering. - Encourage (resident #12) to change positions slowly - Encourage (resident #12) to wear non-slip footwear at all times . .- Assist (resident #12) to sit properly in the recliners in the Day Room - Monitor for ill side effects from his medication - (Resident #12) prefers to have a night light on in his room at night - (Resident #12) to sit on a pressure pad when sitting in a recliner in the Day Room - Distract and assist to walk outdoors if agitated and needs redirection - if able - (Resident #12) will have spill proof cup with fluids at bedside to avoid spills on floor. 10/26/22 . Review of resident #12's Fast Investigation reports, showed: - The FAST committee reviewed the fall that occurred on 10/1/22, another resident made physical contact, throwing resident (#12) on to the floor. Root cause of the fall was determined to be that, resident was thrown on the floor by another resident. The Fast committee implemented one staff member to be positioned just outside the doorway to the day room during rounds, to keep both residents within line of site. - The FAST committee reviewed two falls that occurred on 10/8/22 when resident #12 fell while ambulating in the secured unit hallway. The committee determined that resident #12 did not sustain any injury related to the falls. The root cause of the falls was determined to be loss of balance while ambulating resulting in resident #12 falling to the floor. The FAST committee found, Resident's (#12) goal for no injury was met. Will continue with current POC. - The FAST Investigation, dated 10/19/22, showed the FAST committee reviewed the fall that occurred on 10/15/22 where resident #12 was leaning back while ambulating, and this resulted in him falling. The committee determined resident #12 did not sustain any injury related to the fall. The committee determined the root cause of the fall was leaning back while ambulating. The FAST committee found, Resident's (#12's) goal of being free of injury with falls was met. No new interventions implemented. Will continue to follow current POC. - The FAST Investigation, dated 10/28/22, showed the FAST committee reviewed three falls. The first fall on 10/24/22 at 6:40 a.m., was determined to be caused by resident fatigue, related to the resident being up all night. The second fall, on 10/24/22 at 3:50 p.m., was determined to be an assisted fall, and resident #12 was leaning back while ambulating. The third fall 10/26/22 at 1:15 a.m. was determined to be caused by spilled water jug near resident #12's bed. The committee determined resident #12 did not sustain any injury related to the falls. The FAST committee implemented, . Staff to continue following current plan of care to prevent injuries. A spill proof cup with fluids kept at bedside. Offer or insert ear plugs if resident allows. Review of a facility document, Fall Prevention & Management, not dated, showed: . B. After level of fall risk has been identified appropriate intervention strategies will be implemented. Interventions considered will include but not be limited to the following: 1. Low bed 2. Non-slip grip footwear 3. Assign resident to bed that allows resident to exit towards stronger side 4. Lock moveable transfer equipment prior to transfer 5. Non-skid floor mat or strips 6. Adequate nighttime lighting 7. Medication review 8. Exercise program 9. Toileting program 10. Scoop mattress 11. Fall mat beside bed 12. Hip, elbow or knee protectors 13. Alarm system (bed, floor, door, etc.) 14. Move closer to nursing station . 3. Supervision During an interview on 11/3/22 at 8:23 a.m., staff member G said resident #13 was very independent and thinks he does not need assistance when he actually needs a lot of assistance. He was very unpredictable with his behaviors. Staff member G said staff has been instructed to keep resident #13 in line of sight at all times and to follow him. Review of facility document, Investigation of Suspected Abuse, dated 10/6/22 showed resident #12 and #13 were involved in an altercation in the secured unit hallway. Resident #12 reached out, looking for direction or someone to hold on to. Resident #12 encountered resident #13, and resident #13 grabbed resident #12, and threw him down. Review of a facility document, FAST Investigation, dated 10/7/22 showed the FAST committee reviewed the fall that occurred on 10/1/22, and another resident made physical contact, throwing resident (#12) on to the floor. The root cause of the fall was determined to be that resident was thrown on the floor by another resident. The Fast committee implemented one staff member to be positioned just outside the doorway to the day room during rounds, to keep both residents within line of site. Review of a facility reported incident, dated 10/14/22, and sent to the State Survey Agency, showed: Three staff members were assisting other residents in their rooms, and the remaining staff member was in the day room overseeing the residents in that area. Review of resident #13's care plan, not dated, showed: . Approaches: -Keep (resident #13) in line of sight at all times . - (Resident #13) must be monitored at all times. Ensure (resident #13) does not enter room next . door through the bathroom. - When resident #13 is ambulating, he must be followed at a distance, remaining in your line of sight. Review of a facility reported incident, dated 10/21/22, showed resident #11 and #16 were involved in an altercation in the secured unit hallway. The altercation occurred at the change of shift, and six staff members were present at the time of the incident. Two staff members were on their phones. All staff were questioned, and all staff were unaware of the location, of resident #11 or #16, at the time of the event. Review of a facility document, Investigation of Suspected Abuse, dated 10/26/22 showed: . Through this investigation it was discovered that the incident occurred within feet of the day room where all of the staff were located. Most of the staff reported that they were sitting opposite the hallway where the incident occurred. One staff member reported she was sitting around the corner from where the incident occurred. Furthermore, it was discovered that two staff members were on their phones at the time this incident occurred. . The DON also reviewed the expectations of care in the SCU, the policy on cell phone use, and the importance of knowing where the residents are at all times.

Based on observation, interview, and record review, the facility failed to prevent falls with injury due to lack of supervision for 1 (#197); multiple falls due to unsafe use of an electric recliner, no scoop mattress, and call light not in reach for 1 (#13); and falls due to unsafe transfers with staff for 2 (#s 2 and 30) of 5 sampled residents. Findings include: 1. Review of resident #197's SBAR note, dated 1/19/21, showed the resident fell a total of three times, on 1/3, 1/15, and 1/17/21. Interventions implemented to prevent further falls included one to one staffing during the day, depending on staff availability, pressure sensor pad in her recliner, a motion sensor when in bed, and to move the resident to the SCU for closer staff supervision. Review of resident #197's SBAR note, dated 4/1/21, showed the resident was asleep in her bed, and the CNA stepped out of the room to put away the trash. The resident got out of bed, pulled her brief down around her knees, took a few steps, and fell against the door frame. The root cause of the fall was determined to be lack of supervision, and the motion sensor not going off at the time of the fall. During an interview on 2/3/22 at 8:15 a.m., staff member C stated resident #197's motion sensor was working during the fall on 4/1/21, but it took a 'few moments' to signal the resident's motion. Review of resident #197's physician's note, dated 4/7/21, showed she was sent to the ER after the fall on 4/1/21 and sustained a nose bleed, a laceration to her left hand, and a laceration and contusions to her head. The scalp wound was closed using staples, and the forehead wound was closed with Dermabond. 2. Review of resident #13's FAST Committee notes showed the resident had fallen a total of 12 times, on 5/7, 5/8, 5/12, 5/14, 5/16, 5/27, 6/28, 8/16, 8/18, 10/3, 12/19, and 12/28/21. The majority of resident #13's falls were out of bed, and the family did not want a scoop mattress placed on the bed. Review of resident #13's SBAR note, dated 'late entry 8/17/21' showed, He has a lift electric chair . This is the 3rd fall out of the recliner, he does not know how to operate the chair and sometimes unaware that he is pressing the chair control. The facility recommended a manual recliner, and the family declined changing the chair. Review of resident #13's SBAR note, dated 10/6/21, showed the resident fell out of the recliner, and the root cause was a lack of the resident's knowledge on the operation of the chair remote, and the Dycem on the chair had been covered with a towel by staff. The CNAs were educated on the use of the Dycem in the chair. Review of resident #13's FAST Committee note, dated 12/19/21, showed the resident fell , and the root cause was the call light was out of reach. During an observation on 2/2/22 at 2:09 p.m., resident #13 was sitting in his recliner. His call light was on his bed, and he was not able to reach it. His recliner remote was on the arm of the recliner, which he thought was his TV remote. Review of resident #13's FAST Committee note, dated 12/28/21, showed the resident fell on [DATE], and the root cause was staff not following the plan of care for transferring resident #13. 3. Review of resident #2's SBAR note, dated 3/19/21, showed the resident fell while being assisted by a CNA in the bathroom. The root cause was determined to be the CNA did not use a gait belt during the transfer. The SBAR note did not include education for staff on using the gait belt for a safe transfer. During an interview on 2/3/22 at 8:15 a.m., staff member C stated the process that occurs after a fall was for staff involved in the fall to do a post fall huddle. She stated the huddle was a 'cheat sheet' for the nurses so they included all the required information. She stated the post fall huddle document was not kept once it was completed. Staff member C stated falls were discussed daily at the IDT meeting, and the fall committee met weekly to review causes and interventions. She stated the CNAs should know the resident fall risks and interventions through the use of the pocket care plan. 4. During an observation on 2/2/22 at 8:18 a.m., resident #30 was lying in bed receiving his morning medications, and the resident was moaning in pain. Review of a Facility Reportable Incident, dated 1/12/22, showed resident #30 had a fall with potential injury and Resident had an assisted fall at 01:30 in his bathroom as he was being assisted to transfer from the toilet seat to his wheelchair by the CNA on shift. His legs gave way as he stood and he was too heavy for the CNA to support him alone, the CNA lowered him safely to the floor. Resident now has severe knee pain. Knee is swollen and very painful. During an interview on 2/2/22 at 8:21 a.m., staff member N stated resident #30 had a fall a month ago or so and he had some knee pain. Staff member N stated He does take scheduled Tylenol a.m. and p.m. 600 mg, and he has prn [MEDICATION(S)] that he takes occasionally. The medication he is on does seem to control his pain. We haven't had him ask for it very much, but we do remind him that he has the PRN [MEDICATION(S)] he can take. During an interview on 2/2/22 at 9:29 a.m., staff member C stated a CNA was in with the resident assisting him to the bathroom on 1/12/22. Resident #30 was in a hurry because he needed to use the toilet urgently, so the CNA quickly tried to transfer the resident, and she confirmed that she did not use a gait belt. He fell in the bathroom on his knees. He did have some knee pain after the fall and he was taken for an X ray. It showed no knee fractures. He was put on pain medication. The staff were trained on Expectations of Care. This policy does go over transferring residents, care plans, and pocket care planning. The staff member knew she should have used a gait belt, but she felt rushed. During a QAPI interview on 2/2/22 at 1:45 p.m., staff member E stated falls came up frequently in the meetings. Review of the facility training document titled Expectations of Care and Conduct 2021 with a revision date of 12/6/21 showed, . Resident Handling .It is important for both residents and employee safety to abide by the documented transfer status . Necessary equipment and training are provided as outlined and complete cooperation is expected from every employee .

