Every finding on record at Eventide Heartland

Based on record review, review of facility policy and staff interview, the facility failed to fully inform the resident or resident's representative regarding treatment with psychotropic medications for 1 of 5 residents (Resident #8) reviewed for unnecessary medications. Failure to fully inform the resident or resident's representative of the risks, benefits, or alternative options for psychotropic medications does not allow residents the right to choose treatment options.Findings include:Review of the facility policy titled Psychotropic Medication Use occurred on 05/20/26. This policy, dated 02/16/26, stated, . Informed consent for psychotropic medications will be obtained from the resident/resident representative prior to initiation. The resident/resident representative will be provided with information on the medication . will document this information in the medical record.Review of Resident #8's medical record occurred on 05/20/26. Diagnosis list includes insomnia. Physician orders included Mirtazapine (an antidepressant) one time a day related for insomnia.The medical record lacked evidence the facility full informed Resident #8 or the resident's representative of the risks, benefits, and alternative options for the use of a psychotropic medication.During an interview on 05/20/26 at 12:03 p.m., an administrative nurse (#1) confirmed the record lacked a consent form for psychotropic medication.

Based on observation, review of facility policy, and staff interview, the facility failed to provide privacy for 2 of 3 sampled residents (Resident #15 and #27) observed during personal cares while positioned in a mechanical sit-to-stand lift. Failure to ensure privacy during personal care infringes on the resident's rights and does not enhance their quality of life. Findings include: Review of the facility policy titled Standards of Care occurred on 05/20/26. This policy, dated 02/17/26, stated, . Dignity . Privacy curtain/door to be closed anytime cares are being completed. -Observation on 05/18/26 at 4:24 p.m. showed Resident #27 upright in the sit to stand lift and two CNAs (certified nurse aides) (#3 and #5) completed a brief change. The CNA's failed to close the blinds in the resident's room and the resident's buttocks were exposed to the courtyard. -Observation on 05/19/26 at 1:05 p.m. showed Resident #15 positioned in a sit-to-stand lift and seated on the toilet. A CNA (#13) raised the resident from the toilet, performed perineal care, and wheeled the resident out of the bathroom to the room. The CNA's failed to close the blinds in the resident's room and the resident's buttocks were exposed to the courtyard. During an interview on 05/20/26 at 11:52 a.m., an administrative staff member (#4) stated she expected staff to close window coverings prior to resident cares.

Based on observation, record review, review of facility policy and staff interview, the facility failed to ensure a safe, clean, comfortable, and homelike environment for 1 of 1 supplemental residents (Resident #60) on oxygen. Failure to clean personal fans does not provide a safe and clean environment and may place the resident at risk for illness.Findings include:Review of facility policy titled Proper Cleaning of a Room occurred on 05/20/26. This policy, dated 02/09/26, stated, . Clean all surfaces .Review of Resident #60's medical record occurred on 05/20/26. Diagnoses included acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, shortness of breath, and obstructive sleep apnea.Observations on all days of survey showed a layer of dust on the cover/grate and blades of the personal fan in Resident #60's room.Observation on 05/19/26 at 5:00 p.m. showed Resident #60 seated in the room, oxygen administered via nasal cannula, and the dusty, circulating fan blowing air directly on the resident.During an interview on 05/20/26 at 8:17 a.m., a housekeeping staff member (#7) stated the resident's fans are cleaned by the maintenance department.During an interview on 05/20/26 at 1:00 p.m., a maintenance staff member (#6) stated housekeeping should clean the resident's fans during each scheduled room cleaning.

Based on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.20.1), and staff interview, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 2 of 17 sampled residents (Resident #5 and #9). Failure to accurately complete the MDS does not allow each resident's assessment to reflect their current status/needs and may affect the accurate development of a comprehensive care plan and the care provided to the residents. Findings include: SECTION A: IDENTIFICATION INFORMATION The Long-Term Care Facility RAI User's Manual, revised October 2025, pages A-30-32, stated, . Section A1500: Preadmission Screening and Resident Review (PASRR) . Coding Instructions . Code 1, yes: if PASRR Level II screening determined that the resident has a serious mental illness . and continue to A1510 . Section A1510 . Coding instructions Code A, Serious mental illness: if resident has been diagnosed with a serious mental illness . - Review of Resident #9's medical record occurred on all days of survey and identified diagnoses of schizophrenia spectrum and psychotic disorder. An annual MDS, dated [DATE], showed the facility failed to code Sections A1500 and A1510 for serious mental illness. During an interview on 05/19/26 at 3:08 p.m., an administrative staff member (#14) confirmed staff failed to accurately code Section A on Resident #9's MDS. SECTION N: MEDICATIONS The Long-Term Care Facility RAI User's Manual, revised October 2025, page N-8, stated, . Coding Instructions . N0415K1: Anticonvulsant: Check if an anticonvulsant medication was taken by the resident at any time during the 7-day observation period.- Review of Resident #5's medical record occurred on all days of survey. Current medications included Gabapentin (an anticonvulsant) three times a day. The quarterly MDS, dated [DATE], showed the facility failed to code the anticonvulsant medication. During an interview on 05/20/26 at 11:45 a.m., an administrative staff member (#14) confirmed the facility failed to accurately code Section N.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to properly utilize assistive devices necessary to prevent accidents for 3 of 5 sampled residents (Resident #8, #15, and #27) observed during transfers with a mechanical sit-to-stand lift. Failure to properly utilize a mechanical sit-to-stand lift during transfers placed the residents at risk for injury and falls.Findings include: Review of the policy titled Standing Lifts occurred on 05/20/26. This policy, dated 02/17/26, stated, Use of this lift is [a] participatory process on the part of the resident, and they must be able to balance and bear-weight. place the sling behind their back. Position the wings of the sling under the resident's arms . Secure the buckle around the lower abdomen . and pull it snug. -Review of Resident #8's medical record occurred on all days of survey. The current care plan stated, . Proper footwear with all transfers . Prevalon [heel support] boots to both feet at all times. To be removed only with transfers. Observation on 05/20/2026 at 8:17 a.m. showed a certified nurse aide (CNA) (#2) utilized a mechanical sit-to-stand lift to transfer Resident #8 from the bed to a wheelchair. The CNA failed to remove the resident's Prevalon boots prior to the transfer. During an interview on 05/20/26 at 10:26 a.m., an administrative staff member (#12) stated she expected staff to remove the Prevalon boots and ensure proper footwear use during Resident #8's transfers. -Review of Resident #15's medical record occurred on all days of survey. The current care plan stated, .PAL [a type of mechanical sit-to-stand lift] assist x 1 [one staff] for all transfers. Observation on 05/19/26 at 1:05 p.m. showed Resident #15 seated on a toilet with a mechanical sit-to-stand lift sling secured around the resident's waist and attached to the lift. A CNA (#13) instructed the resident to hold onto the handlebars and raised the resident to a standing position. The resident briefly held onto the handlebars and then let go and hung in the lift with his arms up and out in front of him. The CNA continued cares without asking the resident to hold onto the handlebars and then transferred the resident into a recliner. -Review of Resident #27's medical record occurred on all days of the survey. The current care plan stated, . I transfer with staff assist x1 with PAL. Observation on 05/18/26 at 4:24 p.m., showed two CNAs (#3 and #5) transferring Resident #27 with a mechanical sit-to-stand lift. The surveyor questioned the CNAs regarding straps hanging on each side of the resident's abdomen. The CNA (#5) stated the CNA (#3) forgot to secure the sling around the resident's waist and both CNAs continued with and completed the transfer without the abdomen strap secured. During an interview on 05/20/26 at 11:52 a.m., an administrative staff member (#4) stated she expected staff to secure the sling around the resident's waist during the mechanical sit-to-stand lift transfers.

Based on observation, record review, review of the dialysis contract, review of the dialysis communications forms, and staff interview, the facility failed to provide care and services consistent with professional standards of practice for 1 of 1 sampled resident (Resident #7) receiving hemodialysis. Failure to complete dialysis treatment communications may result in an unidentified change in the resident's condition.Findings include: Review of the dialysis contract between the facility and the dialysis center occurred on 05/20/26. This contract, dated 05/10/19, stated, . Collaboration. Both the ESRD [end-stage renal disease center] and SNF [skilled nursing facility] are responsible for ensuring collaboration necessary to provide dialysis care coordination to each SNF resident receiving dialysis treatments. Review of Resident #7's medical record occurred on all days of survey. A physician's order, date 11/13/25, identified hemodialysis three times weekly on Mondays, Wednesdays, and Fridays. Review of Resident #7's dialysis communication forms between the facility and the dialysis center, dated 01/07/26 through 05/18/26 (42 visits), identified the facility failed to complete their resident assessment section prior to the resident's dialysis appointment on 35 of the 42 forms. Five additional dialysis communication forms in Resident #7's medical record lacked a name and/or date. During an interview on 05/20/26 at 9:22 a.m., two administrative staff members (#1 and #2) confirmed facility staff failed to accurately complete the dialysis communication forms.

