Every finding on record at Eventide Jamestown

Based on review of nurse staffing schedules and staff interview, the facility failed to provide the services of a registered nurse (RN) for eight consecutive hours a day, seven days a week, for 2 of 45 days reviewed (07/04/26 and 07/05/26). Failure to ensure sufficient, qualified nursing staff are available eight consecutive hours a day has the potential to affect the health and safety of all the residents residing in the facility. Findings include:On 07/20/26, the facility provided a copy of the nurse staffing schedules for the period of June 14-July 18, 2026. A review of the schedules showed the facility failed to have the required RN coverage on 07/04/26 and 07/05/26. During an interview on 07/22/26 at 11:12 a.m., an administrative nurse (#1) confirmed the facility lacked RN coverage on the above dates.

Based on staff interview, the facility failed to ensure 1 of 1 dietary manager (#5) obtained the proper qualifications to serve as the director of food and nutrition services. Failure to ensure staff have the qualifications to carry out the functions of food and nutrition services may place residents at risk for adverse nutritional needs. Findings include: During an interview on 07/20/26 at 9:55 a.m., the dietary director (#5) stated she is currently enrolled in a certified dietary manager (CDM) program through University of North Dakota (UND) and has not completed a certified program. The facility failed to ensure the dietary director (#5) completed the required education for a certified dietary manager, certified food service manager, or a national certification for food service management and safety from a national certifying body.

Based on observation, review of the facility policy, and staff interview, the facility failed to ensure medications were secured on 3 of 6 medication carts (Wing 1/Wing 2, Wing 4, and Wing 5). Failure to lock medication carts may result in unauthorized access to the medication. Findings include:Review of the facility policy titled Medication Administration and Storage occurred on 07/22/26. This policy, dated February 2026, stated, Medication storage: Medications will be stored in a designated and secured (locked) area.- Observation on 07/21/26 at 11:33 a.m. showed a nurse (#2) gathered supplies to administer medication, walked down the hallway and left the unlocked medication cart at the Wing 1/Wing 2 nurses' station. The medication cart remained unsupervised for approximately 5 minutes. - Observation on 07/21/26 at 1:40 p.m. and at 2:55 p.m. showed an unlocked and unsupervised medication cart at the Wing 1/Wing 2 nurses' station. - Observation on 07/21/26 at 4:52 p.m. showed a nurse (#3) gathered supplies to administer medication, walked to a resident's room and left the unlocked medication cart in the Wing 5 hallway. The unlocked medication cart remained unsupervised for approximately 3 minutes. - Observation on 07/22/26 at 8:21 a.m. showed a nurse (#4) gathered supplies to administer medication, walked to a resident's room and left the unlocked medication cart in the Wing 4 commons area. The unlocked medication cart remained unsupervised for approximately 10 minutes. - Observation on 07/22/26 at 11:09 a.m. showed an unlocked unsupervised medication cart in the Wing 4 commons area. A nurse (#4) accessed the medication cart and locked it at 11:17 a.m.During an interview on 07/22/26 at 2:13 p.m., an administrative nurse (#1) stated she expected all unattended medication carts to be locked.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to follow standards of infection control and prevention for 4 of 12 sampled residents (Resident #11, #12, #34, and #50) and one supplemental resident (Resident #16) observed during cares and/or insulin administration. Failure to practice infection control standards related to dressing changes, perineal cares, hand hygiene, and glove usage has the potential to spread infection throughout the facility. Findings include: Review of the facility policy titled Hand Hygiene occurred on 07/23/26. This policy, dated 02/11/26, 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 . Hand Hygiene is a general term that applies to either hand washing or alcohol-based hand rub . Review of the facility policy titled Simple Dressing Change occurred on 07/23/26. This policy, dated 02/17/26, stated, . PROCEDURE: . 2. Perform hand hygiene and assemble equipment/supplies. 4. Put on gloves and clean working surface with a germicidal wipe . 6. Remove gloves and perform hand hygiene. 7. Set up supplies/equipment on clean surface. 10. Apply gloves. 11. Remove dressing. Fold dressings with drainage contained inside and remove gloves inside out. 12. Dispose of gloves and soiled dressing in trash receptacle. 13. Perform hand hygiene. 14. Apply gloves. 15. Cleanse wound as ordered . 16. Remove gloves and perform hand hygiene. 17. Apply gloves. 18. Apply clean dressing as ordered. 20. Remove gloves and perform hand hygiene. 22. Clean the working surface with a germicidal wipe . 24. Perform hand hygiene. Review of the facility policy titled Insulin - Subcutaneous occurred on 07/22/26. This policy, dated February 2026, stated, Procedure: 1. Perform hand hygiene and apply clean gloves. Clean site with an alcohol swab . Inject medication. -Review of Resident #12's medical record occurred on all days of survey. Diagnoses included a non-pressure chronic ulcer to the left foot. A physician's order, dated 05/15/26, stated to cleanse the wound on the left second toe with a wound cleansing solution, cover with an antimicrobial wound dressing, and secure with tape daily. Observation on 07/21/26 at 7:59 a.m. showed a nurse (#2) entered Resident #12's room to perform wound care. The toe showed no prior dressing in place. Without performing hand hygiene, the nurse (#2) applied gloves, cleansed the wound with wound cleanser, dried the area with gauze, and with the same gloves applied the new dressing and tape. Without performing hand hygiene, the nurse left the room with the supplies. During an interview on 07/23/26 at 10:04 a.m., an administrative nurse (#1) stated she expected staff to wash their hands prior to gloving, perform hand hygiene and apply new gloves after removing soiled dressings prior to applying clean dressings, and perform hand hygiene prior to leaving the resident's room. -Review of Resident #34's medical record occurred on all days of survey. A physician's order, dated 07/21/26, stated, Monitor Skin tear to R [right] upper arm. Xeroform [a type of sterile dressing] applied and covered with non-adherent dressing wrapped with kerlix [gauze roll]. Change . every shift for skin tear . Observation on 07/21/26 at 8:17 a.m. showed a nurse (#4) entered Resident #34's room to change the dressing to the resident's arm. Without performing hand hygiene, the nurse (#4) applied gloves obtained from his/her uniform pocket, removed the old dressing and steri-strips, and with the same gloves placed the clean wound care supplies directly on the arm rest and seat of the resident's recliner without cleaning the surface. Without changing gloves, the nurse cut a piece of Xeroform, applied it and the non-adherent dressing to the skin tear, wrapped the arm with Kerlix, and taped it in place. With the same gloves, the nurse carried the supplies and placed them on top of the supply cart outside the room, dropped the scissors on floor, picked them up, and without disinfecting, placed them in his/her uniform pocket. During an interview on 07/23/26 at 10:11 a.m., an administrative nurse (#1) stated she expected the nurse to place clean supplies on a clean surface, perform hand hygiene, and change gloves between dirty and clean tasks. -Observation on 07/22/26 at 9:46 a.m. showed a certified nurse aide (CNA) (#6) entered Resident #50's room, completed hand hygiene, and applied clean gloves. The CNA (#6) removed the resident's wet brief, initiated perineal cares, and with the same gloves, placed a clean brief under the resident, and completed perineal cares. The CNA (#6) removed the soiled gloves and without completing hand hygiene, applied clean gloves, applied powder to the resident's groin area, fastened the clean brief, and removed the soiled gloves. Without completing hand hygiene, the CNA put on the resident's pants and grippy socks, assisted the resident into a sitting position, utilized a mechanical sit to stand lift, positioned the resident into a wheelchair, and inserted the resident's hearing aids. The CNA performed hand hygiene and exited the room with the sit to stand lift. The CNA failed to sanitize the lift. - Observation on 07/21/26 at 4:54 p.m. showed a nurse (#3) performed hand hygiene, prepared the insulin pen, and without applying gloves, cleansed Resident #11's skin with an alcohol wipe and administered the insulin injection. - Observation on 07/21/26 at 5:09 p.m. showed a nurse (#3) performed hand hygiene, prepared the insulin pen, and without applying gloves, cleansed Resident #16's skin with an alcohol wipe and administered the insulin injection. The nurse failed to apply gloves prior to administering the injections. During an interview on 07/22/26 at 2:13 p.m., an administrative nurse (#1) stated staff are expected to wear gloves when administering injections.