Based on observation, interview, and record review, the facility failed to assess for pain during a pressure ulcer dressing change while the resident continued to complain of pain, scream obscenities, pull away, and curse at staff during the treatment for 1 (#5) of 15 sampled residents; and, the facility failed to identify symptoms of pain for two residents with dementia who had communication barriers, and who voiced pain; and failed to assess and treat the resident with as needed pain medications ordered by the physician when the resident was exhibiting pain symptoms for 2 (#s 1 and 2) out of 15 sampled residents. Findings include: 1. Resident #5 was admitted to the facility with [DIAGNOSES REDACTED]. A review of an Admission MDS, with an ARD of 8/10/15, reflected the resident required extensive, two person physical assistance with bed mobility, transfers, personal hygiene and dressing. A review of a Quarterly MDS, with an ARD of 4/25/16, reflected the resident required extensive, two person physical assistance with bed mobility, transfers, hygiene and dressing. A review of the resident's care plan, Alteration in Comfort, which was evidenced by verbalization of pain was initiated 8/11/15 and revised on 4/26/16, read, Monitor effectiveness of current pharmacological intervention .Anticipate activities, give meds prior to activity and monitor effect. A review of the resident's care plan, Verbal Abuse Toward Staff, showed evidence of yelling and swearing at the staff, initiated 9/9/15 and revised on 4/25/16, read, Ensure resident is comfortable. Assess for pain . A review of the physician orders [REDACTED]. Treatment orders included dressing changes twice daily. A review of nurses notes, dated 6/1/16 at 5:21 p.m., read, He is verbally abusive with staff and refusing his dressing changes in the evenings. A review of the MAR for 6/1/16 failed to show the resident was offered or medicated with PRN pain medications. A review of nurses notes, dated 5/25/16 at 2:56 p.m., read, He is verbally abusive with staff and refusing his dressing changes in the evenings. A review of the MAR for 5/25/16 failed to show the resident was offered or medicated with PRN pain medications. A review of nurses notes, dated 5/18/16 at 4:35 p.m., read, He is verbally abusive with staff and refusing his dressing changes in the evenings. A review of the MAR for 5/18/16 failed to show the resident was offered or medicated with PRN pain medications. A review of nurses notes, dated 5/11/16 at 5:23 p.m., read, He is verbally abusive with staff and refusing his dressing changes in the evenings. A review of the MAR for 5/11/16 failed to show the resident was offered or medicated with PRN pain medications. A review of nurses notes, dated 5/4/16 at 2:56 p.m., read, He is verbally abusive with staff and refusing his dressing changes in the evenings. A review of the MAR for 5/4/16 failed to show the resident was offered or medicated with PRN pain medications. During an observation on 6/7/16 at 1:03 p.m., staff members E and H instructed the resident to lean onto his left side. Staff member H assisted the resident while staff member E removed a 2x2 gauze dressing from the resident's right upper abdominal quadrant. The resident complained of pain. There was a circular 1 cm x 1 cm, stage two open area with thickened margins and small amounts of clear serous drainage. Staff member E sprayed [MEDICATION NAME] onto 4x4 gauze and wiped the drainage from the wound. The resident screamed obscenities, pulled away, and cursed at the staff member. At 1:10 p.m., staff member E cut a 1 cm x 1 cm circular piece of [MEDICATION NAME], stuck it to a 2.5 x 2.5 piece of white porous tape and covered the open area. The resident complained of pain, screamed out, pulled away and cursed at the staff member. At 1:14 p.m., staff member E instructed the resident to lay on his right side with his left elbow pointed towards her. The staff member removed a large, blood tinged dressing that covered the resident's entire left elbow. The resident complained of pain. He had a stage 3 pressure ulcer that covered his entire elbow. The proximal skin was red 1/4 of the way up his arm. The margins of the wound were thick and pale. There were two small circular areas over the medial elbow with yellow slough which were removed when the staff member wiped the wound with 4x4 gauze. The resident complained of pain and cursed at the staff member. Staff member E covered the pressure ulcer with 2.5 x 2.5 [MEDICATION NAME]. She cut two strips of porous tape and covered the [MEDICATION NAME]. The resident complained of pain, screamed obscenities, pulled away and cursed at staff. At 1:17 p.m., staff member E sprayed [MEDICATION NAME] onto 4x4 gauze and removed a blood tinged 2x2 dressing covering a stage two pressure ulcer on the resident's left scapula. The wound was approximately 1 cm x1 cm x 0.2 cm's with a dark red center and thickened margins. The staff wiped the wound with the moistened gauze. The resident complained of pain, screamed obscenities, pulled away and cursed at staff. At 1:20 p.m., staff member E cut a piece of [MEDICATION NAME] to size and used the stick end of a 6 Q-tip to pack the wound. The resident complained of pain, pulled away, and cursed at the staff member. At 1:25 p.m., staff member E sprayed [MEDICATION NAME] onto 4x4 gauze and removed a blood and yellow tinged dressing covering an area on the resident's right lateral thigh. There was a stage three pressure ulcer approximately 6 cm x 2 cm with some granulated tissue to the wound bed. The margins were thickened and there was some yellow slough at the distal end of the ulcer. The resident complained of pain, screamed obscenities, pulled away and cursed at the staff member. At 1:28 p.m., the staff member removed a dressing covering a stage two pressure ulcer over the resident's right knee cap. The staff member cut a piece of [MEDICATION NAME] dressing to size and covered the ulcer. The resident complained of pain. At 1:35 p.m., staff member E began to remove a Kerlix gauze bandage from the resident's right, below the knee, amputation. There was dried blood which had pooled onto the posterior amputation causing the Kerlix gauze to stick to the resident's skin. The staff member pulled the [MEDICATION NAME] gauze bandage away from the resident's skin. The resident rolled towards his right side, screamed out, complained of intense pain, asked for some salve. There were six pressure ulcers, stages two and three, to the amputation site. The resident's skin was weeping clear serous fluid and bright red blood. The resident screamed out in pain and requested some salve be put on the amputation. At 1:44 p.m., the staff member wiped the amputation pressure ulcers with 4x4 gauze drenched in [MEDICATION NAME] spray. The resident screamed obscenities and cursed at the staff member as she covered the amputation with a large Optilock dressing and Kerlix gauze dressing roll. The resident stated his screams made him sound like Tarzan. At 1:50 p.m., staff member E removed a bandage dressing to the resident's left fourth toe. There was a stage 2 pressure ulcer over the anterior fourth toe and it partially extended to the web space of the third toe. The staff member sprayed [MEDICATION NAME] onto some 4x4 gauze and wiped the ulcer. The resident screamed obscenities and cursed at the staff member. The staff member cut a piece of Optilock dressing and pinched it onto the resident's toes. The resident screamed out, WHAT ARE YOU DOING? You are trying to squeeze my toes off! At 2:00 p.m., the resident complained of severe pain and requested a pain pill. A review of the resident's June 2016 MAR indicated [REDACTED]. During an interview on 6/7/16 at 2:05 p.m., staff member E stated pain assessments were to be done prior to and during a dressing change. She stated the resident's dressing changes are usually done in the morning after his dose of scheduled [MEDICATION NAME] had been administered. She stated the procedures done that day had been delayed due to the facility being out of supplies and stated the resident usually exhibited these behaviors during dressing changes. The staff member stated she thought the resident exaggerated his pain symptoms because the procedure was being monitored by a surveyor. She stated she was going to request a follow up by the physical therapy department for updated recommendations on dressing changes. During an observation on 6/8/16 at 8:27 a.m., staff member F entered the resident #5's room with three [MEDICATION NAME] with adhesive boarder dressings, one [MEDICATION NAME] sacral dressing, and one [MEDICATION NAME] 2.5 x 2.5 dressing with five pre-cut pieces of [MEDICATION NAME]. The resident was laying supine in his bed covered with a white bath blanket. At 8:32 a.m., the staff member applied pressure ulcer dressings to the resident's right elbow, right lateral abdomen, right lateral thigh and right [MEDICAL CONDITION]. She used the [MEDICATION NAME] dressing and white porous tape to cover the dressings. At 8:36 a.m., the staff member opened a Kerlix gauze dressing roll and covered the [MEDICATION NAME] sacral dressing used on the resident's right [MEDICAL CONDITION]. The resident did not complain of pain. At 8:40 a.m., the staff member covered the resident's fourth toe and web space to the third toe with [MEDICATION NAME] dressing and porous tape. The resident did not complain of pain. During an interview on 6/9/16 at 8:50 a.m., staff member F stated the resident's pressure ulcer wound dressings are changed twice daily. She stated the resident should be medicated with his PRN [MEDICATION NAME] one hour prior to the dressing procedure and a pain assessment should be monitored throughout the procedure. She stated if the resident complained of pain during the dressing change, the resident should be given his PRN [MEDICATION NAME] dose after the dressing change if he hadn't already been medicated. During an interview on 6/9/16 at 8:55 a.m., staff member B stated staff member E did not document pressure ulcer assessments for resident #5 on 6/7/16. She stated staff member E was going to request recommendations from the physical therapy department. Staff member B stated nurses should be documenting in the resident's medical record their pressure ulcer assessments and treatments. A review of the facility's Pressure Ulcers- definition, treatment, assessment and documentation policy, pages 3 and 4 of 7, read, Stage II and III Pressure Ulcer(s) .B. Goals: to protect surrounding skin, promote healing; avoid/manage infection and pain management. A review of the facility's Pain assessment, reassessment and management policy, revised 7/2014, read, To respect and support the patient's (sic) right to optimal pain assessment and management .To provide optimal management for the patient (sic) who is experiencing pain, to enhance healing and promote both physical and psychological wellness .If the screening assessment reveals pain is present in the patient (sic), it is the responsibility of clinical staff to conduct an in-depth clinical assessment of the pain, and periodic reassessments of the patient (sic) for determination of pain and relief from path (sic), including intensity and quality (i.e., character, frequency, location and duration of pain), and responses to treatment .Pharmaceutical management, as ordered by a licensed practitioner, including: Opioids/narcotics. 2. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During an observation on 6/7/16 at 10:25 a.m., the resident began to get up out of a recliner, which had been reclined. The resident had not put the footrest of the recliner down prior to attempting to get out of the chair. Staff member U assisted the resident, who then began to ambulate around the dining room. The resident went to a chair at a table, and began to sit down. Prior to placing her buttocks on the chair, the resident stood back up. She then went to another dining chair and did the same thing. The resident appeared restless. Staff member U asked the resident if she was tired, and offered to assist the resident with sitting, but the resident did not respond. Staff member U then assisted the resident when the two of them went out for a walk in the courtyard. The resident then came in and sat on the couch. The staff member prepped the resident's morning meal, which the resident took only two bites of. The resident then got back up and wanted to leave. Staff member U then asked the resident if she needed to use the bathroom, and assisted the resident to her room. During the observation, the resident was asked questions by the staff member. The resident was unable to respond to the questions, and did not communicate what her needs were. During interviews on 6/7/16 at 6:00 p.m., staff members W and X stated the resident had pain in her legs all the time. They stated the resident would become agitated and walk up and down the hallways for long periods of time. The resident would become fatigued, and her pain would increase. They stated the resident could hardly stand or walk because she was so tired, but she would keep going. The staff stated the resident's legs would give out on her due to fatigue from walking. During an interview on 6/8/16 at 7:30 a.m., staff member R stated the resident would grimace and clench her jaw or grind her teeth when in pain. She stated when the resident was restless, she would walk constantly. When this occurred, the resident's legs would hurt and Because of this the resident was a huge fall risk. Staff member R stated the resident escalated in her behavior quickly, and staff would need to pick up on the non-verbal cues the resident exhibited because the resident would not always say she had pain. A review of the Pain Assessment, Reassessment, and Management policy showed pain was to be assessed by all clinical staff. The pain scale was numerical, and included the Faces of Pain scale. The policy did not address a resident who was unable to accurately report pain, or verbalize pain. A review of the resident's Significant Change MDS, with an ARD of 12/14/15, showed the resident's cognition level was unable to be determined, and she had short and long term memory deficits. The resident displayed inattention and disorganized thinking that fluctuated, and was documented as having no resistive behaviors. The resident was documented as taking a scheduled pain medication, but no PRN pain medication, and no documented Non-medication interventions were coded as being in place. The Quarterly MDS, with an ARD of 3/14/16, showed no changes in these areas. A review of the resident's Nursing Notes and Occurrence Reports showed the resident had 11 falls from her date of admission to 4/23/16. The resident had three injuries to the head, to include a laceration. The falls occurred when the resident was walking, attempting to sit, had lost her balance, her knees gave out, or she was found on the floor. During an interview on 6/8/16 at 8:20 