Based on observation, review of facility policy, review of professional reference and staff interviews, the facility failed to label over the counter (OTC) medications in accordance with professional standards for 2 of 2 medication carts. Failure to ensure appropriate and legible labels placed residents at risk for potential medication errors.Findings include:Review of facility policy titled Medication Administration and Storage occurred on 05/20/26. This policy, dated 02/16/26, stated, . Purpose: To provide safe and effective drug therapy . Medications will be labeled according to accepted pharmacy standards.Kozier & Erb's Fundamentals of Nursing, 11th Edition eText, 2021, Pearson, Boston, Massachusetts, page 841, stated, . Always check the medication label to make sure the correct medication is being taken.Observation on 05/19/26 at 10:52 a.m. showed a medication aide (MA) (#10) administered AZO D-Mannose, an OTC medication for urinary tract health, with an illegible pharmacy label over the drug facts and dosage information. Review of the physician's order stated, AZO D-Mannose 500mg [milligram] capsule by mouth once daily. When asked about the label, the MA stated, the label covers the dose capsule serving amount but from experience and administering it for so long, I know it's one capsule.The MA (#10) failed to verify the capsule dose prior to administration of OTC medication.Observation of a medication cart on 05/19/26 at 4:46 p.m. showed a clear bottle containing an OTC medication with an illegible pharmacy label. A sticker on top of bottle cap stated, Iron 325mg. When questioned about the label, the nurse (#8) stated the pharmacy medication labels fade out and the facility placed a handwritten label on the OTC bottle to identify OTC medication.During an interview on 05/20/26 at 12:16 p.m., an administrative nurse (#1) confirmed the pharmacy should replace labels when illegible.

Based on observation, review of professional references, and staff interview, the facility failed to follow professional standards of infection control and prevention for 2 of 9 sampled residents (Resident #15 and #30) observed during cares. Failure to practice infection control standards related to hand hygiene, glove use, and when emptying catheter bags has the potential to spread infection throughout the facility. Findings include: Information found at https://medlineplus.gov/ency/patientinstructions/000142.htm, reviewed 01/01/25, stated, . Urine drainage bags collect urine. Follow these steps for emptying your bag . Hold the bag over the toilet, or special container . Open the spout at the bottom of the bag, and empty it [the urine] into the toilet or container. Clean the spout with rubbing alcohol . Close the spout tightly. Information found at https://www.cdc.gov/clean-hands/hcp/clinical-safety/index.html, dated 02/27/24, stated, . Know when to clean your hands . After touching a patient . Know when to wear (and change) gloves. Gloves are not a substitute for hand hygiene. Always clean your hands after removing gloves. When to change gloves and clean hands . If moving from work on a soiled body site to a clean body site on the same patient . have . body fluids on them after completing a task. -Observation on05/18/26 at 1:28 p.m., showed a certified nurse aide (CNA) (#15) entered Resident #15's room, opened the drainage spout on the catheter bag, drained the urine into a graduate container, and without sanitizing the spout, closed the spout and secured it back into the holder on the bag. -Observation on 05/18/2026 at 2:18 p.m., showed a CNA (#11) entered Resident #30's room, opened the drainage spout on the catheter bag, drained the urine into a graduate container, and without sanitizing the spout, closed the spout and secured it back into the holder on the bag. -Observation on 05/19/26 at 1:05 p.m., showed a CNA (#13) wore a gown and gloves and provided perineal cares for Resident #15. The CNA removed the soiled gloves, and applied clean gloves without performing hand hygiene. The CNA applied a clean brief, pulled up the resident's pants, and transferred the resident to a recliner. With the same gloves, the CNA operated the remote control to adjust the recliner, removed the sling around the resident's waist, removed a pillow from the resident's bed, placed the pillow behind the resident's head, and placed a blanket onto the resident's lap. The CNA rearranged items on top of the resident's bed, removed the gown and gloves, performed hand hygiene, and exited the room. The CNA (#13) failed to perform hand hygiene after removing the soiled gloves and before applying clean gloves and between dirty and clean tasks. During an interview on 05/20/26 at 11:00 a.m., an administrative staff member (#2) confirmed hand hygiene is a concern.