Based on information received from the complainant, review of facility policy and resident interviews, the facility failed to ensure reasonable accommodation of needs regarding call lights for 4 of 8 confidential residents (Residents C, D, E, and G. Failure to answer call lights timely, may result in discomfort, increased falls, and/or incontinence.Findings include:Review of the facility policy titled Standards of Care occurred on 08/26/25. This policy, revised August 2024, stated, . Staff will respond to call lights in a timely manner .-During an interview on 08/26/25 at 11:20 a.m., Resident D stated, I have my call light now but sometimes they forget to give it to me. Sometimes it takes a half hour or longer for help. One time I waited on the toilet and had to yell for someone to come.-During an interview on 08/26/25 at 11:30 a.m., Resident E stated, A couple of months ago I had soiled myself in bed and needed to be changed. I waited for almost two hours.-During an interview on 08/26/25 at 11:55 a.m., Resident G stated, Staff run ragged around here and they aren't very nice. One time I had my light on for over an hour and when they came in, I told them I wouldn't have had an accident [incontinent bowel movement] if they would have come sooner. The aide got mad at me for scolding her and walked out. I had to wait for someone to come back.During an interview on 08/26/25 at 5:29 p.m., an administrative staff member (#2) stated she expected staff to answer call lights within 5 minutes as that is her baseline for audits.

Based on observation, and confidential resident interviews, the facility failed to provide palatable and attractive food for 5 of 10 confidential residents (Residents B, D, F, G, and H). Failure to ensure residents receive food that is palatable, places residents at risk of weight loss and nutritional decline.Findings include:Review of the lunch menu served on 08/26/25 identified tater tot casserole (hotdish), tomato wedges, pacific blend vegetables, and a sundae brownie. -During an interview on 08/26/25 at 11:20 a.m., Resident D stated, They told me they didn't have anything for me [special diet], so I ordered plain mashed potatoes, but they covered them in gravy, so I didn't eat. -Observation on 08/26/25 at 11:45 a.m. showed a meal tray in Resident F's room. The plate contained two mounds of a brown substance (that did not resemble tater tot casserole) and the resident stated, This is supposed to be tater tot hotdish. The food is terrible. The dietitian gave me Ensure [a supplement] but I get tired of that but there's nothing else to eat. The resident ate only the dessert.-Observation on 08/26/25 at 11:55 a.m. showed a meal tray in Resident G's room. The resident pointed to the tray and stated, It is disgusting. This is supposed to be hotdish, but it reminds me of liver sausage I had to eat growing up, but this is worse. One day we had soup that a dog wouldn't eat. The resident ate only the dessert.-During an interview on 08/26/25 at 12:10 p.m., Resident H identified staff warmed food from the resident's personal refrigerator per request for lunch and stated, I wasn't going to eat the stuff they were serving, it's terrible.-During an interview on 08/26/25 at 2:40 p.m., Resident B stated, the food seems to be of lesser quality. I can't eat it. They offer me something else but how many cheese sandwiches can you eat.Observation of the main dining room on 08/26/25 at 12:20 p.m. showed five separate plates with untouched hot dish left on the plates. During an interview on 08/26/25 at 4:35 p.m. an administrative staff member (#1) stated staff served the casserole with portion scoops which made the mounds on the plate.