a.m., staff member X stated the resident would lean forward when she was walking, and this was a sign of pain in her legs. She stated she would ask the resident if she had pain, and would report it to the nurse, but then was unsure if the nurse acted on the report. She stated she knows at times the nurse gives the resident [MEDICATION NAME], but this has not helped at all, and now the resident is basically one on one care. A review of the resident's Care Plan showed the facility had not addressed the resident's pain adequately, to include symptoms she exhibited, her communication deficits related to pain, and her inability to comply with recommendations for pain. During an interview and observation on 6/8/16 at 3:03 p.m., the resident was agitated. She was not able to be redirected by staff who attempted to offer non-medicinal interventions. Staff member Z stated the resident was having pain in her back. She stated the resident had been walking around a lot, to the point that the resident had problems walking. A review of the resident's Physician order [REDACTED]. The resident's June 2016 Physician order [REDACTED]. The order was written on 5/24/16. The resident also had a PRN order for [MEDICATION NAME], which was 5/325 mg, once a day as needed. [MEDICATION NAME] was also ordered on [DATE], with a documented [DIAGNOSES REDACTED]. A review of the resident's monthly Medication Regimen Reviews, lacked evidence to show pain had been addressed as a potential behavior contributor, or that the [MEDICATION NAME] was being utilized to treat pain symptoms. A review of the resident's Physician/Provider Progress notes showed: - On 10/8/15, the provider documented the resident sun downed in the morning, afternoon, and evening. The resident had Right knee with blocky overgrowth (sic). She did appear to be tender when I palpated this. The resident was rambling incoherently and had disconnected speech, with advancing dementia. The documented plan was to initiate Aspercreme PRN to the knees, and for the low back and hips as well, with the already ordered Tylenol. - On 1/22/16, the provider documented the resident had no new issues reported by nursing. The physician documented a recent fall, and a concern with fall risk. Pain was not addressed. - On 3/15/16, the provider reviewed the resident's medications with no changes made. Pain was not addressed. - On 3/22/16, the Provider documented the resident's behavior was cyclical, and she goes until she is totally exhausted. She grinds her teeth, was very repetitive with her behavior, and she actually walks until she is very sweaty and exhausted. The provider addressed the medications for behavior, but did not address pain. The previously added medications, [MEDICATION NAME] and [MEDICATION NAME], Had not seemed to help. - On 3/29/16, the provider again addressed the resident's behavior of gritting her teeth, restlessness, and lack of sleep. The Plan was to initiate [MEDICATION NAME] for the behaviors. Pain was not addressed. - On 4/26/16, the provider documented the resident continued to be restless with the [MEDICATION NAME], which was increased to 100 mg in the morning. The resident continued to use the [MEDICATION NAME], but pain was not addressed. - On 5/6/16, the provider documented the resident was up and wandering, difficult to settle down, and her agitation was not easily altered. No other issues were noted, and pain was not addressed. Medications were reviewed. - On 5/11/16, the provider again documented the resident's medications, Had not adequately controlled her being awake at various hours, very agitated, and walked until she was totally exhausted. The provider was going to consult with a behavioral facility out of town for further assistance. The plan was to change the resident's behavioral medications, and complete laboratory testing to See if we can quiet her behavior. - On 5/17/16, the provider documented, She had been continuing to pace, whether daytime, or nighttime, grinding her teeth. Mood and behavior review did bring up this pain issue. She had a history of [REDACTED].Will start her on [MEDICATION NAME] 5/325 one a day and one a day prn, to see if this cuts down on her teeth grinding and make her more comfortable overall. A review of an IDT progress note, dated 5/17/16, for behavior showed the physician added pain medication, to include a PRN dose, in an attempt to alter the resident's behavior. - On 5/24/16, the provider noted the resident was given [MEDICATION NAME] when she was rubbing her knees, and clenching her jaw and was relaxed after and fell asleep. The resident continued to walk, but yesterday (5/23/16), the resident was agitated again and clenching the jaw and rubbing her knee. The plan was to increase the [MEDICATION NAME] to help quiet the clenching, anxiety and constant walking. A review of the Nursing Progress notes for this day showed the resident had increased signs of agitation and restlessness, but [MEDICATION NAME] was given. Pain was not assessed per the documentation, and a PRN dose of [MEDICATION NAME] was not given. During an interview on 6/8/16 at 10:10 a.m., staff member SA stated the resident had Tylenol for pain prior to the [MEDICATION NAME]. She stated the resident was admitted with behaviors and was so agitated that the goal was to decrease the behavior and have better control of them. She stated Tylenol was frequently scheduled for the geriatric population who had arthritis pain. The resident had been clenching her jaw, which was the only pain symptom she correlated pain to, which is why the pain medication, [MEDICATION NAME], was initiated. The goal was to start her out with a low dose of the [MEDICATION NAME], and the PRN dose, and see if this helped with alleviating the resident's discomfort. Then the medications would be reviewed the following week for changes. The staff member was out of town so the pain medication, and use of the PRN dose, was not addressed the following week. Staff member SA stated she relied on the nursing documentation, and staff reports on resident observations related to pain and behavior. A review of the Nursing Progress notes, dated 2/29/16 to 6/7/16, showed the resident displayed: anxiousness, walking continuously up to three hours or more at a time, ignored attempts to offer activities, uneasily altered, grinding and clenching her teeth, shaking from muscle tension, extreme restlessness, stumbling, facial diaphoresis, lack of sleeping, aggression and behavior toward others, and refusing care. On 3/25/16, the nurse documented the resident commented on knee pain. The nursing progress notes lacked assessments for pain when the resident was acting out, or showed pain symptoms. At times the documentation showed the resident was given [MEDICATION NAME] for agitation to treat the behaviors. Throughout this timeline, the resident's behaviors remained consistent. During an interview on 6/8/16 at 11:20 a.m., staff member E stated the resident had enough cognition to report if she was in pain. She stated you could also tell by her expression. Staff member E said the resident had scheduled pain medication in place, so the resident did not need to be assessed for pain. She stated the resident would act different if she was in pain, and would get Agitated, short tempered, and aggressive, and that meant it hurts. A review of the resident's Medication Administration Record [REDACTED]. Documentation showed: - March - The resident was given [MEDICATION NAME] 14 times in the month. Aspercreme was utilized nine times. - April - [MEDICATION NAME] was given 15 times, and Aspercreme was used seven times. - May - [MEDICATION NAME] had been given 23 times. All but one dose was given between 1:00 p.m. and midnight. [MEDICATION NAME], which was ordered on [DATE], was used four times. - June - [MEDICATION NAME] was given four times. [MEDICATION NAME] was not utilized. During interviews on 6/7/16 at 6:00 p.m., staff members W and X were able to state the resident's pain symptoms consisted of clenching her jaw. Both staff members worked with the resident daily. They stated they would tell the nurse if the resident had pain, but did not normally know if the nurse treated the pain. During an interview and observation on 6/8/16 at 3:03 p.m., staff member Z stated the resident was having pain in her back but had not reported the concern to the nurse yet. Staff member E arrived, and was informed of the resident's pain. Staff member E sat next to the resident, and asked the resident if she had pain. The resident responded, Yes. The resident did not respond when the location or rating of the pain was questioned. Staff member E exited the room. Staff member Z stated she would try to toilet the resident, provide a snack, and reposition the resident prior to a medication intervention being given for pain. During an interview on 6/8/16 at 9:45 a.m., staff member A stated the facility needed to focus on pain, so the provider was asked to join the behavior committee each week. This change took place in late 2015. She stated staff member SA had an individualized approach to pain, and when reviewing pain she looks at all facets of care. At 11:10 a.m., she stated the secure unit staff needed more education, as well as the nurses, and they need to talk with the CNAs more on what they are seeing. She stated if a behavioral medication is not working, such as the [MEDICATION NAME] ordered for the resident, then an alternate medication for pain should be attempted sooner. During an interview on 6/8/16 at 4:00 p.m., staff member E stated the resident was given a [MEDICATION NAME] tablet when she had pain, and when reassessed a short time later the resident was comfortable, her behaviors had subsided, and she was resting in a chair. Staff member E stated the medication worked well, and It's the best she had been in a while. 3. Resident #2 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. During an observation on 6/7/16 at 9:50 a.m., the resident was in a fell ow resident's room. Staff member CC attempted to redirect the resident, but she adamantly refused to leave the other resident's room. Shortly after, the resident exited the room and was observed walking in the hallway. She walked to the dining area slowly and sat down. She stated she did not feel well, and had pain in her back. The resident's communication was clear. The facility was notified of the resident's pain. During an interview on 6/7/16 at 10:15 a.m., staff member T stated the resident's behaviors were hard to redirect, and You just have to wait it out. During an observation and interview on 6/7/16 at 12:40 p.m., the resident was sitting in a chair outside. She was able to respond to questions, and stated she did not feel well. She stated she had pain in her stomach, but denied having an upset stomach. The facility was notified about the resident's pain. During interviews on 6/7/16 at 6:00 p.m., staff members W and X stated the resident had pain in her legs and she would often rub her legs. She stated this had been a longstanding issue for the resident. That's how she knew the resident had pain. During an observation on 6/8/16 at 5:10 p.m., the resident was going outside to sit in a chair. When she attempted to sit she grimaced, and slowly put herself in the chair. She rubbed her knee and thigh area on both legs. The resident stated Oh, I just don't know how I am, I hurt all over. She attempted to readjust herself in the chair, and grimaced with the movement. Staff were notified of the resident's statement. A review of the resident's Annual MDS, with an ARD of 4/18/16, showed she had severely impaired cognition. She was mildly depressed, and for pain was documented as having a scheduled pain medication and a PRN pain medication in place. Pain was documented as not present on the assessment, and no pain indicators were identified. A review of the resident's Nursing Notes showed she had complained of pain on 4/12/16 at 3:30 a.m., which was in her legs. The resident was provided Tylenol. Prior to this, pain was not documented as being a concern for the resident. Further review of the resident's Nursing Notes, Intake Records, MAR, and Behavior Documentation showed that beginning in May 2016, the resident began to have an increase in pain complaints, behavior outbursts, acting out toward others, her meal intake decreased, she began refusing medications, and she was frequently confused. During an interview on 6/8/16 at 10:10 a.m., staff member SA stated she did not believe any testing had been completed while the resident was at the facility for her knees/legs, and usually she started out treatment conservatively, working up to radiological testing. She was not aware the resident had a change which began in May. A review of a Pain Summary, completed on 4/20/16, showed the resident was assessed for pain, and she did not verbalize pain. The resident did not display signs or symptoms of pain. The resident had Tylenol available if needed. A review of the resident's Physician order [REDACTED]. The physician orders [REDACTED]. A review of the Telephone Orders showed changes were made to the resident's behavioral and mood medications in an attempt to decrease behaviors, but not for pain. A review of the resident's MARs from March 2016 to June 2016 showed the PRN Tylenol was used one time, which was in April. The resident's MARs showed she had not refused her medications in March or April of 2016, but in May began refusing consistently, beginning on the seventh of the month. These refusals carried over into June 2016. The Nursing Notes lacked evidence to show if the provider had been notified of the refusals. During an interview on 6/9/16 at 8:30 a.m., staff member B stated the nurse is required to notify the physician if a medication was refused so the provider could make changes if needed. A review of the Provider Progress Notes showed: - On 10/15/15 the resident was complaining of leg pain. It was usually at night after she went to bed. The provider documented it appeared to be in her lower legs, and she did not walk as much as she used to. Staff also reported she rubbed her legs a lot, and that helped her. - On 1/26/16, the provider documented that the resident continued to report leg pain frequently, and pointed to the shin area. She occasionally complained of knee pain. The physician initiated Aspercreme four times a day to her legs, and Tylenol to see how this helped the pain. The pain was not addressed in the provider notes following this. A review of the resident's Pain Care Plan showed she would grab at her legs, continuously ambulate, and grimace when in pain. Staff were to assess pain when this occurred and administer pain medication as ordered. A review of the [MEDICAL CONDITION] Drug Use Policy showed pain should be assessed as an underlying cause for behaviors exhibited by residents. After the facility was made aware of the resident's complaints on 6/7/16 and 6/8/16, no follow-up had occurred prior to the exit of the survey team.