Based on review of the facility reported incident (FRI) investigation, record review, review of facility policy, and staff interview, the facility failed to ensure residents remained free from physical abuse for 1 of 1 sampled resident (Resident #1) who displayed physical and verbal aggression toward other residents. Failure to ensure an environment free from physical and verbal abuse placed all residents at risk for injury, fear, anxiety, and/or psychosocial harm. Findings Include:Review of the facility policy titled Vulnerable Adult - North Dakota occurred on 04/08/26. This policy, dated February 2026, stated, . Vulnerable Adult - Every resident of the facility . Abuse - the willful infliction of injury . Physical abuse - conduct that produces pain or injury and is not accidental . Examples of abuse . resident to resident abuse . A FRI report, dated 02/14/26, stated, . Staff heard [resident name] yelling out and went to where he was. When they arrived, [resident name] was on the floor in the hallway . [Resident #1] was seen scurrying away from the area . Mgr [manager] on call checked video footage to investigate incident. Upon review, it was noted that [Resident #1] was back in the hallway where incident occurred and had entered [resident's name] room and then came out. [Resident name] was making his way down the hallway and hadn't come near the room that [Resident #1] had exited. Per video, [Resident #1] exited [resident's name] room and went up to him and pushed him down. After she pushed him, she hurried away. [Resident #1] has a hx [history] of targeting the males in the MCU [Memory Care Unit] . Review of Resident #1's medical record occurred on all days of survey. Diagnoses included Alzheimer's disease and anxiety. A Brief Interview for Mental Status (BIMS), dated 01/08/26, identified a score of 9 indicating moderate cognitive impairment. The current care plan stated, . has hit, pinch [sic], push [sic] staff when staff are helping other residents. Noted to yell at staff/other residents.Review of Resident #1's progress notes identified the following:*01/01/26 at 5:19 p.m., . Resident was getting very irritated and aggravated with resident [resident number] . she then shoved him out of the way from the table . Prior to supper resident was upset that [resident number] was walking by . and grabbed the back of his shirt and shoved him ahead.*01/10/26 at 5:32 p.m., . Resident started becoming verbally aggressive. She was yelling at other residents .*01/12/26 at 11:43 a.m., Fax communication sent to [provider name] regarding residents continued aggressive behaviors.*01/20/26 at 4:10 p.m., Resident was irritated with another female resident this morning, raised up her fist towards other resident .*01/23/26 at 6:12 p.m., Resident began slapping [resident number] arm after he hit a staff member.*01/25/26 at 3:00 p.m., Res [resident] was walking in the dining room and a [resident number] was wandering around in the dining room . and res shoved him out of the way. Then later before breakfast res swatted at [resident number] when other resident was reaching over attempting to help another resident cover up with a blanket. Res [Resident #1] then took blanket from resident and threw the blanket at [resident number]. Later this afternoon, [resident number] was pleasantly wandering in the dining room, then resident shoved a chair at [resident number].*01/28/26 at 1:04 p.m., Resident had a minor verbal altercation with [resident number].*02/01/26 at 6:20 p.m., Resident has been aggressive with staff and other Residents [sic]. Resident [sic] had taken the dining room chairs and barricaded the dining hall . a little while later, a CNA [certified nurse aide] was walking back onto the unit and saw resident try and push another resident who was walking through the unit . *02/03/26 at 6:38 a.m., . male resident was pleasantly wandering into the dining room, hands in his pockets . Resident then stood up and grabbed male by the hand and swung him around to get him out of the way.*02/12/26 at 2:21 p.m., . yelled at another resident .*02/14/26 at 2:54 p.m., . Resident was a bit irritable this morning, demanding other residents to sit here or there, demanding other residents to come with her . Res did shove another male resident in the dining room.*The medical record lacked documentation of the incident that occurred on 2/14/26 at approximately 5:51 p.m., the date the facility reported the incident (FRI) when Resident #1 pushed another resident to the floor. *02/15/26 at 9:59 p.m., . pulling chairs out from table and placing in hallway like a barricade.*02/16/26 at 9:03 p.m., . Move to main unit .During an interview on 04/09/26 at 8:11 a.m., an administrative nurse (#1) reported the facility was aware of Resident #1's behaviors toward other residents while on the memory care unit and were adjusting her medications. After the incident on 02/14/26, the facility moved Resident #1 to a different unit in the facility. The administrative nurse (#1) stated she expected staff to monitor all residents, intervene immediately, and report any incidents to management. The facility failed to protect other residents from verbal and/or physical abuse from Resident #1.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to follow standards of infection control and prevention for 2 of 3 sampled residents (Resident #3 and #6) observed during cares and 1 of 1 sampled resident (Resident #7) observed during a dressing change. Failure to practice infection control standards related to glove usage and hand hygiene has the potential to spread infection throughout the facility. Findings Include:Review of the facility policy titled Hand Hygiene occurred on 04/09/26. This policy, dated February 2026, stated, . Hand hygiene will be done: A. Before and after resident contact (before you leave the room). B. Before every clean procedure. C. After every dirty procedure. The purpose is to prevent the spread of infection.-Observation on 04/08/26 at 1:00 p.m. showed a nurse (#2) performed hand hygiene, applied a gown, mask, and gloves, and entered Resident #7's room to complete a dressing change. The nurse cleansed the bedside table with a disinfecting wipe, and removed the resident's sock and soiled dressing. The nurse removed the soiled gloves, applied new gloves, cleansed the wound area with normal saline and dried with gauze. The nurse removed the soiled gloves, applied clean gloves, completed the wound dressing change and reapplied the resident's sock. The nurse removed the soiled gloves, gown and mask, performed hand hygiene and exited the room. The nurse failed to remove soiled gloves after disinfecting the table and failed to perform hand hygiene in between glove changes. -Observation on 04/08/26 at 1:31 p.m. showed two certified nurse aides (CNAs) (#3 and #4) performed hand hygiene and entered Resident #3's room to complete cares. After the CNAs washed the resident's upper body, the CNA (#3) completed perineal care and applied barrier cream to the resident's buttocks. The CNA (#3) removed the soiled gloves and without performing hand hygiene, applied clean gloves. Both CNAs placed a new brief on the resident and repositioned the resident in bed. The CNA (#3) gathered the soiled linen, and the other CNA (#4) gathered the garbage. The CNAs (#3 and #4) removed their soiled gloves and without performing hand hygiene, put a clean shirt on the resident and placed a pillow under the left hip. The CNAs failed to perform hand hygiene between glove changes.-Observation on 04/08/26 at 3:21 p.m. showed two CNAs (#4 and #5) performed hand hygiene and entered Resident #6's room to complete toileting cares. After the CNAs transferred Resident #6 to the toilet, the CNA (#5) pulled down the resident's pants and removed the soiled brief. The CNA (#5) removed the soiled gloves and without performing hand hygiene applied clean gloves. The CNA (#5) removed the resident's gripper socks and leg stockings, washed the stockings, and hung them to dry. The CNA (#5) removed the soiled gloves, and without performing hand hygiene applied clean gloves. The CNA (#5) washed and dried the Resident's face, back, chest, arms, and arm pits. Without removing the soiled gloves, the CNA (#5) put a clean shirt on the resident. The CNA (#5) removed the soiled gloves and without performing hand hygiene, obtained wipes from the resident's bedside table, reentered the bathroom and applied clean gloves. The CNA (#5) completed the resident's perineal cares and without removing the soiled gloves, the CNA applied a clean brief, and both CNAs (#4 and #5) pulled up the brief and the resident's pants. Both CNAs (#4 and #5) removed their soiled gloves and without performing hand hygiene, transferred the resident to the wheelchair. The CNAs failed to change soiled gloves and perform hand hygiene between glove changes. During an interview on the morning of 04/09/26, an administrative nurse (#1) confirmed staff should be following the Hand Hygiene policy.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to ensure a medication error rate of less than five percent for 5 of 7 residents (Resident #2, #19, #20, #21, and #58) observed during medication administration. Thirteen medication errors occurred during staff administration of 37 medications, resulting in a 35% error rate. Failure to properly prime insulin pens and administer medications at the correct time may result in residents receiving an ineffective and/or inaccurate dose and experience adverse reactions. Findings include: Review of the facility policy titled Medication - Administration and Storage occurred on 04/30/25. This policy, dated March 2025, stated, . POLICY: Medications will be administered according to the following directives. Medications will be considered as given at the correct time if administered one hour before or one hour after the scheduled time. Review of the facility policy titled Insulin - Subcutaneous occurred on 04/30/25. This policy, dated September 2024, stated, . Remove cap from insulin pen . Prime the insulin pen . pointing upward . - Observation on 04/29/25 at 11:18 a.m. showed a staff nurse (#2) prepared Resident #58's Humalog insulin pen for administration. The nurse primed the insulin pen holding the pen down towards the garbage can. - Observation on 04/29/25 at 11:37 a.m. showed a staff nurse (#2) prepared Resident #21's Humalog insulin pen for administration. The nurse primed the insulin pen holding the pen down towards the garbage can. - Observation on 04/29/25 at 5:01 p.m. showed a staff nurse (#4) prepared Resident #20's Humalog insulin pen for administration. The nurse primed the insulin without removing the cap. - Observation on 04/29/25 at 4:15 p.m. showed a Medication Aide (MA) (#3) administered the following medications to Resident #19: * Seroquel (antipsychotic) scheduled at 8:00 p.m. * Metolazone (diuretic) scheduled at 5:30 p.m. * Olanzapine (antipsychotic) scheduled at 8:00 p.m. * Polyethylene Glycol Powder (treats constipation) scheduled at 5:30 p.m. * Saccharomyces boulardii (probiotic) scheduled at 8:00 p.m. * Docusate Sodium (treats constipation) scheduled at 5:30 p.m. * Genteal Tears (artificial tears eye drops) Ophthalmic Solution scheduled at 5:30 p.m. * Potassium Chloride scheduled at 9:00 p.m. * Rivaroxaban (medication to prevent blood clots) scheduled at 9:00 p.m. When the MA (#3) prepared Resident #19's medications she stated, He likes all his meds [medications] at this time. I've gotten to know how he likes things and I realize that is not how they are set up. Record review showed the MA (#3) failed to administer the medications at the scheduled times or within one hour before or after. Observation on 04/29/25 at 4:32 p.m. showed a MA (#3) administered Cymbalta (antidepressant) to Resident #2, scheduled to be administered at 3:00 p.m. Record review showed the MA (#3) failed to administer the medication at the scheduled time or within one hour before or after. During an interview on 04/30/25 at 11:35 a.m., an administrative nurse (#1) stated she expected staff to prime insulin pens with the cap off and with the needle pointed upright. The nurse also stated, It is unacceptable for staff to administer medications at anytime other than an hour before or an hour after the scheduled medication time.

Based on record review, facility policy review, and staff interview, the facility failed to review and revise the comprehensive care plan to reflect the current status for 2 of 20 sampled residents (Resident #29 and #58). Failure to revise the care plan limited the ability of staff to communicate care needs and ensure continuity of care for each resident. Findings include: Review of the facility policy titled Care Plans occurred on 04/28/25. This policy, revised November 2021, stated, . develop a person-centered care plan . that reflects the actual care, condition. The comprehensive care plan . will be reviewed and updated monthly and as needed. Review of the facility policy titled Smoking/Tobacco Free occurred on 04/29/25. This policy, revised January 2024, stated, . maintain a policy where all buildings, grounds . are free of tobacco products. Use of tobacco products . are not permitted. - Review of Resident #29's medical record occurred on all days of survey. The care plan, dated 02/24/25, stated, . Will be assessed to be safe to smoke if she does engage in this activity. Resident will safely use tobacco products off facility grounds and not incur any injury from smoking. Resident instructed to keep cigarettes/lighter at the nurses station if she has in facility. Charge nurse will give resident cigarettes and will be notified of residents leaving facility to smoke. During an interview on 04/29/25 at 10:12 a.m., an administrative nurse (#1) stated, Resident #29 is a former smoker, but has not smoked since admission to the facility. During an interview on 04/30/25 at 12:23 p.m., an administrative nurse (#1) agreed staff failed to update the resident's care plan. - Review of Resident #58's medical record occurred on all days of survey and included diagnoses of hemiplegia and hemiparesis (paralysis on one side of the body) following cerebral infarction (blood clot in the brain) affecting the right dominant side. Physician's orders included an ankle-foot orthosis (AFO) brace to the right lower leg and ankle, monitor the daily application and for possible skin breakdown. Observation on all days of survey showed Resident #58 wore an AFO to the right lower leg and ankle. The care plan failed to include an AFO to Resident #58's right lower leg and ankle. During an interview on 04/30/25 at 10:40 a.m., an administrative staff member (#1) agreed staff failed to update the care plan to include the AFO.