Based on observation, review of the North Dakota Long Term Care Ombudsman Program's Guide to Resident Rights, review of facility policy, and staff interview, the facility failed to provide care in a manner that maintained, enhanced, and respected the resident's dignity for 2 of 14 sampled residents (Resident #5 and #222). Failure to treat residents with dignity, speak respectfully, and provide privacy during toileting has the potential to affect the residents' psychosocial wellbeing and does not enhance the residents' quality of life. Findings include: The North Dakota Long Term Care Ombudsman Program's Guide to Resident Rights, updated 03/21/23, stated, . The facility must treat you courteously, fairly and with dignity. Review of the facility policy titled Standards of Care occurred on 05/21/25. This policy, dated August 2024, stated, . Dignity . door to be closed anytime cares are being completed. - Observation on 05/19/25 at 1:23 p.m. showed a certified nurse aide (CNA) (#9) attempted to transfer Resident #5 from the wheelchair to the bed. The resident had difficulty standing up and the CNA stated, She usually gets up herself, but she's my drama queen. - Observation on 05/20/25 at 10:13 a.m. showed a CNA (#9) and a nurse (#12) entered Resident #222's room and left the door open. Observation from the hall showed the resident seated on the commode. At 10:24 a.m., the nurse (#12) exited Resident #222's room and left the door open. Observation showed the resident on the bed with only a shirt on. During an interview on 05/21/25 at 1:08 p.m., an administrative staff member (#1) stated she expected staff to treat residents with respect, dignity, and privacy.

Based on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.19.1), and staff interview, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 2 of 18 sampled residents (Resident #1 and #55). 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 2024, page A-32, stated, . Complete if A0310A = 01 . Annual assessment . Coding Instructions Code A, Serious mental illness: if resident has been diagnosed with a serious mental illness . Review of Resident #1's medical record occurred on all days of survey. The medical record included the diagnosis of schizophrenia, neurocognitive disorder, bipolar, and dementia. The facility failed to code the serious mental illness on the annual MDS, dated [DATE]. During an interview on 05/21/25 at 10:40 a.m., an administrative staff member (#13) confirmed staff failed to code Resident #1's MDS for a serious mental health illness. SECTION H: BOWEL AND BLADDER The Long-Term Care Facility RAI User's Manual, revised October 2024, page H-2, states, . Check next to each appliance that was used at any time in the past 7 days. H0100A, indwelling catheter . - Review of Resident #55's medical record occurred on all days of survey. A physician's order, dated 02/04/25, identified an indwelling catheter. A quarterly MDS, dated [DATE], Section H0100A, lacked documentation to indicate the presence of an indwelling catheter. During an interview on 05/21/25 at 10:26 a.m., an administrative staff member (#13) confirmed staff failed to code Resident #55's MDS for the presence of an indwelling catheter.

Based on observation, record review, review of facility policy, and staff interview the facility failed to ensure residents received the necessary services to maintain personal and oral hygiene for 2 of 8 sampled residents (#5 and #52) dependent on staff for personal hygiene. Failure to provide assistance with oral care and personal hygiene may result in poor hygiene, and decreased self-esteem and quality of life. Findings include: Review of the facility policy titled Standards of Care occurred on 05/21/25. This policy, dated December 2023, stated, . Oral cares are provided a minimum of AM [morning] and PM [evening](teeth/dentures cleansed and mouth rinsed or swabbed). Peri-cares are provided after each toileting or brief change . - Review of Resident #5's medical record occurred on all days of survey. The care plan stated, . Self-care deficit . Bathing: assist of 1 . Grooming: assist of 1 . Toileting: Check and change . Assist of 1 . Observation on 05/19/25 at 1:20 p.m., showed Resident #5 sat in the wheelchair in her room, with her pants half off, disheveled hair, and faced towards the door. A certified nurse aide (CNA) (#9) knocked, entered the resident's room and turned to leave until the surveyor informed the CNA the resident needed assistance. Observation on 05/20/25 at 8:04 a.m., showed two CNAs (#9 and #11) assisted Resident #5 with morning cares (dressing and toilet use). After the resident voided, the CNA (#9) wiped the resident's perineal area with toilet paper. The CNAs assisted Resident #5 back to the wheelchair and transported him/her to the dining room for breakfast. The CNAs failed to assist Resident #5 with oral cares and cleansing the perineal area. - Review of Resident #52's medical record occurred on all days of survey. The care plan stated, . Self -care deficit . Grooming: assist of 1 . Toileting: Assist X [of] 2 w/Medi-stand [sit to stand mechanical lift] q3 [every three] hours and PRN [as needed] . Observation on 05/19/25 at 12:33 p.m., showed two CNAs (#6 and #7) assisted Resident #52 with toileting. The CNA (#6) assisted the resident with lowering pants and removed the wet brief. When the resident finished toileting the CNA (#6) used the mechanical lift to assist the resident to a standing position, and the CNA (#6) applied a clean brief and the other CNA (#7) assisted the resident to dress. The CNAs failed to complete perineal cares. During an interview on 05/21/25 at 1:08 p.m., an administrative nurse (#1) stated she expected staff to provide dependent residents with ADLs.