Based on observation, interview, and record review, the facility failed to ensure a resident with a physician's ordered fortified diet received the fortification for meals which were not provided by the dietary department, but were prepared on the secure unit by CNA staff for 1 (#2) of 15 sampled residents. Findings include: Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During an observation on 6/7/16 at 9:30 a.m., the meal cart arrived. The CNA staff assisted with setting up the trays, and condiments for the meal. An observation of the tray card for resident #2 showed she was to have a fortified diet. During an observation on 6/7/16 at 6:15 p.m., snacks were being offered to the residents. This included meat sandwiches, juice, and pudding. The CNA staff were observed making the sandwiches for the residents from items kept in the kitchenette. A fell ow resident was provided what appeared to be hot cereal. During an interview, staff member X stated she got supplies from the kitchen for the food. During the observation, resident #2 was offered a sandwich, and declined. She also declined a drink, but when staff member AA provided a drink, she drank it. A review of the resident's Care Card, utilized by CNA staff, showed the resident was to have a reg/reg/reg diet, with Ensure at 1300 and 1900. The card did not show the diet was fortified. A review of the Physician Orders for June 2016, reviewed in the electronic health system, showed the resident was to have a fortified diet regular diet. A request for a copy of the physician's orders was made, but they were not received prior to the end of the survey. A review of the resident's nutritional care plan showed a fortified regular diet was to be provided. A review of the resident's Nutritional Assessment, dated 4/19/16, showed the residents goal body weight was 149 pounds, and the resident weighed 123 pounds. The only problem identified on the assessment was related to a lack of fluid intake, related to thirst sensation. During an interview on 6/8/16 at 10:50 a.m., staff member D stated cereals were fortified with milk sent from the kitchen. He stated fortification would be added to eggs, and extra butter would be used when food was prepared. He was not aware of any system in place to notify the staff of how to fortify food they prepare, except by way of the diet card. During an interview on 6/8/16 at 1:30 p.m., staff member BB stated the CNA care card would notify the staff if the resident had a fortified diet, and she had checked, and found the card had not been updated to reflect the fortified diet. During an interview on 6/8/16 at 4:00 p.m., staff member Z stated she would make the resident's a milkshake or add fortified powder to the resident's milk. She was not sure of anything else she was required to do to ensure the resident received the fortified diet. During an interview on 6/8/16 at 4:10 p.m., staff member X stated she had no idea what fortified meant on the tray card. She questioned if it meant thickening powder. The items in the refrigerator were observed, which included three kinds of milk, juices, health shakes, individual resident items, a bag of frozen meat slices, peaches in cups, and tuna. The cupboards were checked and found to have no items to fortify a meal with, but a box of cream of wheat was present. During an interview and observation on 6/8/16 at 4:30 p.m., staff member BB stated hot cereal should not be available in the kitchenette, and when she looked in the cupboard she observed the cream of wheat box and disposed of it. Staff member BB and staff member D were observed discussing ways to provide documentation to show the CNAs how they could fortify a diet if they provided the food from the kitchenette. A review of the policy/educational materials titled High-Calorie, High-Protein Nutrition Therapy, which was not available to the CNA staff who prepared the fortified food in the secured unit during the survey, showed options for consuming more fat, choosing high-calorie drinks, and choosing high-protein foods.

Based on record review and interview, the failed to prevent mistreatment and neglect for 6 (#s 2, 3, 11, 25, 31 and 32) of 32 sampled and supplemental residents. IMMEDIATE JEOPARDY On 4/23/15 at 5:13 p.m., the facility administrator was notified by the survey team that an immediate jeopardy situation existed in the areas of Resident Behaviors and Facility Practices and Quality of Care. PLAN TO RESOLVE THE IMMEDIATE JEOPARDY The facility submitted an acceptable plan to resolve the immediate jeopardy on 4/24/15 at 2:32 p.m. After the plan to resolve the Immediate Jeopardy was accepted, the scope and severity of this deficiency at K was moved to a scope and severity of G, reflecting one resident experienced harm. A summary of the facility's plan to resolve the immediate jeopardy was as follows: 1. Termination of 1 contract employee and suspension (pending investigation) for 1 permanent employee. 2. Abuse and Neglect Training for all staff employed by the facility starting 04/23/15 beginning at 5:30 p.m. 3. Mechanical Lift Training for all staff employed by the facility starting 04/23/15 starting at 5:30 p.m. 4. Appointment of an Abuse Coordinator. 5. Notification to all residents and family members of the Abuse Coordinator's appointment and all contact information for the Abuse Coordinator. Findings include: 1. Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident BIMS score was 15 on his annual MDS with an ARD of 2/23/14. During a review of the facility's Report of Suspected Resident Abuse from 3/26/15 showed a report as follows: "On 3/25/15 I took (resident #11) to the urologist. I loaded up (resident #11) and his sling so that I could transfer him when we got to his office and get him up on the exam table so the Dr. could change his catheter. When we got to the Dr. we met (Staff member N) who was already checking in (resident #11) so we went right back into the exam room. When got to the exam room I parked (resident #11) and explained that I was going to go up to Extended Care and get the lift. (Staff member N) stated 'no' I said 'what do you mean no? I will go up and get the lift I'll be right back.' (Staff member N) pulled (resident #11) up towards the exam table scooted (resident #11) forward when (resident #11) started yelling 'No, No don't do that. You can't lift me. You can't lift me by yourself it takes two or 3 people to lift me safely.' (Staff member N) replied '(Resident #11) don't worry I have done this before.' (Resident #11) was protesting when (staff member N) gave him a bear hug and lifted him out of his wheelchair and told me to swing his feet up. I explained that his catheter was still attached to the wheelchair unhooked the wheelchair and lifted (resident #11's) feet to the exam table. (Resident #11) started telling (staff member N) that he hurt his chest. I stayed with (resident #11) while waiting for the Dr. and (resident #11) mentioned a couple of times about how his chest hurt and that man should not have lifted him like that. When the Dr. came in to get started changing the cath he stated he wanted to scoot (resident #11) up on the table, (staff member N) walked around the table and lifted him up with Dr. When (resident #11) saw (staff member N) He yelled 'NOT YOU!! YOU, GET AWAY FROM ME YOU ALREADY HURT ME ONCE!' (Staff member N) chuckled and said yes (resident #11) I am a big brute. When the cath was changed and I had gotten (resident #11's) pants back on (staff member N) said 'you will just have to pull his pants up when I stand him up' We sat (resident #11) up. (Resident #11) began to plead 'please, please don't hurt me again. Please, don't you know I'm an old man you can't treat me an old man like that.' When I loaded (resident #11) up in the van (resident #11) told me 'thank you for staying with me and you made the trip almost bearable that big guy that lifted me...he might be qualified in most situations to lift people he is healthy and strong but not in mine. I'm a big boy, and I'd have to say as tall as he is you know, and squeezing me in such a way like he did that really hurts an old man like me. Now listen sweetheart if something comes of this and this pain gets worse I might need you to tell someone about it so they don't think I am pulling their leg or telling stories. I assured (resident #11) I would stick up for him (sic)." Review of the facility's Investigation of Suspected Abuse dated 3/30/15 showed, "(Resident #11) is an [AGE] year old gentleman who lives on the the general floor. His [DIAGNOSES REDACTED]. He is well known to cry out when knowing that a procedure is going to be happening, as he was aware the morning of 3/25/15. Upon investigation the actions identified during the appointment are not abusive. The decisions identified were not clearly explained to (resident #11) or the other CNA-Coordinator helping during the appointment, and other options were not discussed. The CNA-Coordinator making decisions during that appointment, has been counseled and re-educated regarding who can make decisions that deviate from the standards of care and the care plan." Review of resident #11's Care Plan showed the resident to be an extensive assist of 2 PCGA with mechanical lift. The facility's policy reflected all mechanical lifts were a two person assist with transfer. Review of resident #11's records showed an "XR Ribs R w/o Chest PA. Reason for examination: Pain. Impression: No no acute radiographic abnormality in the ribs.(sic). During an interview on 4/23/15 at 11:36 a.m., staff member B, DON, stated she did not need to follow up with staff member N following his verbal reprimand for the improper transfer of resident #11; since the incident, he has not been out of the facility on transport. Staff member B stated the CNA had been in her office letting her know that he had sent out two CNAs with a lift to all doctor appointments for residents. Staff member B stated the CNA had been in her office volunteering this information. Staff member B stated the CNA had been re-educated on resident rights verbally, but not with a written disciplinary action. Staff member B stated there had not been any written disciplinary follow up for staff member N on resident rights. During an interview on 4/23/15 at 3:30 p.m., staff member N stated he had made an assessment of the room and decided the lift would not be a safe transfer, as the resident could get jostled. He said he felt his transfer would be safer and he used good body mechanics. In response to why he continued with the transfer when the resident was asking him not to, he replied "Have you met (resident #11)? Everything is no, don't do that. (The resident) says his ribs still hurt, but tomorrow it will be something else." During an interview on 4/22/15 at 4:10 p.m., resident #11's family member stated the resident was hurt at the doctor's office when he was lifted up with out a lift. When the CNA lifted the resident, he hurt his ribs. The resident was sent for an X-Ray of his ribs to make sure there was not a fracture. During an interview on 4/24/15 at 10:05 a.m., resident #11 stated a "man big and strong grabbed me around my middle and had (sic) to have X-Ray's because he hurt me so bad when he did that." A review of the facility's policy and procedure for Resident Handling Policy showed, "All residents who have been assessed as being a Mechanical Lift will require the use of the mechanical lift when performing any transfer. All Mechanical Lift transfers will require a two person for the safety of the staff and the resident." "All employees directly involved in resident transfers (excluding therapists or rehab aids treating residents to improve functional status) will follow the documented transfer status. Any employee not using a lift for designated residents or not using a gait/transfer belt while assisting resident to transfer or not following specific directives regarding transferring as outlined in each resident's plan of care is subject to disciplinary action." 2. Resident #2 was originally admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. 3. Resident #32 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the grievance file showed resident #2 had filed a grievance on 02/24/15 regarding neglect by staff member X, CNA. The summarization of the grievance reflected, "Staff member tell (resident #2) and (resident #32) she will be back to lay (resident #32) down but she never comes back. Sitting at nurses station. Put call light on approx. 3 times." 4. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the grievance file showed resident #3 had filed a grievance on 02/23/15 regarding neglect by staff member X, CNA. The summarization of the grievance reflected, "(Resident #3) said (staff member X) answered her call light and (resident #3) said she needed to use porta potty. (Staff member X) said she needed to get help and never returned. (Resident #3) stated this has happened before with (staff member X)." 5. Resident #25 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the grievance file showed resident #25 filed a grievance on 01/16/15 related to rude, hostile comments and rough cares by staff member X, CNA. The summarization of the grievance stated: "Both (resident #25) and a CNA reported to SS that 2 other CNAs were very rude and hostile to (resident #25) w/AM cares (staff member X and an unidentified staff). (Resident #25) was very upset ~ stated she was left on the toilet for 45 minutes. CNA reported (resident #25) also wanted her table in a certain area and was told, "No, we're going to leave it this way. I don't want to deal with it." 6. Resident #31 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the grievance file showed resident #31 filed a grievance on 02/23/15 related to neglect. The summarization of the grievance stated, "(Resident #31) said when (staff member X, CNA) answers her call light and (resident #31) asks for water, (staff member X) says she's busy and will be back later and never comes back or she just leaves the room and never comes back." Review of the facility's policy titled, "Resident Abuse" defined abuse as: "Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm or pain or mental anguish. (42 CFR 488.30) This also includes the deprivation by an individual, including a caretaker, of good or services that are necessary to attain or maintain physical, mental, and psychosocial well being. This presumes that instances of abuse of all residents, even those in a coma, cause physical harm, or pain or mental anguish." This policy goes on to define verbal abuse as: "Verbal Abuse is defined as any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. Examples of verbal abuse include, but are not limited to threats of harm, saying things to frighten a resident, such as telling a resident that they will never be able to see their family again. " This policy also defines neglect as: "Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Non action which results in emotional, psychological, or physical injury is viewed in the same manner as that caused by improper or excessive action. All actions in which employees engage with resident must have as their legitimate goal, the healthful, proper, and humane care and treatment of [REDACTED].