1. Based on observation, record review, policy review, professional reference, and staff interview, the facility failed to follow professional standards of practice for medication administration for 1 of 7 residents (Resident #19) observed during medication administration. Failure to document medications at the time of administration does not reflect the actual time of administration and may cause adverse effects for the resident. Findings include: Review of the facility policy titled Medication - Administration and Storage occurred on 04/30/25. This policy, dated March 2025, stated, . documentation . immediately following administration. Kozier & Erb's Fundamentals of Nursing, Concepts, Process and Practice, 11th Edition eText, 2021, Pearson, Boston, Massachusetts, page 836, stated, . Ten Rights of Medication Administration . Right Documentation . Document medication administration after giving it . The record [medication administration record] should . include the exact time of administration . Observation on 04/29/25 at 4:15 p.m. showed a medication aide (MA) (#3) administered the following medications to Resident #19: * Metoprolol (blood pressure medication) scheduled at 5:00 p.m. * Seroquel (antipsychotic) scheduled at 8:00 p.m. * Metolazone (diuretic) scheduled at 5:30 p.m. * Olanzapine (antipsychotic) scheduled at 8:00 p.m. * Polyethylene Glycol Powder (treats constipation) scheduled at 5:30 p.m. * Saccharomyces boulardii (probiotic) scheduled at 8:00 p.m. * Docusate Sodium (treats constipation) scheduled at 5:30 p.m. * Genteal Tears (artificial tears eye drops) Ophthalmic Solution scheduled at 5:30 p.m. * Potassium Chloride scheduled at 9:00 p.m. * Rivaroxaban (medication to prevent blood clots) scheduled at 9:00 p.m. Following the medication administration, the MA (#3) returned to the medication cart and only signed off the metoprolol as administered. When asked when she will sign the other medications as administered the MA stated, When they turn yellow [indicating the correct time for the medication to be given] on the MAR [medication administration record]. During an interview on 04/30/25 at 11:35 a.m., an administrative nurse (#1) stated she expected staff to document medications at the time of administration. 2. Based on observation, record review, and staff interview, the facility failed to provide care and services for 1 of 2 sampled residents (Resident #58) with an ankle foot orthosis (AFO). Failure to place the order for an AFO brace on the treatment administration record (TAR) may result in staff not applying the AFO or monitoring its use and may delay healing of the foot and ankle. Findings include: Observation on all days of survey showed Resident #58 wore an AFO to the right lower leg and ankle. Review of Resident #58's medical record occurred on all days of survey and included diagnoses of hemiplegia and hemiparesis (paralysis on one side of the body) following cerebral infarction (blood clot in the brain) affecting the right dominant side. Physician's orders included an AFO brace to the right lower leg and ankle, monitor daily application of the AFO, and monitor for skin breakdown. During an interview on 04/30/25 at 10:40 a.m., an administrative staff member (#1) stated she expected staff to update Resident #58's treatment record related to the AFO.

Based on observation, record review, review of facility policy, review of operator's instructions, and staff interview, the facility failed to ensure residents received adequate supervision/assistance to prevent accidents for 1 of 4 residents (Resident #9) observed during a sit-to-stand mechanical lift transfer. Failure to utilize a mechanical lift properly, complete a nursing assessment, and implement a safe transfer method placed Resident #9 at risk for pain and/or injury. Findings include: Review of the EZ Way Smart Stand [type of sit-to-stand mechanical lift] 400, 500 & 800 lb [pound] Capacities Operator's Instructions occurred on 04/30/25. The operator's instructions, revised 09/29/23, on page 2-6, stated, . Patients should be able to bear some weight, have upper body strength and be able to follow simple commands. Review of the facility policy titled Standing Lifts occurred on 04/30/25. This policy, dated January 2024, stated . Use of this lift is participatory on the part of the resident and they must be able to balance and bear-weight. Have the resident hold onto the handle grips. Review of Resident #9's medical record occurred on all days of survey. Diagnoses included Alzheimer's disease, osteoarthritis, and anxiety. The quarterly Minimum Data Set (MDS), dated [DATE], identified substantial/maximum assistance with transfers. The care plan stated, . Transfer: Assist of 1 [staff] with PAL [sit to stand mechanical lift], may use assist of 2 [staff] with behaviors/syncope episodes. A physician's order, dated 04/24/25, stated, . OT [occupational therapy] starting to demonstrate increase in shoulder abduction during PAL transfer. A nursing progress note, dated 04/25/25 stated, . Order for OT . Indication/Diagnosis: weakness with transfers. Observation on 04/28/25 at 10:20 a.m. showed a certified nurse aide (CNA) (#8) transferred Resident #9 from the wheelchair to the toilet utilizing a sit-to-stand mechanical lift. The CNA placed the lift harness around the resident's waist and then physically placed the resident's hands on the handle grips of the lift. During the transfer the resident failed to hold onto the handle grips, the harness slid up the resident's back to the axilla area, the resident leaned forward with both elbows turned outward and raised above the shoulders. Facility staff failed to complete a nursing assessment to provide Resident #9 with an alternative safe transfer option before assessment by OT. During an interview on 04/30/25 at 10:34 a.m., an administrative staff member (#9) verified staff should have completed a nursing assessment to provide an alternate safe transfer method for Resident #9 until OT assessed the resident.

Based on observation, record review, and review of facility policy, the facility failed to follow standards of infection control and prevention for 3 of 14 sampled residents (Resident #19, #25 and #46) observed during cares. Failure to practice infection control standards related to hand hygiene and enhanced barrier precautions (EBP) has the potential to spread infection throughout the facility. Findings include: Review of the facility policy titled Infection Control - Enhanced Barrier Precautions occurred on 04/30/25. This policy, revised December 2024, stated, . Enhanced barrier precautions are used to limit or prevent the spread of resistant organisms during high-contact resident care activities. These may be indicated for residents with . chronic wounds that include pressure ulcers . venous ulcers . gown and gloves must be worn during high-contact resident care activities such as . wound care for chronic wounds requiring a dressing . Review of the facility policy titled Hand Hygiene occurred on 04/30/25. This policy, dated November 2024, stated . Hand hygiene will be done: a. Before and after resident contact (before you leave the room) b. Before every clean procedure c. After every dirty procedure . - Review of Resident #19's medical record occurred on all days of survey. The current care plan stated, . is on Enhanced Barrier Precautions for presence of RLE [right lower extremity] venous ulcer . increased risk for infections . Observation on 04/27/25 at 1:03 p.m. showed a nurse (#5) entered Resident #19's room, applied gloves, and provided wound care. The nurse (#5) failed to follow EBP and apply a gown during high contact wound care. - Review of Resident #46's medical record occurred on all days of survey. A quarterly MDS, dated [DATE], identified an indwelling foley catheter. The current care plan stated, . is at increased risk of infections related to foley catheter . on Enhanced Barrier Precautions . Observation on 04/27/25 at 1:51 p.m. showed a certified nurse aide (CNA) (#6) entered Resident #46's room, donned gloves, and provided catheter care. The CNA (#6) failed to follow EBP and don a gown during high contact catheter care. - Observation on 04/27/25 at 3:45 p.m. showed a CNA (#7) assisted Resident #25 with perineal care. The CNA (#7) applied gloves, performed perineal care, applied a clean brief, assisted the resident off the toilet, collected the garbage, exited the room, threw away the garbage, and removed the soiled gloves. Without performing hand hygiene, the CNA reentered the room and assisted the resident to the commons area in the wheelchair. The CNA (#7) failed to remove the soiled gloves after providing perineal care and failed to perform hand hygiene. During an interview on 04/30/25 at 11:45 a.m. and 12:29 p.m., an administrative nurse, (#1) stated she expected facility staff to follow appropriate hand hygiene and EBP. 40489

Based on observation, review of facility policy, and staff interview, the facility failed to ensure posting of accurate and complete staffing information on 1 of 4 days of survey (April 27, 2025). Failure to post accurate staffing data does not allow residents and visitors to be aware of the number of licensed and unlicensed staff on duty each shift. Findings include: Review of the facility policy titled Staffing Levels occurred on 04/30/25. This policy, revised on February 2024, stated, . the Director of Nursing is responsible for ensuring that nursing hours are posted daily . determines the level of nursing hours for the facility . Observation on 04/27/25 at 12:02 p.m., showed a staffing report dated 04/25/25. The facility failed to update the number of licensed and unlicensed staff working the days of 04/26/25 and 04/27/25. During an interview on 04/30/25 at 12:22 p.m., an administrative staff member (#1) stated she expected the charge nurse to complete and post a daily census/staffing report.