Based on observation, record review, review of facility policy, review of professional reference, and staff interview, the facility failed to properly utilize assistive devices necessary to prevent accidents for 2 of 9 sampled residents (Resident #5 and #49) observed during transfers. Failure to utilize and/or properly use gait belts and lock wheelchair brakes during transfers placed the residents at risk of injury and/or pain. Findings include: Review of the policy titled Standards of Care occurred on 05/21/25. This policy, dated August 2024, stated, . A gait belt will be used for all assisted transfers . [NAME], [NAME], and Frandsen, Kozier & Erb's Fundamentals of Nursing: Concepts, Process, and Practice, 11th edition, eText 2021, Pearson Education, Inc., New Jersey, page 1106, stated, . Positioning a client in good body alignment . are essential aspects of nursing practice . Page 1117, stated, Wheelchair Safety: Always lock the brakes on both wheels of the wheelchair when the client transfers in or out of it. Ensure the client is positioned well back in the seat of the wheelchair. -Review of Resident #5's medical record occurred on all days of survey. Diagnosis included a history of falls. The care plan stated, Unsteadiness on feet . Weakness . Transfers: Assist X [of] 1 [staff] . Observation on 05/19/25 at 1:23 p.m. showed Resident #5 seated in a wheelchair in her room. A certified nurse aide (CNA) (#9) attempted to transfer Resident #5 from the wheelchair to the bed by placing her arms under both of the resident's armpits and the resident stated, Ow. The CNA (#9) reseated the resident and left the room to get additional staff assistance. Two CNAs (#9 and #10) entered the resident's room and attempted to assist the resident to stand. The CNA (#10) stated, We need to use the gait belt and applied a gait belt. Both CNAs (#9 and #10) placed one hand on the gait belt, placed their opposite arm under the resident's armpits, and transferred the resident to the bed. Observation on 05/20/25 at 8:04 a.m., showed two CNAs (#9 and #11) placed a gait belt around Resident #5's waist. The CNAs assisted the resident to stand and transferred the resident to the toilet. As they walked, the gait belt slid up under the resident's armpits. The CNAs failed to properly apply/secure the gait belt prior to the transfer. -Review of Resident #49's medical record occurred on all days of survey. The care plan stated, High Risk for injury . Ambulation: Non-Ambulatory Gait: wc [wheelchair] with assist . Transfers: Assist X [of] 1 with Medi stand [sit-to-stand mechanical lift]. Observation on 05/20/25 at 8:24 a.m. showed two CNAs (#4 and #5) transferred Resident #49 from the bed, to the toilet, and from the toilet to the wheelchair utilizing a sit-to-stand mechanical lift. The CNAs failed to lock the brakes on the wheelchair, and the wheelchair rolled away. One of the CNAs noticed and locked one of the brakes. As the CNAs (#4 and #5) lowered the resident into the wheelchair, the chair pivoted away from the lift, and the back wheels of the chair lifted off the ground. The CNAs lowered the resident into the wheelchair and told her to scoot back while still in the lift harness. Resident #49 tried to scoot back but failed. The CNAs (#4 and #5) removed the lift harness and pushed on the resident's chest causing the resident to lean back, hips still forward, and slouching in the wheelchair. The CNAs (#4 and #5) reclined the wheelchair back. The CNAs (#4 and #5) failed to lock the wheels on the wheelchair, and place Resident #49 in a comfortable seating position in the wheelchair. During interviews on the afternoon of 05/21/25, three administrative staff members (#1, #2, and #3) stated they expect staff to lock all wheelchair brakes prior to transfers and staff member (#1) stated she expected staff to properly utilize gait belts for all assisted transfers.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to provide respiratory care for 1 of 1 sampled resident (Resident #5) with an order for oxygen. Failure to administer oxygen according to physician orders may result in complications and compromise the residents' respiratory status. Findings include: Review of the facility policy titled Oxygen use and Storage occurred on 5/21/25. This policy, dated July 2023, stated, . Oxygen will be administered per practitioner orders . Review of Resident #5's medical record occurred on all days of survey and identified a physician's order, dated 05/14/25, stated, oxygen at 2 liters per minute per nasal cannula. Observation on all days of survey showed Resident #5 without oxygen. During an interview on 05/21/25 at 1:08 p.m., an administrative staff member (#1) stated she expected staff to administer oxygen as ordered.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to follow standards of infection control and prevention for 3 of 14 sampled residents (Resident #43, #49, and #52) and one supplemental resident (Resident #272) observed during cares. Failure to practice infection control standards related to hand hygiene, enhanced barrier precautions (EBP), and disinfecting of mechanical lifts has the potential to spread infection throughout the facility. Findings include: Review of the facility policy titled Hand Hygiene occurred on 05/21/25. This policy, revised November 2024, stated, . hand hygiene will be done: a. Before and after resident contact (before you leave the room) . After every dirty procedure . Review of the facility policy titled Transmission-Based Precautions occurred on 05/21/25. This policy, revised December 2024, stated, . Enhanced barrier precautions . gown and gloves must be worn during high-contact care activities such as . assisting with toileting . - Observation on 05/19/25 at 12:33 p.m. showed two certified nurse aides (CNAs) (#6 and #7) applied gloves and used a mechanical lift to transfer Resident #52 to the toilet. The CNA (#6) removed the resident's pants and wet brief, provided incontinence cares, and with the same gloves, the CNA (#6) utilized the mechanical lift to position the resident upright. The CNA (#7) dressed the resident and both CNAs (#6 and #7) transferred the resident to the recliner. The CNA (#7) pulled the lift away, helped remove the torso strap, retrieved the TV remote from a dresser drawer, and offered the resident a drink of water. The CNAs (#6 and #7) failed to remove gloves after completing toileting cares, failed to perform hand hygiene with glove removal, and failed to cleanse the lift before removing the lift from the room. - Observation on 05/19/25 at 4:35 p.m. showed a CNA (#14) assisted Resident #43 with perineal cares after a bowel movement. The CNA (#14) applied gloves, performed perineal care, removed her gloves, applied clean gloves, assisted the resident into her wheelchair and removed her gloves. The CNA (#14) assisted the resident to her room, gave the resident the call light, collected the garbage, and exited the room. The CNA (#14) failed to perform hand hygiene after removing the soiled gloves, before applying clean gloves, and before exiting the resident's room. - Observation on 05/20/25 at 8:24 a.m. showed Resident #49 in bed and two CNAs (#4 and #5) performed perineal care. The CNA (#4) completed the perineal care and without removing the soiled gloves, performing hand hygiene, and applying clean gloves, utilized the mechanical lift and transferred Resident #49 to the toilet. The CNAs (#4 and #5) pulled down the pants and brief, and sat the resident on the toilet. The CNA (#4) completed perineal care, transferred the resident to the wheelchair, offered water, and combed the resident's hair. The CNA (#4) then removed the soiled gloves and performed hand hygiene. - Review of Resident #272's medical record occurred on all days of survey. The care plan stated, . skin integrity r/t [related to] surgical incision . Enhanced Barrier Precautions . Observation on 05/20/25 at 9:35 a.m. showed a nurse (#15) assisted Resident #272 with toileting. The nurse applied gloves and performed perineal care. The nurse (#15) failed to follow EBP guidelines and apply a gown during a high contact care activity of toileting. During an interview on 05/21/25 at 10:45 a.m., an administrative nurse (#16) stated she expected staff to perform hand hygiene after glove changes, before leaving a resident's room, and to follow EBP guidelines.