Based on record review and interview, the facility failed to follow their policy titled, "Abuse Prevention," for 5 (#s 2, 3, 25, 31 and 32) of 32 sampled and supplemental residents. Findings include: IMMEDIATE JEOPARDY On 4/23/15 at 5:13 p.m., the facility administrator was notified by the survey team that an immediate jeopardy situation existed in the areas of Resident Behaviors and Facility Practices and Quality of care. PLAN TO RESOLVE THE IMMEDIATE JEOPARDY The facility submitted an acceptable plan to resolve the immediate jeopardy on 4/24/15 at 2:32 p.m. After the plan to resolve the Immediate Jeopardy was accepted, the severity and scope of this deficiency at a K was moved to a severity and scope of E. A summary of the facility's plan to resolve the immediate jeopardy was as follows: 1. Termination of 1 contract employee and suspension (pending investigation) for 1 permanent employee. 2. Abuse and Neglect Training for all staff employed by the facility starting 04/23/15 starting at 5:30 p.m. 3. Mechanical Lift Training for all staff employed by the facility starting 04/23/15 starting at 5:30 p.m. 4. Appointment of an Abuse Coordinator. 5. Notification to all residents and family members of the Abuse Coordinator's appointment and all contact information for the Abuse Coordinator. Findings include: 1. Resident #2 was originally admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. 2. Resident #32 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the grievance file showed resident #2 had filed a grievance on 02/24/15 regarding neglect by staff member X, CNA. The summarization of the grievance reflected "Staff member telling (resident #2) and (resident #32) she will be back to lay (resident #32) down, but never comes back. Sitting at nurses station. Put call light on approx. 3 times." 3. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the grievance file showed resident #3 had filed a grievance on 02/23/15 regarding neglect by staff member X, CNA. The summarization of the grievance showed: "(Resident #3) said (staff member X) answered her call light and (resident #3) said she needed to use porta potty. (Staff member X) said she needed to get help and never returned. (Resident #3) stated this has happened before with (staff member X)." 4. Resident #25 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the grievance file showed resident #25 filed a grievance on 01/16/15 related to rude, hostile comments and rough cares by staff member X, CNA. The summarization of the grievance showed, "Both (resident #25) and a CNA reported to SS that 2 other CNAs were very rude and hostile to (resident #25) w/a.m. cares (staff member X and unidentified staff), (Resident #25) was very upset - stated she was left on the toilet for 45 minutes. CNA reported (resident #25) also wanted her table in a certain area and was told "No, we're going to leave it this way. I don't want to deal with it." During an interview, on 04/23/15 at 11:20 a.m., resident #25 said that staff member X, CNA, grabbed her arm and yanked it through the sleeve of her dress. Resident #25 told staff member X that she need to slow down and not jerk her arms because it hurt. Resident #25 said that staff member X continued getting her dressed, pulling too quickly on her limbs. Resident #25 said that staff member X told her, "You only get 15 minutes from me." Resident #25 said staff member X had "attitude." When staff member X would enter resident #25's room, she would say, "Are we going to have a good day?" Resident #25 felt like staff member X was implying it was resident #25's problem. 5. Resident #31 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the grievance file showed resident #31 filed a grievance on 02/23/15 related to neglect. The summarization of the grievance reflected: "(Resident #31) said when (staff member X, CNA) answers her call light and (resident #31) asks for water, (staff member X) says she's busy and will be back later and never comes back or she just leaves the room and never comes back." During an interview, on 4/22/15 at 2:50 p.m., staff member B, director of nursing, said the facility does not do abuse training with the contract staff. Staff member B also said the facility does not do disciplinary action with contract staff and the facility does not keep personnel files for the contract staff. When staff member B was asked how the facility ensured that abuse and neglect training, especially the Montana Elder Abuse Act, was current for contract staff, she replied, "We don't." Staff member B was asked if she was ok that staff had exhibited abusive, neglectful behaviors towards the residents. She replied, "No." She then stated that staff member X's contract would be terminated. Staff member B, said the facility does "on-boarding" (training) with the contract staff. It takes approximately six hours to complete the "on-boarding" process. This training did not include any abuse and neglect training for the contract staff. Review of the contracts for the five staffing agencies, used by the facility, indicated that two of the staffing agencies did not provide abuse and neglect training for their staff. One of these agencies had provided 11 contract staff in the facility during the survey time. Ten of the staff were CNAs and 1 staff was an LPN. Review of the facility's on-line course titled: "2014 Abuse, Neglect, and Exploitation" identified all the facility employed staff that had completed the training. The facility had 83 facility employed staff listed on their roster and of those 83, only 35 staff had completed the training for 2014 and no one employed by the facility had completed abuse and neglect training for 2015. Review of the facility's policy of Abuse Prevention reflected, "(The facility) explicitly prohibits any actions or communications that are or could be perceived to be abuse, neglect, involuntary seclusion, or misappropriation of property by any employee or volunteer." Review of the Abuse Prevention policy section on training shows: General orientation and regular in-service programming includes training to equip each staff member with skills: 1. To deal appropriately with aggressive and/or catastrophic reactions of residents/patients. 2. To report any knowledge of allegations related to inappropriate practice observed by self or residents/patients or visitors (see grievance procedure). 3. To recognize signs of stress that could lead to inappropriate or harmful behavior. 4. To understand the full scope and definition of abuse, neglect, and misappropriation of property. Review of the Abuse Prevention policy section on investigation shows: 1. The following investigation procedures are in place for situations of suspected abuse/neglect: a. All complaints by residents, patients, family visitors or staff are followed up on; b. All grievances filed by staff members; c. Any unusual occurrences; and d. Any bruise, skin tear or injury that does not have a documented cause. 2. Staff members responsible for the reporting and investigation are identified. 3. Residents/patients are protected during any investigation, i.e., alleged perpetrator is relieved of duties and/or assigned to another area pending decision following investigation.

Based on observation, record review and interview, the facility failed to administer the facility in a manner as to maintain or improve the resident's physical, emotional and psychosocial well being for 8 (#s 2, 3, 8, 11, 25, 30, 31 and 32 ) out of 32 sampled and supplemental residents; and, failed to maintain dated resident skin treatment and wound supplies and dispose of out-dated supplies that had the opportunity to affect all residents with wound and skin treatments. IMMEDIATE JEOPARDY On 4/23/15 at 5:13 p.m., the facility administrator and director of nursing were notified by the surveyors that an immediate jeopardy situation existed in the areas of Resident Behavior and Facility Practices and Quality of Care. PLAN TO RESOLVE THE IMMEDIATE JEOPARDY The facility submitted an acceptable plan to resolve the immediate jeopardy on 4/24/15 at 2:32 p.m. After the plan to resolve the Immediate Jeopardy was accepted, the scope and severity of this deficiency at K was removed to an E. A summary of the facility's plan to resolve the immediate jeopardy was as follows: 1. Termination of 1 contract employee and suspension (pending investigation) for 1 permanent employee. 2. Abuse and Neglect Training for all staff employed by the facility starting 04/23/15 starting at 5:30 p.m. 3. Mechanical Lift Training for all staff employed by the facility starting 04/23/15 starting at 5:30 p.m. 4. Appointment of an Abuse Coordinator. 5. Notification to all residents and family members of the Abuse Coordinator's appointment and all contact information for the Abuse Coordinator. Findings include: 1. The facility failed to keep the residents free from abuse and involuntary seclusion. notify the physician and responsible party after falls, with and without injury for two (#s 11 and 25) of 32 sampled and supplemental residents. Refer to F223. 2. The facility failed to prohibit mistreatment/neglect/misappropriation for 6 (#s 2, 3, 11, 25, 31 and 32) of 32 sampled and supplemental residents. Refer to F224. 3. The facility failed to ensure that all contract staff had received abuse and neglect training, especially regarding the Montana Elder Abuse Act. The facility also failed to ensure permanent facility staff had received current abuse and neglect training for 5 (#s 2, 3, 25, 31, and 32) of 32 sampled and supplemental residents. Refer to F226. 4. The facility failed to provide care and services to maintain the highest well being for one (#11) of 15 sampled residents. Refer to F309. 5. The facility failed to assess and provide necessary services to maintain as much bladder functioning as possible for 2 (#s 8 and 11) of 15 sampled residents. Resident #11 entered the facility with a bladder prosthesis that was not properly maintained resulting in injury to the resident and surgical removal of the prosthesis. The facility failed to discontinue an indwelling catheter for resident #8 when there was no further existing indications for its use. Refer to F 315. 6. The facility failed to safely transfer 2 (#s 8 and 30) of 32 sampled and supplement residents. The facility failed to prevent a fall, causing major injury during a transfer of resident #8. The facility failed to utilize the correct sling for the correct mechanical lift and failed to provide proper sling placement on resident before transferring resident #30. Refer to F323.