Based on record review, review of facility policy, and staff interview, the facility failed to provide the resident and/or the resident's representative a written bed hold notice for 1 of 1 closed record (Resident #10) reviewed for hospital transfers. Failure to provide a written copy of the bed hold notice does not allow the resident and/or their representatives to make an informed decision regarding their care. Findings include: Review of the facility policy titled Bed-Hold occurred on 12/04/24. This policy, revised October 2021, stated, . Upon transfer/admission to the hospital, the Social Worker or designee will complete the following information with the resident/responsible party. * Review Notice of Transfer For hospitalization (ND [North Dakota]) . and obtain signature. * Review Bed Hold form and obtain signature. * Provide a signed copy to the resident/responsible party. * Ensure that a copy of the notice(s) accompanies the resident to the hospital. * File the signed forms in the resident's electronic health record. Review of Resident #10's medical record occurred on all days of survey and identified a hospital transfer occurred on 11/18/24. The medical record lacked documentation the facility provided Resident #10 and/or the resident's representative with a written bed hold notice. During an interview on 12/04/24 at 4:45 p.m., an administrative staff member (#2) confirmed staff failed to provide the required bed hold notice to the resident and/or the resident's representative upon transfer to the hospital.

Based on record review, review of the facility reported incident and investigation documents, and review of facility policy, the facility failed to provide appropriate supervision and/or assistance to prevent an accident for 1 of 1 resident (Resident #1) who fell during a mechanical stand lift transfer. Failure to provide two-person assistance and failure to utilize the shin strap resulted in Resident #1's fall from the stand lift, injury, and placed all residents transferred via a stand lift at risk for falls and/or injury. This citation is considered past non-compliance based on review of the corrective actions the facility implemented immediately following the incident. Findings include: The surveyor determined a deficient practice existed on 09/17/24. The facility completed the corrective action on 09/23/24. The final facility reported incident report, dated 09/17/24, stated, . The charge nurse was outside of room and heard resident calling for help in a loud tone, nurse immediately went in to investigate. Upon entering the room, the nurse witnessed [Resident #1] on the floor with the wheelchair behind her. The PAL [type of mechanical lift] lift jacket was secured around mid-upper chest; the residents' [sic] hands were outstretched above her head, not touching the lift handles. Residents' [sic] lower legs and feet were resting on the right side of PAL foot board. Leg straps were not secured in place at the time of fall. [Name of certified nurse aide (CNA #1)], the CNA working with resident that evening, was seen standing at operating pad of PAL lift. [Resident #1's] right hip grazed the foot pedal of the wheelchair in [sic] which caused an abrasion to her right hip. RCM [Resident Care Manager] witnessed several transfers with resident . The transfers witnessed went without concern, therefore the care plan was left as assist x [times] 2 staff via Pal Lift. Review of the facility policy titled Standing Lifts occurred on 12/04/24. This policy, revised January 2024, stated, . Secure leg straps around the resident's lower legs for additional security and support if appropriate. Review of Resident #1's medical record occurred on all days of survey. The quarterly Minimum Data Set (MDS), dated [DATE], identified dependance on staff for sit-to-stand transfers. The current care plan stated, . assist of two for all transfers for safety of resident . transfers from wheelchair, recliner, or toilet PAL lift assist x 2 with . leg strap secured. The progress notes stated the following: * 09/17/24 at 11:59 p.m., . Time of fall: 2000 [8:00 p.m.] . Fall had acquired [sic] during transfer via PAL lift. Abrasion to R) [right] hip . Staff educated to follow plan of care appropriately. Resident is to be assist x 2 for all transfers. * 09/18/24 at 8:00 a.m. and 4:00 p.m., . Resident ROM [range of motion] as before fall. She said her right hip is sore but denies any other pain. * 09/28/24 at 8:40 a.m., . has a healed scratch to right lateral hip and small pink scratch to her left upper scapula [shoulder blade] . Based on the following information, non-compliance at F689 is considered past non-compliance. The facility implemented corrective actions to ensure the deficient practice does not recur by: * Completing an investigation on 09/17/24, including an interview with the CNA #1 who transferred Resident #1 via a stand lift. * Determining the CNA #1 provided assistance without waiting for her coworker and failed to utilize the shin strap during the stand lift transfer resulting in Resident #1's fall from the lift, injury, and placed all residents at risk for falls with/without injury. * Suspending the CNA #1 on 09/17/24 and removing her from her position on 09/23/24. * Immediately re-educating every CNA who worked the evening shift on 09/17/24 on the importance of following the care plan and the severity of falls involving mechanical lifts. * Observing the CNAs transferring Resident #1 to ensure there were no immediate safety concerns. * Referring Resident #1 to Physical Therapy for reassessment of her transfer abilities. * Educating all staff who operate the mechanical stand lift on the use of the lift, the different safety concerns when operating the lift, and the importance of following the care plans as written. * Completing quality assurance audits to ensure resident safety during lift transfers.

Based on record review, facility incident report, and staff interview, the facility failed to ensure a complete and accurate medical record for 1 of 4 sampled residents (Resident #9) reviewed for resident-to-resident altercations. Failure to have a complete and accurate medical record limited staff's access to the most recent medical information regarding the residents. Findings include: Review of a facility incident report, dated 11/12/24, stated, Staff overheard elevated voices and went to intervene. When approached, both residents had their hands placed onto the walker attempting to take it away from one another. No physical contact was noted resident to resident during this situation. During an interview on 12/03/24 at 5:04 p.m., an administrative nurse (#2) confirmed the other resident involved in the incident, dated 11/12/24, was Resident #9. Review of Resident #9's medical record occurred on all days of survey and included a diagnosis of Alzheimer's Disease. The medical record lacked documentation related to the 11/12/24 incident between Residents #4 and #9. During an interview on 12/03/24 at 5:33 p.m., an administrative nurse (#2) confirmed Resident #9's medical record lacked documentation related to the 11/12/24 incident and would expect documentation to be completed for both residents related to this incident.

THIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED ON 02/15/23. Based on observation, record review, review of facility policy, and staff interview, the facility failed to ensure reasonable accommodation of needs regarding call lights for 1 of 3 sampled residents (Resident #227) with a soft touch call light. Failure to place Resident #227's call light within reach may result in an inability to call for help, discomfort, increased falls, and/or incontinence. Findings include: Review of the facility's policy titled Standard of Care occurred on 04/18/24. This policy, revised January 2024, stated, . The following standards of care will be followed in proving care to the residents . Call light will be accessible for residents in their rooms . Review of Resident #227's medical record occurred on all days of survey. Diagnoses included weakness and history of falls. The current care plan stated, . High risk for falls . Keep call light within reach at all times when in room (soft touch) . Resident not to be left in room alone in wheelchair without supervision . Resident is assist x [times] 2 for toileting hygiene . Observation on 04/15/24 at 4:08 p.m., showed two certified nurse aides (CNAs) (#2 and #3) entered Resident #227's room and observed him attempting to get out of bed. He indicated he had to use the bathroom. Resident #227 did not have a call light in reach. After toileting, the CNAs (#2 and #3) transferred Resident #227 to a Broda chair (high back recliner) and left him in the room alone with no call light in reach. During an interview on 04/18/24 at 11:32 a.m., an administrative nurse (#1) stated the facility's standard of care is every resident has their call light within reach.