Based on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.18.11), and staff interview, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 2 of 20 sampled residents (Resident #2 and #75). 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 2023, pages A-30 through A-32, Section A: . Coding Instructions . Code 1, yes: if PASRR Level II screening determined that the resident has a serious mental illness and/or ID [Intellectual Disability] or related condition, and continue to A1510, Level II Preadmission Screening and Resident Review (PASRR) Conditions. - Review of Resident #2's medical record occurred on all days of survey. Diagnoses include mild intellectual disabilities. The annual MDS's reviewed from April 2017, 2018, 2019, and 2021 showed A1500 coded Yes. The annual MDS, dated [DATE], showed staff failed to code yes for A1500. During an interview on 04/03/24 at 11:42 a.m., an administrative staff member (#1) confirmed staff failed to code item A1500 as yes on Resident #2's annual MDS. SECTION K - SWALLOWING/NUTRITIONAL STATUS The Long-Term Care Facility RAI User's Manual, revised October 2023, page K-8, states, . weight should be monitored on a continuing basis; weight gain should be assessed . Code . yes, not on physician-prescribed weight-gain regimen: if the resident has experienced a weight gain of . 10% or more in the last 180 days, and the weight gain was not planned and prescribed by a physician. Review of Resident #75's medical record occurred on all days of survey. The admission MDS, dated [DATE], showed a weight of 168 pounds and the quarterly MDS, dated [DATE], showed a weight of 203 pounds (a weight gain of 20%). The facility failed to code K0310 for a weight gain of greater than 10% on the MDS dated [DATE]. During an interview on 03/19/24 at 12:55 p.m., an administrative staff member (#2) confirmed staff failed to code a weight gain greater than 10% on Resident #75's quarterly MDS. 46964

Based on observation, record review, review of the operations manual for the mechanical lift, and staff interview, the facility failed to provide adequate supervision and/or assistive devices for 2 of 20 sampled residents (Resident #29 and #43) with call lights and 1 of 3 sampled residents (Resident #29) with stand lifts. Failure to ensure proper use of a mechanical sit-to-stand lift and/or proper placement of a call lights placed Resident #29 and #43 at risk for injury. Findings include: Review of facility's Operator's Instructions for the [NAME] 3000 Stand Lift, occurred on 04/04/24. The instructions, dated November 2014, stated, . Have patient place feet on the foot plate and position their shins into the shin pad . position the sling around the patient's lower back . with the resident's arms outside the sling . fasten the support strap securely; the strap should be tight, but comfortable for the patient . carefully push the [NAME] 3000 in closer make full lower leg contact with the knee support . fasten support strap around the patient's legs . the strap should be tight, but comfortable . Encourage the resident to lean forward to enable the sling to be placed around his/her lower back . when raising the resident with a standing lift . the resident's body posture shall go from seated to standing position . - Review of Resident #29's medical record occurred on all days of survey. Diagnoses included dementia, Parkinson's disease, and skin breakdown. A physician's order, dated March 2024, stated, Heel Boots on at all times except with transfers . The current care plan stated, . Transfer: Assist of 1 with sit to stand . Use caution and go slow with transfers and repositioning . Keep call light within reach . Resident has a soft touch call light . Don't leave resident in the room in wheelchair unattended . Keep at nurses' desk for closer monitoring as needed . Observations showed the following: * 04/01/24 at 3:25 p.m., Resident #29 laid in his bed with heel boots on both feet. A certified nurse aide (CNA) (#5) transferred Resident #29 utilizing a sit-to-stand lift. The CNA (#5) positioned Resident #29's feet on the foot plate and failed to remove the heel boots and apply the support strap around the legs. Resident #29 remained in a semi-seated position while the CNA performed the transfer. The harness straps pulled upward into Resident 29's armpits, raising his shoulders to ear level. * 04/02/24 at 8:40 a m., a CNA (#4) exited Resident #29's room. The resident remained alone until 9:25 a.m. (45 minutes). Resident #29 sat in his wheelchair with his back facing the bed and the soft touch call light on the bed and out of reach. The CNA (#4) failed to ensure Resident #29 could reach the call light and left the resident unattended. -Review of Resident #43's medical record occurred on all days of survey. Diagnoses included dementia, a history of falls, and a left tibia fracture. A physician's order, dated March 2024, stated, . left brace needs to be on for transfers . hoyer lift for transfers . The current care plan stated, . Risk for Injury r/t [related to] potential for falls . fracture of left tibia . anticipate and meet needs . be sure call light is within reach and respond promptly to all requests for assistance . Ambulation: non ambulatory . non weight bearing on left lower extremity . Observations showed the following: * 04/02/24 at 3:22 p.m., Resident #43 laid in bed, calling out, Where is my call light? Where is my urinal? They don't give it to me. Observation showed the call light on the opposite end of the room and out of reach. * 04/02/24 at 4:20 p.m., Resident #43 laid in bed, while two CNAs (#6 and #7) provided cares. After completing the cares, the CNAs exited the room, leaving the call light on the dresser and out of reach of the resident. The CNAs (#6 and #7) failed to ensure Resident #43 had access to his call light. During an interview on the morning on 04/04/24, an administrative staff member (#1) indicated she expects staff to provide adequate supervision and assistive devices to ensure residents' safety.