Based on record review and interview, the facility failed to ensure 2 (#s 11 and 25 ) of 32 sampled and supplemental residents were free from staff mistreatment and failed to respect the resident's right to refuse an unsafe transfer, resulting in an injury to a resident. IMMEDIATE JEOPARDY On 4/23/15 at 5:13 p.m., the facility administrator and director of nursing were notified by the surveyors that an immediate jeopardy situation existed in the areas of Resident Behavior and Facility Practices and Quality of Care. PLAN TO RESOLVE THE IMMEDIATE JEOPARDY The facility submitted an acceptable plan to resolve the immediate jeopardy on 4/24/15 at 2:32 p.m. After the plan to resolve the Immediate Jeopardy was accepted, the scope and severity of this deficiency was removed to a G, reflecting the resident received harm. A summary of the facility's plan to resolve the immediate jeopardy was as follows: 1. Termination of 1 contract employee and suspension (pending investigation) for 1 permanent employee. 2. Abuse and Neglect Training for all staff employed by the facility starting 04/23/15 starting at 5:30 p.m. 3. Mechanical Lift Training for all staff employed by the facility starting 04/23/15 starting at 5:30 p.m. 4. Appointment of an Abuse Coordinator. 5. Notification to all residents and family members of the Abuse Coordinator's appointment and all contact information for the Abuse Coordinator. Findings include: 1. Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's BIMS score was 15 on his annual MDS with an ARD of 2/23/15. During a review of the facility's Report of Suspected Resident Abuse from 3/26/15 showed "On 3/25/15 I took (resident #11) to the urologist. I loaded up (resident #11) and his sling so that I could transfer him when we got to his office and get him up on the exam table so the Dr. could change his catheter. When we got to the Dr. we met (Staff member N) who was already checking in (resident #11) so we went right back into the exam room. When got to the exam room I parked (resident #11) and explained that I was going to go up to Extended Care and get the lift. (Staff member N) stated 'no' I said 'what do you mean no? I will go up and get the lift I'll be right back.' (Staff member N) pulled (resident #11) up towards the exam table scooted (resident #11) forward when (resident #11) started yelling 'No, No don't do that. You can't lift me. You can't lift me by yourself it takes two or 3 people to lift me safely.' (Staff member N) replied '(Resident #11) don't worry I have done this before.' (Resident #11) was protesting when (staff member N) gave him a bear hug and lifted him out of his wheelchair and told me to swing his feet up. I explained that his catheter was still attached to the wheelchair unhooked the wheelchair and lifted (resident #11's) feet to the exam table. (Resident #11) started telling (staff member N) that he hurt his chest. I stayed with (resident #11) while waiting for the Dr. and (resident #11) mentioned a couple of times about how his chest hurt and that man should not have lifted him like that. When the Dr. came in to get started changing the cath he stated he wanted to scoot (resident #11) up on the table, (staff member N) walked around the table and lifted him up with Dr. When (resident #11) saw (staff member N) He yelled 'NOT YOU!! YOU, GET AWAY FROM ME YOU ALREADY HURT ME ONCE!' (Staff member N) chuckled and said yes (resident #11) I am a big brute. When the cath was changed and I had gotten (resident #11's) pants back on (staff member N) said 'you will just have to pull his pants up when I stand him up.' We sat (resident #11) up. (Resident #11) began to plead 'please, please don't hurt me again. Please, don't you know I'm an old man you can't treat me an old man like that.' When I loaded (resident #11) up in the van (resident #11) told me 'thank you for staying with me and you made the trip almost bearable that big guy that lifted me...he might be qualified in most situations to lift people he is healthy and strong but not in mine. I'm a big boy, and I'd have to say as tall as he is you know, and squeezing me in such a way like he did that really hurts an old man like me. Now listen sweetheart if something comes of this and this pain gets worse I might need you to tell someone about it so they don't think I am pulling their leg or telling stories. I assured (resident #11) I would stick up for him.(sic)" Review of the facility's Investigation of Suspected Abuse dated 3/30/15 stated, "(Resident #11) is an [AGE] year old gentleman who lives on the the general floor. His [DIAGNOSES REDACTED]. He is well known to cry out when knowing that a procedure is going to be happening, as he was aware the morning of 3/25/15. Upon investigation the actions identified during the appointment are not abusive. The decisions identified were not clearly explained to (resident #11) or the other CNA-Coordinator helping during the appointment, and other options were not discussed. The CNA-Coordinator making decisions during that appointment, has been counseled and re-educated regarding who can make decisions that deviate from the standards of care and the care plan." Review of resident #11's Care Plan showed the resident to be an extensive assist of 2 PCGA with mechanical lift. Review of the facility's policy indicated all mechanical lifts were a two person assist with transfer. Review of resident #11's records showed an "XR Ribs R w/o Chest PA. Reason for examination: Pain. Impression: No no acute radiographic abnormality in the ribs. During an interview on 4/23/15 at 11:36 a.m., staff member B, DON, stated she did not need to follow up with staff member N following his verbal reprimand for the improper transfer of resident #11; since the incident, he has not been out of the facility on transport. Staff member B stated he had been in her office letting her know that he had sent out two CNAs with a lift to all doctor appointments for residents. Staff member B stated the CNA had been in her office volunteering this information. Staff member B stated the CNA had been re-educated on resident rights verbally, but not with a written disciplinary action. Staff member B stated there had not been any written disciplinary follow up for staff member N on resident rights. During an interview on 4/23/15 at 3:30 p.m., staff member N stated he had made an assessment of the room and decided the lift would not be a safe transfer, as the resident could get jostled. He said he felt his transfer would be safer and he used good body mechanics. In response to why he continued with the transfer when the resident was asking him not to, he replied "Have you met (resident #11)? Everything is no, don't do that. (The resident) says his ribs still hurt, but tomorrow it will be something else." During an interview on 4/22/15 at 4:10 p.m., resident #11's family member stated the resident was hurt at the doctor's office when he was lifted up with out a lift. When the resident was lifted up by the CNA, the CNA hurt the resident's ribs. The resident had to have a chest X-Ray to make sure no ribs were fractured. During an interview on 4/24/15 at 10:05 a.m., resident #11 stated a "man big and strong grabbed me around my middle and had to have X-Ray's because he hurt me so bad when he did that (sic)." A review of the facility's policy and procedure for Resident Handling showed: "All residents who have been assessed as being a Mechanical Lift will require the use of the mechanical lift when performing any transfer. All Mechanical Lift transfers will require a two person for the safety of the staff and the resident. Training and Participation: All employees directly involved in resident transfers (excluding therapists or rehab aids treating residents to improve functional status) will follow the documented transfer status. Any employee not using a lift for designated residents or not using a gait/transfer belt while assisting resident to transfer or not following specific directives regarding transferring as outlined in each resident's plan of care is subject to disciplinary action." 2. Resident #25 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the facility's grievance file showed on 01/16/2015, resident #25 filed a grievance related to rude, hostile comments and rough care by staff member X, CNA. During an interview, on 04/23/15 at 11:20 a.m., resident #25 said that staff member X, CNA, grabbed her arm and yanked it through the sleeve of her dress. Resident #25 told staff member X that she needs to slow down and not jerk her arms because it hurt. Resident #25 said that staff member X continued getting her dressed, pulling too quickly on her limbs. Resident #25 said that staff member X told her, "You only get 15 minutes from me." Resident #25 said staff member X had "attitude." When staff member X would enter resident #25's room, she would say, "Are we going to have a good day?" Resident #25 felt like staff member X was implying it was resident #25's problem. The grievance file contained a form, Concern & Comment Form, that contained three sections. The first section was for the summarization of the concern, a second section was titled, "Action (Refer all concerns to the appropriate department manager for review)," and a third section was titled, "Follow-Up (Refer the concern to the Executive Director after review by the Department Manager)." The first section of the Concern & Comment Form was completed by staff member G, social services, on 01/16/2015. There was a hand written note which reflected, "Given to DON on 1/16/2015." The second and third sections of the form were blank. At the bottom of the form a hand written note showed, "Return to staff member G by January 23rd, 2015." During an interview on 4/22/15 at 9:40 a.m., staff member B, director of nursing, was asked if she had reviewed the Concern & Comment Form. Staff member B said, "Total over-sight on my part. I just totally missed it." Review of the facility's policy, Resident Abuse, reflected: "Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm or pain or mental anguish. (42 CFR 488.30) This also includes the deprivation by an individual, including a caretaker, of good or services that are necessary to attain or maintain physical, mental, and psychosocial well being. This presumes that instances of abuse of all residents, even those in a coma, cause physical harm, or pain or mental anguish." This policy goes on to define verbal abuse as: "Verbal Abuse is defined as any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. Examples of verbal abuse include, but are not limited to: threats of harm; saying things to frighten a resident, such as telling a resident that they will never be able to see their family again." 3. Resident #00 requested to remain anonymous. Review of resident #00's most recent MDS reflected an intact cognition (C0500). During an interview on 4/21/15 at 8:30 a.m., resident #00 stated some of the staff were not respectful, but did not know the staff names. Resident #00 thought they no longer worked there. Resident #00 stated the concerns had not been reported. Resident #00 stated it would not do any good to report staff concerns because they would get upset and hold it against you. Resident #00 stated some of the CNAs treat the residents like they were bodies, not like people, and they make sure to let you know who was in charge. Resident #00 asked to be anonymous because of fear of possible retaliation.