Based on record review, review of facility policies/procedures, review of the facility's investigation reports, and staff interviews, the facility failed to ensure freedom from neglect for 1 of 1 closed resident record (Resident #3) who experienced exposure of his/her body while residing in the facility. Failure of staff to provide supervision/assistance unnecessary exposure of Resident #3 ' s body in public areas of the facility and may have resulted in emotional distress and loss of dignity. Findings include: Review of the facility policy titled Vulnerable Adult -North Dakota occurred 02/15/23. This policy, revised May 2022, stated, . Neglect - failure to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being . caretaker neglect - failure of the caretaker to provide necessary food, clothing, shelter, health care, or supervision . Review of the facility's Vulnerable Adult Report, dated 01/18/23, stated, Date/Time of incident: 01/14/2023 @ [at]0545 [5:45 a.m.] . housekeeping came to work around 0540 AM [5:40 a.m.]. [Housekeeper (#3)] stated that she saw resident sitting in the recliner without any clothes on. At 0545 AM [5:45 a.m.] [staff nurse (#4)] came into work. When she walked to the front nurse's station she saw resident sitting in the recliner with no clothes on. Review of Resident #3's medical record occurred on all days of survey. An admission Minimum Data Set (MDS), dated [DATE], identified severe cognitive impairment and extensive assistance with dressing. Diagnoses included dementia and left femur fracture. Review of physician's orders identified the following: * 01/06/23 hydroxyzine HCL (an anxiety medication) 25 milligrams by mouth every 8 hours as needed for agitation. * 01/08/23 oxycodone HCL (a narcotic pain medication) 5 milligrams by mouth every 6 hours as needed for pain. A nursing progress note dated, 01/14/23 at 5:04 a.m., stated, Resident awake all night disrobing, wandering and yelling at staff. Staff attempted to redirect her offered snacks and activates [sic]. Behaviors continued throughout the night. Staff 1:1 [one to one] with resident this NOC [night]. Resident #3's care plan stated, . alteration in comfort . evidence by need of pain management r/t [related to] L) [left] hip fracture . give pain Rx [medication] as ordered . mood/behavior: resident noted to pull her call light out of wall and swing it at staff . medications as ordered . 1:1 visits. During an interview on 02/14/23 at 2:45 p.m., a staff nurse (#4) stated when she arrived to work on 01/14/23, around 5:40 a.m. she found Resident #3 sitting in one of our big red recliner chairs with the feet up by the med room, she was naked . she had a hospital gown tucked to the side. She identified that the night nurse (#8) was in the nurse's station and then asked the night nurse (#8), Can we call someone to help her? [The night nurse (#8)] said 'What do you want me to do about it she's been like this all night.' And she wouldn't call a CNA [certified nursing assistant], wouldn't give me a walkie [handheld communication device]. The staff nurse (#4) identified she found a CNA (#5) walking into work, and they assisted Resident #3 to dress. The staff nurse (#4) stated the undressing was not a new behavior for Resident #3, and as they assisted Resident #3 to dress for the day, the resident was not distressed or aware she had been naked in a public area. During an interview on 02/14/23 at 2:10 p.m., a CNA (#5) confirmed she assisted the staff nurse (#4) to dress Resident #3 when she arrived to work on the morning of 01/14/23 and Resident #3 sat undressed in a recliner by the medication room across from the nurse's station. She also confirmed the undressing behavior was not new for Resident #3, and while assisting Resident #3 she appeared in no distress. The medical record lacked documentation of attempts made or administration of as needed pain or anxiety medications on 01/13/23 from 6:00 p.m. to 6:45 a.m. on 01/14/23. The staff nurse (#4) stated the taped report for the night shift of 01/13/23 did not address Resident #3's behaviors or any interventions implemented by staff to address them. The facility staff failed to provide goods and services to maintain a dignified existence and avoid emotional distress for of Resident #3 by ensuring she was always dressed while in public areas of the facility, and that all interventions were implemented to meet her physical, mental and psychosocial needs.