Based on record review, review of professional reference, and staff interview, the facility failed to ensure appropriate infection control standards during insulin administration for 1 of 1 sampled resident (Resident #45) who reported receiving another resident's insulin. Failure to ensure residents do not share insulin pens may result in the spread of bloodborne pathogens. During a survey started on 03/13/23, the team determined a deficiency existed regarding insulin administration and bloodborne pathogens. Based on the review of the results of the survey, the State Survey Agency (SSA) team determined an Immediate Jeopardy (IJ) situation existed, but this was not conveyed to the facility until 03/21/23. The IJ situation resulted from an interview and record review of Resident #45, who used insulin pens and received insulin from another resident's insulin pen. This finding placed Resident #45 in immediate danger due to incorrect insulin pen use and the potential for the spread of bloodborne pathogens between residents. See F760. * 03/21/23 at 12:30 p.m., the SSA notified the CMS location of the IJ and the CMS location agreed. * 03/21/23 at 2:03 p.m., the survey team and a SSA manager called the facility and notified the administrator and director of nursing of the IJ and requested a removal plan be submitted to the SSA. The SSA emailed the IJ template to the administrator of the facility. * 03/21/23 at 6:30 p.m., the SSA received by email and then approved the removal plan from the facility. * 03/22/23 at 3:30 p.m., the survey team removed and reduced the IJ situation from a scope/severity of J to a scope and severity of D. * 03/22/23 at 5:00 p.m., the SSA notified the regional office of the immediate jeopardy removal. Findings include: Review of the manufacturer's guidelines for the Lantus SoloStar Pre-filled pen (a long-acting insulin), found at https://products.sanofi.us/Lantus/Lantus.html#S5.5, stated, . WARNINGS AND PRECAUTIONS . Never share a LANTUS SoloStar Prefilled Pen, Syringe, or Needle Between Patients. Sharing poses a risk for transmission of blood-borne pathogens. Review of Resident #45's medical record occurred on 03/15/23. Diagnoses included Type II diabetes mellitus (DM). Physician's orders included Levemir FlexTouch Solution Pen-injector 30 units subcutaneously daily. Review of an incident report identified the following: *12/04/22 at 7:44p.m.: Administered wrong insulin to resident [Resident #45]. Administered 30 Lantus instead of 30 Levmier [sic] for evening dose. Resident asked to see pen. Writer went back and look [sic] at pen and noticed gave the wrong insulin. Resident asked to see insulin pen for evening dose. She noticed it was gray. Called on-call Doctor. She said do to [sic] nothing. They are both long acting. The facility failed to inform the provider the insulin pen belonged to another resident and the potential for bloodborne pathogen exposure. Information received from the facility on 03/20/23 at 3:30 p.m. identified the insulin pen used for Resident#45 had previously been used for another resident.

Based on record review, review of the facility reported incident investigation, review of facility policy and procedure, review of personnel records, and staff interview, the facility failed to immediately start Cardiopulmonary Resuscitation (CPR) on 1 of 1 closed resident record (Resident #179) who requested CPR in the event of absence of pulse or respirations. Failure to immediately start CPR may have contributed to Resident #179's death. This citation is considered past non-compliance based on review of the corrective action the facility implemented following the incident. Findings include: Review of the facility policy and procedure titled CPR/AED [Cardiopulmonary Resuscitation /Automated External Defibrillator] CODE LEVEL occurred on [DATE]. This policy, revised [DATE], stated, . All licensed nurses of [facility] will be CPR/AED certified. CPR with the use of AED will be initiated as recommended by the American Heart Association (AHA) . The AHA urges all potential rescuers to initiate CPR unless: 1) a valid DNR [do not resuscitate] order is in place, 2) obvious signs of clinical death (e.g. [for example] rigor mortis, decapitation, or decomposition) are present . CPR is to be performed until an AED arrives on the scene . The licensed nurses trained in the use of CPR/AED will do the following . determine unresponsiveness, activate the EMS [Emergency Medical Services] system, follow AHA guidelines for CPR and emergency cardiac care . Review of Resident #179's medical record occurred on [DATE]. A CODE LEVEL FOR CARDIOPULMONARY RESUSCITATION form, signed by Resident #179 on [DATE] and by the resident's physician on [DATE], stated, Indicate the Code Level orders for this patient/resident. (Check one). The resident placed a X mark by CODE LEVEL 1: All available reasonable technology is used in the event of cardiac or respiratory arrest. Review of progress notes identified the following: * [DATE] at 10:45 a.m. Resident's emergency contact was notified that ambulance is in facility and performing live [sic] saving measures on resident. * [DATE] at 11:08 a.m. Resident had no P [pulse], B/P [blood pressure], or respirations . The facility's investigation report dated [DATE] included the following documentation: * . After being notified of resident on the floor. [name of nurse] sought out and found 1 CNA [certified nursing assistant] and stated resident was on the floor and asked if CNA would need help getting resident off the floor. CNA reported yes. Nurse then walked to other side of the building to find TMA [trained medication aide] to help with lift. CNA arrived at the scene of resident first and attempted to arrouse [sic] and get vitals but was unsuccessful. CNA left room where she met TMA coming toward room and stated a nurse was needed and resident is not responding. TMA turned around and reported this to travel nurse. Travel nurse proceeded to pick up phone and called Resident Care Manager and inform that resident was on the floor and was not responding. No indication of emergency was relayed, and no effort was made by the travel nurse to assess resident or begin CPR. Nurse manager arrived on site with travel nurse and immedietly [sic] assessed resident and activated emergency response and travel nurse left the scene and did not return to [sic]. Upon interview with travel nurse, she informed DON [director of nursing] that she couldn't do CPR because she had work restriction from a prior incident of falling at work. No proof or documentation of these restrictions were brought to any one [sic] in the facility. The facility had no knowledge of restrictions. The travel nurse failed to assess resident and failed to initiate CPR when resident was a Code Level 1. Travel nurse contract ended effective immediately. Report sent to NDBON [North Dakota Board of Nursing]. During an interview on [DATE] at 2:21 p.m., an administrative staff member (#1) stated they expected nursing staff to immediately initiate CPR on Resident #179. Review of personnel records on [DATE] identified: * All licensed nurses held current CPR certification, including Nurse #6 (at time of employment). * Nurse #6's orientation in 2021 included code status, AED, and how to reach EMS services. Based on the following information, non-compliance at F678 is considered past non-compliance. The facility implemented corrective actions for the deficient practice by: * Completing an investigation with interviews of staff who were present on [DATE]. * Determining the investigation showed staff failed to follow CPR policy. * Initially suspending (Nurse #6) then terminating the nurse's contract on [DATE]. * Notifying the appropriate state agencies. The facility addressed measures put in place and implemented systemic changes to ensure the deficient practice does not recur by: * Providing education to all nursing staff on the facility's emergency procedure for CPR during a nursing meeting/education on [DATE]. * Informing the Risk Management committee on [DATE] and determining predisposing factors and what will be implemented. The survey team determined a deficient practice existed on [DATE]. The facility implemented corrective action on [DATE] and completed nursing education by [DATE].