Based on observation, record review and interview, the facility failed to assess and provide necessary services to maintain as much bladder functioning as possible for 2 (#s 8 and 11) of 15 sampled residents. Resident #11 entered the facility with a bladder prosthesis that was not properly maintained resulting in injury to the resident and surgical removal of the prosthesis. The facility failed to discontinue an indwelling catheter for resident #8 when there was no further existing indications for its use. IMMEDIATE JEOPARDY On 4/23/15 at 5:13 p.m., the facility administrator was notified by the survey team that an immediate jeopardy situation existed in the areas of Resident Behaviors and Facility Practices and Quality of care. PLAN TO RESOLVE THE IMMEDIATE JEOPARDY The facility submitted an acceptable plan to resolve the immediate jeopardy on 4/24/15 at 2:32 p.m. After the plan to resolve the Immediate Jeopardy was accepted, the severity and scope of this deficiency at a J was moved to a severity and scope of G, reflecting one resident experienced harm. A summary of the facility's plan to resolve the immediate jeopardy was as follows: 1. Termination of 1 contract employee and suspension (pending investigation) for 1 permanent employee. 2. Abuse and Neglect Training for all staff employed by the facility starting 04/23/15 starting at 5:30 p.m. 3. Mechanical Lift Training for all staff employed by the facility starting 04/23/15 starting at 5:30 p.m. 4. Appointment of an Abuse Coordinator. 5. Notification to all residents and family members of the Abuse Coordinator's appointment and all contact information for the Abuse Coordinator. Findings include: 1. Resident #11 was admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. Resident #11 was admitted to the facility with a bladder pump/sphincter prosthesis. Review of resident #11's admission order set from 3/19/14 reflected there was no documentation of the bladder prosthesis. Review of resident #11's nursing notes from 3/20/14 showed a nursing assessment at the time of admission that stated, "resident (#11) has a bladder pump/port located under scrotum." Review of resident #11's nursing notes from 3/28/14 at 2:57 p.m., reflected, "Res only dribbling voids, unable to obtain sample for UA. cathed Res with 18fr, Res c/o pain, especially at meatus, which is very swollen, red, and tender. Sample obtained, Res drained 2 quarts of dk brown odorous urine (sic)." Review of resident #11's nursing notes from 3/28/14 at 6:39 p.m., showed, "Call placed by RN to FNP regarding [MEDICAL CONDITION] and possibility of bladder port not functioning correctly. Order received to transport resident to (local) ED." Review of emergency room Notes for resident #11 on 3/28/14 showed, Subjective: "This patient had a history of [REDACTED]. He had complained to the NH staff about some abdominal discomfort and they had inserted a straight cath with a large amount of urine -"two quarts" returned. It was after they had removed the straight catheter that they remembered that this patient had some sort of bladder valve or bladder pump. Staff called Dr. to see if the treatment with the Foley was appropriate or could be repeated if needed. Dr. recommended evaluation in the emergency room ." ER Course: "The NH staff contacted (local medical center) reporting that Dr. (urologist), Williston ND, is the patient's urologist. Dr. (urologist) was notified and recommended Foley catheter no larger than #14 French to be inserted to bedside drainage. This was done without incident. He also recommended that the Foley be left in place for the next two days. The Foley catheter may then be removed but again be replaced as needed for [MEDICAL CONDITION]." Review of nursing notes for resident #11 from 3/30/14 illustrated, "Spoke with hospitalist re: removal of artificial urinary sphincter and the concern that the resident will again retain urine d/t staff not being educated on how it functions. Resident and family do not know how it functions either. Order received to leave foley catheter in place and set up urology consult." Review of nursing notes for resident #11 from 4/6/14 showed the resident was started on antibiotics for an urinary tract infection. Review of nursing notes for resident #11 from 4/13/14 showed the family left information on the urinary prosthesis for the facility. Review of nursing notes for resident #11 from 4/23/14 showed a urology consult was set up for resident. Review of Preoperative History and Physical Progress Note from 4/30/14 for resident #11 from the urologist showed, History: "On 3/28/14 a 14-French Foley catheter was placed. His urine initially was without growth, but more recently, despite having the catheter in, he has begun growing Proteus. It should be noted the patient did have greater than 500ml in the bladder at that point..I suspect that this was an artificial urinary sphincter. 80 (sic) in questioning there, it does not appear that the sphincter was being used, since his admission and this most likely explains his incomplete bladder emptying." Plan: "At this point, he is going to be transferred to Billings in the morning for sphincter removal and either Foley placement or suprapubic tube placement." Review of nursing notes for resident #11 from 5/1/14 indicated, "Called Billings Clinic today to get update on resident's status. Nursing states that resident is out of surgery and doing well. He has a Foley catheter placed and plan is to keep in for 1 month. She states there was a hole through the urethra." Review of a Billings Clinic Outreach Note from 7/30/14 for resident #11 indicated, "(resident) comes in today for follow up after having an artificial sphincter removed on May 1. His story was he was in a nursing home. He had transferred. They put a catheter in and then they blew it up, and he subsequently had erosion and infection. He came to Billings, and we had to admit him to the hospital. We had to remove his sphincter. So, we removed his sphincter entirely. We had to use a suprapubic and a perineal incision. He had quite an erosion, and so we had left the catheter in. He was markedly incontinent after a radical prostatectomy in 1995, and that was the reason for his sphincter. So, options were to leave the catheter in and let it heal and then take the catheter out and let him be incontinent or have him leave the catheter in. His son is with him today as we discussed these two options, as well as suprapubic tube. At this time, he is fine with his catheter...I think, at this point in time, his quality of life is probably going to be better with the catheter in rather than just leaking all the time with diapers, and they choose to leave the catheter in for now. We can also change this to a suprapubic tube or always take it out and let him urinate on his own and leak, but for now we are going to leave the catheter in and change it monthly." During an interview on 4/23/15 at 3:06 p.m., staff member L, Risk Management, stated they have been in contact with resident #11's family regarding the urinary prosthesis and facility's failure to manage it accordingly. A disclosure of unanticipated outcomes was discussed with the resident and family. Staff member L, stated the resident was admitted to the facility on [DATE] with a bladder port. It was not on the admit orders, and the physician's history and physical was not received by the facility until a week after the initial visit noting the bladder port. Staff member L stated resident was admitted to the facility mainly for weakness. When he arrived he was wrapped in "Chucks" around the perineal area. Resident #11 was leaking urine. Staff member L stated the facility did not have knowledge of the bladder port on admission until after they received the history and physical from the physician approximately a week later. The facility tried to put a a Foley catheter in resident due to urinary incontinence and could not. He was sent to the emergency roiagnom on [DATE]. Once in the emergency room they found out about the urology problem and contacted a urologist in Williston, ND. The emergency room was advised to use no larger then a 14 French Catheter. Resident was then scheduled for urology consult and set up for surgery to remove the sphincter. The Sphincter was removed on 5/1/14 and this is when the facility notified the family of the disclosure of unanticipated outcomes. Staff member L stated that a root cause analysis was started for this disclosure. Several changes have been made to prevent further failures, such as, physician dictation will be dictated as urgent and sent to the facility right after dictation. The facility has added a new section on pre-admission orders [REDACTED]. If an implant is identified by staff they are to notify all staff and DON immediately to evaluate how to manage the device. If pamphlets are received regarding specialty devices, they will go in the front of the resident's chart. The resident was admitted to the facility on [DATE] with an bladder pump. The interview with risk management indicated the facility did not have knowledge of the bladder pump for resident #11 at the time of his admission. Furthermore, the facility did not know of the bladder pump until after the admission dictation from the admitting provider was received by the facility. Review of resident #11's nursing notes indicated at time of admit on 3/20/14, "resident (#11) has a bladder pump/port located under scrotum." 2. Resident #8 was admitted to the facility on [DATE] and re-admitted on [DATE] with the following [DIAGNOSES REDACTED]. A review of resident #8's physician order [REDACTED]. A review of a follow up orthopedic consultation for resident #8 from 2/6/15 reflected "X-Ray: AP lateral and oblique of the distal tibia and fibula occluding the ankle show excellent callus formation around the highly osteoporotic bone. The fracture has healed in varus. Assessment: Well healed distal tibia and fibula fracture." During an observation on 4/21/15 at 8:21 a.m., resident #8 was in his room. The catheter bag was attached to the side of his electric wheelchair. The tubing from the catheter was dragging on the floor. Resident #8's tibial fracture was healed and records reflected it had been healed since 2/6/15. An indwelling catheter continued to be in place on 4/21/15. During an interview on 4/21/15 at 2:00 p.m., resident #8 stated, "the catheter is a blessing and a curse. It's not that I need the catheter. It does make things easier, but it also makes things harder." During an interview on 4/24/15 at 8:40 a.m., staff member C, RN, stated resident #8 does not want to take out the catheter. Staff member C stated it is his personal preference to leave the catheter in place. Staff member C stated resident #8 sits in his chair all day and with his [MEDICAL CONDITION] and skin breakdown, he doesn't want to go back to having his briefs changed all the time. Staff member C stated the FNP was at the facility to see resident #8 and agreed to leave the indwelling catheter in place. Staff member C stated, "I am not sure if that is documented." During an interview on 4/24/15 at 9:03 a.m., staff member B, DON, stated there was no nursing documentation or resident notification of risk and benefit for continued use of indwelling catheter. Staff member B stated there was no physician notification in resident #8's record on continuing the indwelling catheter. A review of the facility's policy and procedure for Use of Urinary Catheters and Care of Collecting Bag showed, "1. Procedure: Assess daily if there is an indication for indwelling catheter use. Insert catheters only for appropriate indications, and leave in place only as long as needed. Minimize urinary catheter use and duration of use in all patients. Avoid use of urinary catheters in patients and nursing home residents for management of incontinence. 3. Educate patients and family about the need for the indwelling catheter and the goal of removing it as soon as possible to prevent infection."