Based on record review, review of facility policies, incident reports, and staff interview, the facility failed to investigate a fall, report a change in condition to the physician in a timely manner, and promptly and thoroughly investigate an injury of unknown origin for 1 of 2 sampled residents reviewed for falls (Resident #1). These failures resulted in Resident #1 experiencing unnecessary pain, and placed all residents at risk for falls, abuse, neglect, lack of treatment and/or unnecessary pain. During an on-site facility incident investigation on 08/17/22, the surveyor determined a potential Immediate Jeopardy (IJ) situation existed. The IJ potential resulted from review of Resident #1's medical record regarding a fall and injury of unknown origin, the facility's failure to investigate the fall, the failure of staff to immediately inform the provider of Resident #1's significant change in status, an incomplete, and inconsistent facility investigation into the injury of unknown origin, and staff interview. These findings placed residents in immediate jeopardy due to a facility failure to determine how falls/injuries of unknown origin occurred and rule out potential abuse/neglect. Further immediate jeopardy existed due to lack of staff knowledge about notification and follow up with the provider on change of condition in residents that can lead to significant outcome. * 08/17/22 at 1:30 p.m. - The survey team contacted the management staff at the State Survey Agency (SSA) to report the findings and to discuss a potential IJ situation. * 08/17/21 at 2:30 p.m. - The SSA notified the regional office of the IJ situation. * 08/17/22 at 3:05 p.m. - The survey team notified the Administrator of the IJ situation and requested they develop a plan for abatement of the IJ. * 08/18/22 at 1:58 p.m. - The facility provided a written plan (via email) of correction for the IJ. * 08/18/22 at 4:22 p.m. - The survey team reviewed and accepted the facility's written plan. * 08/22/22 at 5:00 p.m. - The survey team determined the IJ situation at a scope/severity of J was abated and reduced to a scope and severity of G. Findings include: Review of the facility policy titled, Vulnerable Adult-North Dakota occurred on 08/17/22. This policy, revised May 2022, stated, . Neglect - failure to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress . Abuse also includes the deprivation by an individual, including a care taker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being . Injury of unknown source - an injury should be classified as an injury of unknown source when both of the following conditions are met . The source of the injury was not observed . and . The injury is suspicious because of the extent of the injury . Examples of neglect . caretaker neglect - failure of the caretaker to provide necessary food, clothing, shelter, health care, or supervision . a resident falls and suffers injury . Examples of unknown injuries . fractures with unknown cause . Reporting . Suggested content of reports to [State Health Agency] . Written Reports . Include copies of any other documents . resulting from the investigation . Review of the facility policy titled, Falls - Resident occurred on 08/17/22. This policy, revised March 2022, stated, . A comprehensive assessment will be completed with every fall in an effort determine the root cause and to develop individualized interventions. Review of the facility policy titled, Change of Condition occurred on 08/17/22. This policy, revised August 2021, stated, . The provider will be notified as soon as an assessment is conducted in the following cases. A significant change in the resident's physical, mental, or psychosocial status . A need to alter treatment . Review of Resident #1's medical record occurred on 08/17/22. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly Minimum Data Set, dated dated dated [DATE] identified severely impaired cognition, no scheduled or as needed (PRN) pain medications taken, and that Resident #1 denied pain. The care plan, dated 08/01/22, stated, . ADL [activities of daily living]/MOBILITY DEFICITS: Resident has self-care deficits AEB [as evidenced by] need for assistance with ADLs including bathing secondary to weakness, balance deficits, activity tolerance and Dx [diagnosis] of dementia and R) [right] [sic] femur fx [fracture] . Interventions. Non-ambulatory. Has an immobilizer to Left leg for Dx of fracture of left femur [initiated 08/01/22] . TRANSFERS: Hoyer lift assist of 3 . One person must keep left leg stable during transfer at all times [initiated 08/01/22] . is at increased risk for falls r/t [related to] poor cognition and poor safety awareness. Scores at high risk for falls. She has fallen in the last 90 days . Interventions . Lipped mattress to bed [dated initiated 07/27/22] . Resident #1's nurse's notes identified: * 07/12/22 at 9:13 p.m., Time of fall: 2050 [8:50 p.m.] Description of event: Staff found her lying on left side by bed. Was the fall witnessed?: no, neuros [neurologic assessment] started [.] Did the resident hit their head?: unknown, no bruising noted . Pain location, description, & pain scale rating: Resident isnt [sic] able to rate pain or state where due to cognition. She is holding left knee. Small bruise noted to top of knee cap, no swelling. Physical Assessment (include any injuries & immediate care provided): She is able to move all extremities. no skin tears. How was the resident assisted up from the fall?: Hoyer of 2 [.] Action Plan/Intervention: Reminded staff to round on resident and to place into bed after supper. [Provider Name] stated to give tylenol, ice left knee, and she will be here in morning to assess. * 07/13/22 at 1:19 p.m., Resident had bath and body audit today. No new skin concerns noted. * 07/13/22 at 5:57 p.m., Resident is follow up fall charting. Vitals and neurochecks stable. No new injuries noted. * 07/15/22 at 9:50 a.m., Resident is on follow up fall monitoring with neuro checks. Neuro checks are negative at this time. No noted injury due to pain. No complaints of pain noted due to fall. Vitals obtained and within normal ranges for resident at this time. No noted concerns at this time. We will continue to monitor further and report any changes or concerns. * 07/16/22 at 2:41 a.m., Resident is follow up fall with neuro checks. Neuro check was negative, VSS [vital signs stable], no noted pain or injury. Last neuro check completed, consider fall resolved. * 07/20/22 at 6:03 a.m., Fax prepared and left for day shift to send. Resident's left knee was found to be swollen, with yellow bruising and fluid behind the knee cap. Knee cap on palpation was deviated down and to the right. Resident screamed in pain with repositioning. Area was warm to the touch. Ice pack applied and pillow placed between knees for support. The facility failed to initiate an investigation on an injury of unknown origin at this time. * 07/20/22 at 2:18 p.m., Resident had bath and body audit this shift, some swelling noted to left knee, fax out to PMD [primary medical doctor]. No other new skin concerns noted nor reported. The facility failed to follow up with the provider regarding the fax and resident condition. * 07/27/22 at 7:52 a.m., Late Entry: res [resident] had w/p [whirlpool]. while doing skin audit writer noted that res had a faded purplish/yellow bruise that went all the around above left knee. her leg above knee was swollen, warm to touch and hard. writer informed [nurse name], RN [Registered Nurse], charge nurse and she will be contacting [provider name]. * 07/27/22 at 10:12 a.m., Writer called to tubroom to note that resident left leg/knee was swollen. Noted that the thigh was swollen and hard to the touch. No redness or warmth noted. Resident does have a lot of pain and does scream out with even the slightest touch. MD [medical doctor] updated and did order to send for xray. * 07/27/22 at 3:29 p.m., Writer and [provider name] called and spoke with residents daughter, [daughter's name] regarding xray results. Will place a brace on the leg to immobilize it. * 07/27/22 at 5:04 p.m., [provider name] did send orders for femur fracture. Resident #1's Radiology Report, dated 07/27/22, stated, . Displaced fracture of the distal left femur. Review of Resident #1's physician's orders dated 07/01/22-08/17/22 showed: * 07/27/22 Tylenol Extra Strength Tablet . (Acetaminophen) Give 500 mg [milligram] by mouth two times a day for musculoskeletal pain * 07/27/22 Tylenol Extra Strength Tablet . (Acetaminophen) Give 500 mg by mouth every 6 hours as needed for musculoskeletal pain * 07/09/22-07/27/22 Acetaminophen Give 650 mg by mouth every 4 hours as needed for pain/fever do not exceed 3000 mg/ [per] 24 hours * 07/27/22 [MEDICATION(S)]-Acetaminophen [narcotic pain reliever] Tablet 5-325 MG Give 0.5 tablet by mouth two times a day for musculoskeletal pain * 07/27/22 [MEDICATION(S)]-Acetaminophen Tablet 5-325 MG Give 0.5 tablet by mouth every 6 hours as needed for musculoskeletal pain Review of Resident #1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] * Acetaminophen Give 650 mg - three times 07/12/22, 07/14/22, 07/20/22 * Tylenol Extra Strength Tablet 500 mg - one time * [MEDICATION(S)]-Acetaminophen Tablet 5-325 mg - twelve times During an interview with an administrative nurse (#1) on 08/17/22 at 12:10 p.m., she reported the facility investigated the fracture of Resident #1's left femur beginning 07/28/22. The administrative nurse provided the investigation documentation which consisted of a handwritten sheet of notes identified as nurse interview/documentation review, and a typed sheet identified as CNA [certified nursing assistant] interviews. Both documents lacked dates and times. Review of CNA interviews completed by the facility on 07/28/22 identified the following regarding Resident #1: * legs were really puffy, knee looked out of place, told [nurse name] that she needs to look at [Resident #1] knee and its puffy. Knee looks as though its not together. Still puffy 2 weeks later, when [CNA name] worked with her again.Difficult to get brief in between legs. * The night she fell she was in pain, nurse was informed and the nurse said she was fine. * 2 weeks ago, helping [CNA name] with transfer, leg is not looking right,. Leg was looking shorter. The leg is hurting, swollen to the knee. reported to the nurse, that it doesn't look right . gradually swell up, wasn't swollen right away. * told the nurse that resident was crying in pain . Doing report, [CNA name] told her she [Resident #1] fell that's why her leg looks twisted. Doesn't look right. Trying to tell them on night shift but they keep bypassing it. A couple days ago told [nurse name] that the leg doesn't look right, . A lot of people had been saying things about it but it was just being bypassed, told that's just how her leg is. * . When you lifted in the hoyer, she was in pain, would do her little cry that she does. Not sure if it was reported to the nurse that she was in pain . Review of the handwritten notes, identified by administrative nurse (#1) as nurse documentation/interviews, dated 07/28/22, identified the following regarding Resident #1: * No reports of pain/swelling/bruising - [didn't] look at it * [Didn't] look at knee - [no] complaints slept through night * [No] reports - didn't look at leg * [No] swelling - yelling in pain w[with]/transfer- assessed leg w/no concerns * Tues [Tuesday] night- pain w/repo [repositioning] - last week - increased swelling & [and] warmth - pain fax made for MD. * [No] signs of pain * [No] signs of pain * Wed [Wednesday] body audit - [didn't] see anything - no increased pain - always looked same. looked different yesterday - Someone has called in everyday to look @ [at] leg. [No] increased. * body Audit - Knee swollen - minimally - [nurse name] & I decided normal * PRN [as needed] Tylenol [pain relief medication] - @ fall that night. yelling w/transfers. [illegible word] reported. * [No] reports pain/swelling - sent fax for [nurse name] Review of the final report received by the State Agency on 08/04/22, stated, . Nurse/DON [Director of Nursing] interview: Multiple CNAs, RNs [Registered Nurses], LPNs [Licensed Practical Nurses] interviewed that had worked with [Resident #1] over the course of two weeks. All denied any swelling to left thigh/knee. All denied resident crying out in pain with transfers or cares. Resident does resist cares/hoyer [mechanical lift]/bath at times. Investigation: Staff, residents, and nurse were interviewed . Conclusion: Review team went over details and concluded allegation. Team determined no abuse seemed to have occurred. Facility assured residents and facility are safe. Resident does have diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident was a hoyer transfer with assist of 2 staff, updated to 3 staff due to fracture. Suspected that fracture happened during resident transfer. During an interview on 08/17/22 at 3:08 p.m., an administrative staff (#3) confirmed he failed to review the final investigation completed or the report submitted to the state agency. The facility failed to initiate a fall investigation for the 07/12/22 fall. The facility failed to notify the provider of the change in condition to Resident #1's left knee/thigh, and increased pain level on 07/20/22. After the provider notification on 07/27/22 (7 days later) the resident went to the emergency department. Staff then initiated an investigation of injury of unknown origin. The facility investigation of Resident #1's left femur fracture lacked dates, times, and completeness. The facility investigation showed CNAs identified changes in Resident #1's left leg and pain level, reported the changes to the nurses, and that nurses assessed and contacted the provider via fax. This contradicted the final report submitted to the State Agency which stated CNAs and Nurses reported no changes to Resident #1's left leg and pain level in the two weeks prior to the discovery of the fracture on 07/27/22. The facility failed to ensure the staff followed the systems in place to protect Resident #1 and all residents from potential abuse, neglect, and unnecessary pain.