Based on observation and staff interview, the facility failed to provide confidentiality of electronic medication administration records (eMAR) for 1 of 4 medication carts observed during survey. Failure to close or lock the eMAR may result in unauthorized viewing of confidential resident records by other residents, unlicensed staff, and visitors. Findings include: Observations on 03/14/23 between 8:15 a.m. to 8:30 a.m. identified an unattended medication cart located in the 300 hallway with the computer screen open, revealing a resident's picture, name, medications and dosages. During an interview on 03/16/23, an administrative nurse (#1) confirmed nursing staff are expected to close or lock the computer screen when medication carts are left unattended.

Based on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.17), and staff interview, the facility failed to ensure the Minimum Data Set (MDS) accurately reflected the residents' status for 1 of 1 sampled resident (Resident #58). Failure to accurately complete Section N (medications) of the MDS, may negatively affect the development of a comprehensive care plan, and the care provided to the residents. Findings include: The Long-Term Care Facility RAI Manual, revised October 2019, page N-7, stated, . N0410H, Opioid: Record the number of days an opioid medication was received by the resident at any time during the 7-day look-back period. Review of Resident #58's medical record occurred on 03/15/23. The current physician's orders lacked an order for an opioid. A quarterly MDS, dated [DATE], identified staff coded section N for opioid use all seven days of the look-back period. During an interview on 03/16/23 at 8:58 a.m., an administrative nurse (#1) confirmed staff coded section N of the MDS incorrectly for Resident #58.

Based on observation, review of professional references, and staff interview, the facility failed to provide assistance and/or assistive devices necessary to ensure safety and prevent accidents or injury for 1 of 9 sampled residents (Resident #40) observed during mechanical sit to stand lift transfers. Failure to transfer residents properly puts the resident at risk for pain, injury, and/or falls. Findings include: Review of the facility policy and procedure document titled Standing lifts occurred on 03/16/23. This document, dated September 2020, stated, . 11. Place the resident's feet on the footplate . 13. Have the resident hold onto the handle grips . 15. Ensure the resident's arms are located outside of the sling . Review of Resident #40's medical record occurred on all days of survey and included a diagnosis of functional quadriplegia and contracture. Observation on 03/14/23 at 10:08 a.m. showed a nurse (#2) and a certified nursing assistant (CNA) (#3) transfer Resident #40 from the wheelchair to the bed and back to the wheelchair with a mechanical sit to stand lift. The resident's feet did not touch the footplate, he/she failed to grasp the handle grips, and he/she arms were on the inside of the sling. During an interview on 03/16/23 at 1:10 p.m., an administrative nurse (#1) stated she expected staff to follow policy and procedure for transfers.

Based on record review, review of professional reference, and resident and staff interview, the facility failed to administer medication in accordance with professional standards for 1 of 1 sampled resident (Resident #45) who reported receiving the wrong type of insulin. Failure to administer the correct insulin may result in adverse health effects for residents. This citation is considered past non-compliance based on review of the corrective action the facility implemented following the incident. Findings include: Berman, Snyder, and Frandsen's Kozier & Erb's Fundamentals of Nursing: Concepts, Process, and Practice, 11th ed., Pearson Education, Inc., New Jersey, page 835-836, stated, . Certain aspects of medication administration are important for the nurse to check each time a medication is administered. These are referred to as the rights. Right Medication . The medication given was the medication ordered . Right Client . Medication is given to the intended client . Review of Resident #45's medical record occurred on March 15, 2023. The quarterly Minimum Data Set (MDS), dated [DATE], identified intact cognition. Physician's orders included Levemir FlexTouch Solution Pen-injector 30 units subcutaneously daily. During an interview on 03/15/23 at 8:05 a.m., Resident #45 identified a nurse (#13) gave the resident Lantus insulin instead of the ordered Levemir 30 units subcutaneously. Resident #45, stated, This happened approximately 6 weeks ago. The nurse didn't notice it, I asked her if I could see the [insulin] pen, and that's when I noticed that the insulin pen was gray colored and my Levemir pen is blue. That is when she realized it. She [the nurse] told me she called the provider and then told me, 'The doctor says that both insulins [the one ordered for resident - Levemir, and the one administered - Lantus] are both long acting, and that nothing needed to be done.' I never heard anything else since then. During an interview on 03/15/23 at 10:30 a.m., an administrative staff member (#1) stated, There was an incident report filed and there was no follow-up monitoring [of Resident #45] required by the staff per the provider orders, as resident remained asymptomatic by her own admission. Review of the facility incident report occurred on 03/15/23, and identified the incident occurred on 12/04/22 at 7:44 p.m. Based on the following information, non-compliance at F760 is considered past non-compliance. The facility addressed measures put in place and implemented the following systemic changes: * Provided education to all nursing staff regarding administering the right insulin to the right resident during the monthly nurses meeting on 02/01/23.