Based on record review and interview, the facility failed to maintain physical well-being for 1 (#11) of 15 sampled residents by not appropriately assessing a bladder prosthesis on admission and failing to manage the bladder prosthesis resulting in surgical removal of the prosthesis. IMMEDIATE JEOPARDY On 4/23/15 at 5:13 p.m., the facility administrator was notified by the survey team that an immediate jeopardy situation existed in the areas of Resident Behaviors and Facility Practices and Quality of care. PLAN TO RESOLVE THE IMMEDIATE JEOPARDY The facility submitted an acceptable plan to resolve the immediate jeopardy on 4/24/15 at 2:32 p.m. After the plan to resolve the Immediate Jeopardy was accepted, the severity and scope of this deficiency at a J was moved to a severity and scope of G, reflecting one resident experienced harm. A summary of the facility's plan to resolve the immediate jeopardy was as follows: 1. Termination of 1 contract employee and suspension (pending investigation) for 1 permanent employee. 2. Abuse and Neglect Training for all staff employed by the facility starting 04/23/15 starting at 5:30 p.m. 3. Mechanical Lift Training for all staff employed by the facility starting 04/23/15 starting at 5:30 p.m. 4. Appointment of an Abuse Coordinator. 5. Notification to all residents and family members of the Abuse Coordinator's appointment and all contact information for the Abuse Coordinator. Findings include: Resident #11 was admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. Review of resident #11's admission order set, from 3/19/14, reflected there was no mention on of a bladder prosthesis. Review of resident #11's nursing notes from 3/20/14 reflected a nursing assessment at the time of admission that showed, "resident has a bladder pump/port located under scrotum." Review of resident #11's nursing notes from 3/28/14 at 2:57 p.m., reflected "Res only dribbling voids, unable to obtain sample for UA. cathed Res with 18fr, Res c/o pain, especially at meatus, which is very swollen, red, and tender. Sample obtained, Res drained 2 quarts of dk brown odorous urine (sic)." Review of resident #11's nursing notes from 3/28/14 at 6:39 p.m., reflected, "Call placed by RN to FNP, regarding [MEDICAL CONDITION] and possibility of bladder port not functioning correctly. Order received to transport resident to (local) ED." Review of the emergency room Notes for resident #11 on 3/28/14 showed, Subjective: "This patient had a history of [REDACTED]. He had complained to the (NH) staff about some abdominal discomfort and they had inserted a straight cath with a large amount of urine- "two quarts" returned. It was after they had removed the straight catheter that they remembered that this patient had some sort of bladder valve or bladder pump. Staff called Dr. to see if the treatment with the Foley was appropriate or could be repeated if needed. Dr. recommended evaluation in the emergency room ." ER Course: "The MV staff contacted (local medical center) reporting that Dr. (urologist), Williston ND, is the patient's urologist. Dr. (urologist) was notified and recommended Foley catheter no larger than #14 French to be inserted to bedside drainage. This was done without incident. He also recommended that the Foley be left in place for the next two days. The Foley catheter may then be removed but again be replaced as needed for [MEDICAL CONDITION]." Review of nursing notes for resident #11 from 3/30/14 showed, "Spoke with hospitalist re: removal of artificial urinary sphincter and the concern that the resident will again retain urine d/t staff not being educated on how it functions. Resident and family do not know how it functions either. Order received to leave foley catheter in place and set up urology consult." Review of nursing notes for resident #11 on 4/6/14 showed the resident was started on antibiotics for urinary tract infection. Review of nursing notes for resident #11 from 4/13/14 showed the family left information on the urinary prosthesis for the facility. Review of nursing notes for resident #11 from 4/23/14 showed a urology consult was set up for resident. Review of a Preoperative History and Physical Progress Note on 4/30/14 from urologist showed, History: "On 3/28/14 a 14-French Foley catheter was placed. His urine initially was without growth, but more recently, despite having the catheter in, he has begun growing Proteus. It should be noted the the patient did have greater than 500ml in the bladder at that point..I suspect that this was an artificial urinary sphincter. 80 (sic) in questioning there, it does not appear that the sphincter was being used, since his admission and this most likely explains his incomplete bladder emptying." Plan: "At this point, he is going to be transferred to Billings in the morning for sphincter removal and either Foley placement or suprapubic tube placement." Review of nursing notes for resident #11 from 5/1/14 reflected, "Called Billings Clinic today to get update on resident's status. Nursing states that resident is out of surgery and doing well. He has a Foley catheter placed and plan is to keep in for 1 month. She states there was a hole through the urethra." Review of a Billings Clinic Outreach Note from 7/30/14 for resident #11 indicated, "(resident) comes in today for follow up after having an artificial sphincter removed on May 1. His story was he was in a nursing home. He had transferred. They put a catheter in and then they blew it up, and he subsequently had erosion and infection. He came to Billings, and we had to admit him to the hospital. We had to remove his sphincter. So, we removed his sphincter entirely. We had to use a suprapubic and a perineal incision. He had quite an erosion, and so we had left the catheter in. He was markedly incontinent after a radical prostatectomy in 1995, and that was the reason for his sphincter. So, options were to leave the catheter in and let it heal and then take the catheter out and let him be incontinent or have him leave the catheter in. His son is with him today as we discussed these two options, as well as suprapubic tube. At this time, he is fine with his catheter...I think, at this point in time, his quality of life is probably going to be better with the catheter in rather than just leaking all the time with diapers, and they choose to leave the catheter in for now. We can also change this to a suprapubic tube or always take it out and let him urinate on his own and leak, but for now we are going to leave the catheter in and change it monthly." During an interview on 4/23/15 at 3:06 p.m., staff member L, Risk Management, stated they have been in contact with resident #11's family regarding the urinary prosthesis and facility's failure to manage it accordingly. A disclosure of unanticipated outcomes was discussed with the resident and family. Staff member L stated the resident was admitted to the facility on [DATE] with a bladder port. It was not on the admit orders, and the physician's history and physical was not received by the facility until a week after the initial visit noting the bladder port. Staff member L stated resident was admitted to the facility mainly for weakness. When he arrived he was wrapped in "Chucks" around the perineal area. Resident #11 was leaking urine. Staff member L stated the facility did not have knowledge of the bladder port on admission until after they received the history and physical from the physician approximately a week later. The facility tried to put a Foley catheter in the resident due to urinary incontinence and could not. He was sent to the emergency roiagnom on [DATE]. Once in the emergency room they found out about the urology problem and contacted urologist in Williston, ND. The emergency room was advised to use no larger than a 14 French Catheter. The resident was then scheduled for urology consult and set up for surgery to remove the sphincter. The Sphincter was removed on 5/1/14 and this is when the facility notified the family of the disclosure of unanticipated outcomes. Staff member L stated that a root cause analysis was started for this disclosure. Several changes have been made to prevent further failures, such as, physician dictation will be dictated as urgent and sent to the facility right after dictation. The facility has added a new section on pre-admission orders [REDACTED]. If an implant is identified by staff they are to notify all staff and DON immediately to evaluate how to manage the device. If pamphlets are received regarding specialty devices, they will go in the front of the resident's chart. Resident was admitted to the facility on [DATE] with an bladder pump. The interview with risk management indicated the facility did not have knowledge of the bladder pump for resident #11 at the time of his admission. Furthermore, the facility did not know of the bladder pump until after the admission dictation from the admitting provider was received by the facility. Review of resident #11's nursing notes indicated at time of admit on 3/20/14, "resident (#11) has a bladder pump/port located under scrotum."

Based on observation, record review and interview, the facility failed to safely transfer 2 (#s 8 and 30) of 32 sampled and supplemental residents. The facility failed to prevent a fall with major injury during a transfer for resident #8. The facility failed to utilize the correct sling for the correct mechanical lift and failed to provide proper sling placement on the resident before transfer for resident #30. Findings include: 1. Resident #8 was admitted to the facility on [DATE] and readmitted on [DATE] with the following [DIAGNOSES REDACTED]. A review of resident #8's care plan indicated the resident was a 2 person extensive assist with mechanical lift. A review of resident #8's local emergency room report from 12/18/14 reflected, "resident of NH fell while being transferred in a mechanical lift." The [DIAGNOSES REDACTED]." A review of resident #8's Hospital Progress note from 12/22/14 reflected "(resident) had a fall out of bed while being transferred with a lift that caught on part of the sling that he was sitting on and was pulled off the bed." A review of the FAST Committee nursing notes for resident #8 from 2/16/15 showed, "Assessment: Resident's sling had reattached to lift when CNA (staff member T) was moving lift away from bed the sling was pulled causing the resident to roll out of bed. Proper procedure and polices were being followed when resident rolled out of bed. Recommendations: Goal of being free from falls and injuries not met. Current care plan was reviewed and staff educated on monitoring the location of straps and lift bar when moving lift away from residents." During an interview on 4/22/15 at 3:45 p.m., staff member N, CNA Coordinator, stated the CNA (staff member T) was in-serviced by staff member's B and C on lift safety after the incident with resident #8. Staff member N stated that education was not provided to all direct care staff regarding lift safety after the incident. Staff member N stated he does do in-service for the direct care staff by having them watch an Invacare video, but doesn't have the staff do a return demonstration to ensure skill retention. Staff member N stated he will do random "spot checks" to ensure proper lift safety is being used by direct care staff with residents when on the unit. 2. Resident #30 was admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. During an observation on 4/20/15 at 7:45 p.m., staff member U and staff member V, CNAs, were preparing to transfer resident #30 from her recliner to her bed using a 4-point Hoyer lift. The sling being used was a 6-point Invacare Sling. The sling was placed behind resident #30's back to the middle of her back, the sling was not tucked to the base of the resident spine. The CNAs attached the middle or second hooks for the back of the sling leaving the first hooks unclasped. Then the CNAs criss-crossed the bottom or the third straps between the resident's thighs and hooked to 4-Point Hoyer. The 4-Point Hoyer was not locked while getting the resident into the sling and hooking the sling up to the Hoyer. Staff member V started the lift and raised resident #30 out of her recliner. When resident #30 was lifted up in the Hoyer Lift, her knees were higher than her head and she was almost bent in half at the waist. While the resident was suspended in the air during the transfer from her recliner to her bed, the resident started to slip out of the sling. The sling was not placed far enough down on the resident's back to give support, so when resident was elevated in the lift, her buttocks started to slide out of the lift. Her knees were bent over the top of the sling, her legs started to slip out of the sling as well. The resident slipped several inches out of the bottom of the sling. The resident was able to be transferred to her bed before slipping any further from the sling. During an interview on 4/24/15 at 9:51 a.m., resident #30 stated the lifts are "freaky and in bad shape." Resident #30 stated "I feel safe (in the lift) depending who puts me in them." During an interview on 4/20/15 at 8:05 p.m., staff member V stated resident #30 is care planned for a 6-point sling only. Staff member V stated that the correct lift to use with the 6-point sling would be the 6-point mechanical lift. Staff member V stated that the 6-point mechanical lift was broken and they were unable to use it for the resident that evening. Staff member V stated the facility has two 6-point mechanical lifts and they are both broken. Staff member V stated they had to use the 4-point-Hoyer mechanical lift for the resident. The CNAs chose to use the wrong lift with the wrong sling. The straps of the sling were connected to the incorrect hooks on the lift. The lift was not locked while the resident was being positioned in the sling and attached to the lift prior to transport. The Invacare Manufacturer Guidelines and Accessories Warning reflect, "Invacare products are specifically designed and manufactured for the use in conjunction with Invacare accessories. Accessories designed by other manufacturers have not been tested by Invacare and are not recommended for use with Invacare products." ¹ During an interview on 4/21/15 at 10:20 a.m., Staff member N, CNA Coordinator, stated no lifts were broken. The CNA stated there was two 6-point lifts and one 4-point-Hoyer lift. Staff member N stated the two 6-point lifts should have been available to the direct care staff that night. Staff member N stated the sling for resident #30 was not placed properly. The sling should have come down to the resident's buttocks. During an interview on 4/22/15 at 3:45 p.m., staff member N stated he has in-service training for lift safety monthly with the most recent in-service training on the first Wednesday in April (2015). Staff member N stated he does keep attendance of in-service training and meetings. No written record of staff attendance was provided during time of survey. Staff member N stated they could not find the records to reflect staff attendance. During the same interview on 4/22/15 at 3:45 p.m., staff member N, CNA Coordinator stated at the most recent in-service training the facility had, they discussed with the direct care staff of a situation with a resident that the straps for the sling were not hooked properly to the lift. This was presented as a learning example to the direct care staff. Staff member N stated a resident whom was care planned for a three person assist with the lift was transferred by two people. When the resident in this example was hooked to the lift, the sling was hooked inappropriately. Staff member N stated both center straps were hooked to the front of the lift. Review of the facility's policy on Resident Handling Policy reflected, "Nursing staff (licensed nurses and nursing assistants) will receive training on transfer technique (one person and two person assist) as well as the use of mechanical lifts and this policy during their orientation. Annual in-services will be held for transferring techniques and the use of mechanical lifts. Additional training may be provided any time a supervisor identified the need for any specific employee. All employees directly involved in resident transfers (excluding therapists or rehab aids treating residents to improve functional status) will follow the documented transfer status. Any employee not using a lift for designated residents or not using a gait/transfer belt while assisting resident to transfer or not following specific directives regarding transferring as outlined in each resident's plan of care is subject to disciplinary action." Review of the facility's policy on Long Term Care Code of Conduct reflected, "In-Service Training and Meetings: You will at times be required to attend in-service meetings or training sessions. These sessions are extremely important for continuing education state regulations, thus making attendance mandatory." References: ¹ Invacare Owner's Operator and Maintenance Manual for Patient Slings.