Based on information provided by the complainant, record review, review of professional reference, review of facility policy, and staff interview, the facility failed to provide the necessary care and services to promote optimal well-being for 1 of 1 sampled resident (Resident #7) and 1 closed record resident (Resident #9) who experienced a fall resulting in a major injury. Failure to assess and provide prompt treatment as changes occurred following a fall resulted in Resident #7 experiencing over 13 hours of significant pain related to her untreated arm fracture and may have contributed to Resident #9's death. Findings include: Information provided by the complainant indicated facility staff failed to assess, identify, and respond to changes in the mental status of a resident who sustained a head injury during a fall. Walters and Kluwar, Lippincott's Nursing Procedures, 5th Edition, 2009, pages ,[DATE] stated, Managing Falls . Provide first aid for minor injuries as needed. Monitor the patient's status for the next 24 hours. Even if the patient shows no signs of distress or has sustained only minor injuries, monitor vital signs every 15 minutes for 1 hour, then every 30 minutes for 1 hour, then every 1 hour for 2 hours, or until his condition stabilizes. Monitor neurological assessments with vital signs . Review of the facility policy titled Falls-Resident occurred on [DATE]. This policy, revised (MONTH) (YEAR), stated, . The two most critical problems to watch for are fractures and head injuries (especially if it was an unwitnessed fall to the floor). Residents who have hit their head or had an unwitnessed fall will have neuro checks, including vital signs, done as follows: upon initial assessment, 2 hours post fall, then every 8 hours x 3 . The physician/practitioner must be notified of a fall immediately if there appears to be any significant injury/change in condition. - Review of Resident #7's medical record occurred on (MONTH) ,[DATE], (YEAR). [DIAGNOSES REDACTED]. The annual MDS, dated [DATE], identified severely impaired cognition and extensive assistance of two persons required for activities of daily living. Resident #7's current care plan identified, . Actual falls related to cognitive and mobility deficit. she has a Hx (history) of fall with Fx (fracture) previous to admit . displays a decreased safety awareness. scores at high risk for fall with hx of falls in facility. The progress notes identified the following: * [DATE] at 6:40 p.m. Resident was heard calling out in pain and found lying on the floor in front of her wheelchair . Resident complains of pain to left shoulder and withdraws left arm when touched. Facial grimacing and calling out occurs when arm is moved . * [DATE] at 9:10 p.m. 2 hour recheck s/p (status [REDACTED]. She continues to show signs of pain to left shoulder including withdrawing the left arm when touch (sic), grimacing, and crying out when arm is touched. * [DATE] at 1:20 a.m. (6 hours and 40 minutes after the fall) . Writer called to resident's room to assess her pain. On assessment, the left arm and shoulder is warm . mild swelling of shoulder present; resident guards arm when touched . she grimaces and cries out when arm is abducted (moved away from the midline of the body). Provided resident with prn (as needed) Tylenol and will monitor pain . * [DATE] at 6:16 a.m. (11 hours a 36 minutes after the fall). Resident continues with pain to left shoulder, guarding. shoulder is swollen. * [DATE] at 8:30 a.m. (13 hours and 50 minutes after the fall) (name of nurse practitioner) was here to see resident. She gave orders for resident to go to clinic for xray of the left shoulder. Facility staff failed to recognize and respond appropriately to Resident #7's continued signs of unmanaged pain and increased swelling, and failed to notify her physician in a timely manner. - Review of Resident #9's medical record occurred on (MONTH) ,[DATE], (YEAR). The admission Minimum Data Set (MDS), dated [DATE], identified moderately impaired cognition. Resident #9's most recent care plan identified, . RISK FOR FALLS . Scores high risk for falls . Appropriate footwear with transfers, Bed at standard height . Wheel chair pedals with staff assisted locomotion. A progress note, dated [DATE] at 3:10 a.m., identified, . Resident fell self transferring to the bathroom . found in middle of room floor on his left side . resident has a large contusion to the left side of his forehead. Ice applied to forehead, and skin tear 1 cm (centimeter) by 1 cm, cleansed to left outer wrist xeroform and border gauze applied. Physician . Fax prepared to notify. Family . Am staff to update family in the am due to time of night. A neuro check flow sheet, dated [DATE] at 3:47 a.m. (37 minutes after the resident was found), identified Resident #9 was alert, oriented, and following commands. A progress note, dated [DATE] at 4:57 a.m. (1 hour and 47 minutes after the resident was found), identified, . [MEDICATION NAME] HCI (pain medication) . Resident is complaining of a headache . A neuro check flow sheet, dated [DATE] at 5:38 a.m. (2 hours and 28 minutes after the resident was found), described Resident #9 as confused. The progress notes, dated [DATE], identified the following: * At 7:30 a.m. (4 hours 20 minutes after the resident was found), CNA (certified nursing assistant) called writer to resident room and resident was very confused and anxious. He could not speak what he needed or what was wrong. Resident appears SOB (short of breath) and has taken 02 (oxygen) off, 02 placed and 02 was up to 92% 2L/nc (2 liters/nasal cannula). Resident continued to not be able to speak but made sounds. CNA did request to put resident on the PAL (mechanical stand lift) due to confusion and that CNA had tried to stand resident and he was very unsteady and noncompliant. Writer did observe PAL transfer and resident was not able to follow commands correctly and did try to walk off the PAL lift. Resident was put into wheelchair. Resident was not comfortable sitting or standing and very unsteady and very anxious. * At 7:40 a.m., Resident at NS (nurses' station) and continues to be very anxious and confused. 02 is at 93% 2L/nc. * At 7:43 a.m., (4 hours and 33 minutes after Resident #9 was found on the floor) (Family member) . called and updated on resident status and the fall. Daughter did request that he be taken to the ER (emergency room ). * At 8:00 a.m., Resident was taken to (ER) per (facility) van and staff. * At 8:50 a.m., (Physician) did call up here and was updated regarding ER transfer and fall. * At 9:29 a.m., (Family member) called and stated that resident has a large subderal (sic) hematoma (collection of blood outside the brain) and states that they will be keeping him at the hospital for comfort cares . Resident #9 died the following day. The certificate of death identified, . IMMEDIATE CAUSE OF DEATH: Late complications of contusion to head as a consequence of subdural hematoma and subarachnoid hemorrhage . Facility staff failed to reassess Resident #9 after he developed a headache and showed increased signs of confusion, and failed to notify his physician in a timely manner. During an interview on [DATE] at 11:15 a.m., two administrative staff members (#1 and #2) acknowledged facility staff failed to recognize/respond to changes/decline in health condition for Resident's #7 and #9 which limited the physician's ability to make informed decisions regarding medical care.

Based on observation, record review, policy and procedure review, and staff interview, the facility failed to use interventions as care planned to prevent injury for 1 of 1 sampled resident (Resident #2) and 1 of 1 closed record resident (Resident #14). Failure of facility staff to follow Resident #14's care plan regarding transfers resulted in a laceration requiring sutures; and increased the risk for injury/falls for Resident #2 and all residents using a chair alarm. Findings include: Review of the facility's policy titled "Fall Management" occurred on the afternoon of 04/16/14. The policy, dated 04/25/13, stated, "Certified Nursing Assistants 1. Follow the intervention as outlined on the care plan. . . ." - Review of Resident #14's medical record occurred on 04/16/14. Medial [DIAGNOSES REDACTED]. . . requires assist with ADLs . . . transfer (assist) of (two) (with) hoyer lift, dated 09/04/13 . . ." Review of Resident #14's nurses' notes identified the following: *09/08/13, 1:00 a.m. - "At 1932 (7:32 p.m.) this nurse was called to memory care unit regarding occurrence with resident. Further staff notified for assist, Res (resident) resting in bed on her left side, large 8 cm (centimeters) laceration noted to RLE (right lower extremity) anteriolateral aspect. Scant bleeding noted. Area cleaned and dry dressing applied to keep area clean and prevent further injury . . res would be transported via ambulance for evaluation and treatment. . . ." *09/08/13, 10:00 a.m. - "changed drsg (dressing). Frank amt (amount) of drng (draining) to bandages. 4 sutures in place lg (large) area of exposed tissue. cleansed (and) hydrogel applied (with) sterile gauze wrapped (with) kling. Tylenol given as scheduled." Review of the investigation report, on 04/16/14, identified Resident #14's leg "got caught on the bed frame" during a two person assist with a gait belt transfer into her bed. Further review of the facility's investigation results indicated the staff that transferred Resident #14 with the gait belt knew that her care plan identified she is a Hoyer lift only transfer. During an interview on 04/16/14 at 11:55 a.m., an administrative nursing staff member (#6) stated staff used a two person assist with a gait belt to transfer Resident #14 on 09/08/13 and should have used a hoyer lift. - Resident #2's current care plan stated, " . . . Dementia with balance, mobility and cognitive deficits. HX (history) of falls resulting in a L) (left) hip fracture. Resident attempting to stand from bed and from w/c (wheelchair) frequently . . . Recent fall resulting in R) hip fx (fracture) . . . Bed and chair alarms, dated 03/11/14, . . . ." Resident #2's nurses' notes identified the following fall from a wheelchair resulting in a right hip fracture: *03/06/14,7:45 a.m. - "Writer and CNA (certified nursing assistant) responded after hearing crash in room. Upon entering w/c laying on its back. . . . Res c/o (complained of) right groin pain. No obvious deformities. ROM (range of motion) impaired during abduction . . .Res unable to do further assessing due to pain level." *03/06/14, 7:50 a.m. - "Notified ambulance need for transfer." *03/06/10:00 a.m. - "Received (sic) (and) observed order to send to (name of hospital). Dx (diagnosis) R) Femoral hip fx." Observations completed April 14-16, 2014 showed Resident #2 seated in his wheelchair with no chair alarm in place. Failure to follow Resident #14's care plan resulted in injury requiring medical intervention. Failure to follow the care plan for Resident #2 may increase the risk of falls/injury.