Based on record review and staff interview, the facility failed to provide medically-related social services to meet the needs of 1 of 1 sampled resident (Resident #3) with sexual and wandering behaviors. Failure to adequately assess and monitor behaviors (including sexual, verbal, physical, and eloping behaviors), develop and implement effective interventions, and ensure collaboration with the facility's Interdisciplinary Team (including psychiatry and social services) to effectively and appropriately manage Resident #3's behaviors resulted in multiple episodes of sexual aggression toward other residents, repeated elopements from the special care unit (SCU) and the facility, and multiple episodes of physical aggression. Findings include: Review of Resident #3's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. Current medications included Risperdal (risperidone, an antipsychotic) 0.5 milligrams (mg) twice per day (BID) (initiated 08/23/14) and Xanax (alprazolam, an anxiolytic) 0.25 mg every 4-6 hours as needed (prn) (initiated 01/12/14), and Zoloft (an antidepressant) 25 mg every evening (initiated 09/03/14). The current MDS, dated [DATE], identified severely impaired cognition and "other" behaviors which occurred on 1-3 days of the 7-day look back period. The current care plan stated, ". . . I am an elopement risk/wanderer. I wander aimlessly, at times into other resident's rooms; demonstrate impaired safety awareness; disoriented to place, person and/or time along with a history of attempts to leave facility unattended seeking to exit via the doors and/or windows of the SCU. . . . wandergurad (sic) in place (date initiated 03/07/14) . . . Interventions/Tasks . . . Document wandering behavior and attempted diversional interventions in behavior charting . . . Distract me from wandering by offering pleasant diversions, structured activities, food, conversations, television, book. . . . I have a mood problem r/t (related to) Dementia dx (diagnosis) w/ (with) agitation and anxiety- wander and have tried to leave even when at home. I am an Elopement Risk and can be invasive into others rooms which puts me at risk. I can make sexual comments/touch others. I can be verbal (scream, swear) and/or have the potential to strike at others or staff. I have been resistive to staff assistance. I can undress in public areas. . . . Interventions/Tasks . . . 15 minute checks . . . Administer medications as ordered. . . . Provide diversional activities, such as: toilet, walk, snack, blocks, puzzles, reading. . . . Reapproach . . . Provide distraction and redirection . . ." An interview with a staff nurse (#24) occurred on 11/17/14 at 11:40 a.m. During the interview, the nurse identified Resident #3 eloped multiple times from the special care unit (SCU). The nurse stated the certified nursing assistants (CNAs) hear the door alarming, but they are often busy in a resident's room and cannot answer the alarm right away. A confidential interview occurred during the survey with two CNAs. One CNA stated, "It's tough, we could definitely use another person back here (in the SCU)." The other CNA agreed and stated, "Most of our time is spent trying to keep (Resident #3) in (the SCU)." Refer to F353. Nurses' notes identified the following sexually inappropriate behaviors: *11/20/13 at 6:53 p.m.: ". . . Resident found leaning over a chair in room (number). (Resident F) sitting in the chair. Resident had his pants unzipped and penis exposed. No physical contact noted. . . ." *01/16/14 at 2:19 p.m.: ". . . Res. (resident) was sitting on (Resident G) bed with her, then res. stood and began unzipping his pants in front of her. CNA redirected residents and brought them out of the room. . . ." *01/21/14 at 7:45 p.m.: ". . . Nurse came to SCU to obtain report from previous shift. CNA immediately informed me that resident was being inappropriate and he had taken his pants off in the living room. They also state that it was noted he had grabbed the hand of (Resident G) and tried to put her hand in his underwear. This act was stopped. Removed (Resident G) from area as (Resident #3) is upset and at times swatting his arms around. Staff attempted to convince resident to put his pants back on. He took them and threw them on the chair next to him, and is very upset. He is swearing at staff as well. . . ." *01/28/14 at 5:37 p.m.: ". . . This nurse was called to the SCU at 1700 (5:00 p.m.) with a concern from the CMA (certified medication aide) on duty about an incident that occurred between (Resident #3) and (Resident G). When I got to the unit I was told that one of the CNAs (certified nursing assistants) had walked into (Resident G) room and found (Resident G) on her bed with only a shirt on and (Resident #3) on top of her with no clothes on. . . ." *01/28/14 at 9:28 p.m.: ". . . (provider name) faxed at this time an update of the incident with (Resident G). This is the second time in one week that an incident has occurred between these two residents. . . . Resident's family very concerned about what they say are more frequent inappropriate and sometimes sexual behaviors. Spouse is upset that these keep happening, she state (sic) she feels that (Resident #3) is not being monitored properly. Reassured her that we are taking care of him well, and that sometimes he is quick to get out of our site. She was appreciative of the information, just stated she was concerned and worried. . . ." *02/04/14 at 3:26 p.m.: ". . . CNA went into room (number) to check on resident and found (Resident #3) sitting in a chair with his pants down and (Resident G) was also standing with her pants down around her ankles and leaning over resident. Staff separated them without difficulty. . . ." *02/04/14 at 9:42 p.m.: ". . . at 2050 (8:50 p.m.) CNA noted she had not seen (Resident #3) in a few minutes so she search (sic) in rooms. She found him in SCU room (number) with female resident (Resident G). (Resident #3) had only a shirt and incontinent product one (sic), no pants. (Resident G) was fully clothed. They were hugging closely and swaying back and forth. Resident's (sic) separated, (Resident #3) assiste (sic) to put clothes back on. . . ." *02/07/14 at 1:45 p.m.: ". . . Resident has been pleasant and cooperative. After lunch, sitting near (Resident G) and holding her hand. . . ." During an interview on the afternoon of 11/19/14, a licensed social worker (#29) stated the facility staff moved the female resident to a different room after the above incidents, although she could not remember exactly when the staff made the room change. Nurses' notes identified the following successful elopements from the SCU: *11/19/13 at 6:26 p.m.: ". . . Resident followed staff member out of the SCU unnoticed at 4:40 pm, he went to the front desk area and attempted to leave through the front doors. Was stopped from going outside with some resistence (sic). Redirected back to the SCU with TLC (tender loving care). Noted resident received a 0.7 cm (centimeter) skin tear to (L) (left) forearm during this time, possibly from when he went out the SCU door. . . ." *03/13/14 at 1:32 p.m.: ". . . Talked with spouse at 9:25 a.m. (Resident #3) had eloped from the unit at 9:05 a.m. and was found out of rear parking lot. Discussed the use of wanderguard with her and she stated he would not wear one and that she was doubtful that we would get one on him. . . ." *07/08/14 at 11:38 a.m.: ". . . Resident had an elopement attempt at 1115 Am. He got out the back door in SCU by room SCU-11. Walked around parking lot for several minutes stating 'I need to find my car. I am tired of this (expletive).' . . ." *08/10/14 at 2:05 p.m.: ". . . Elopment (sic) attempt - Resident had not had any attempts to open any SCU doors until after lunch. At approx (approximately) 1215, he was able to open the main SCU door by holding the bar long enough. Staff heard door alarm and wanderguard alarm going off and immediately came to assess situation. Nurse noted resident shadow outside of main SCU door, and ran out door to redirect resident. . . ." *08/19/14 at 9:25 a.m.: ". . . Resident had an elopement from SCU at 0845 (8:45 a.m.). Got out main SCU door, unable to be redirected by staff, would become agitated with redirection attempts. Walked from SCU door to offices near front reception desk. . . ." *08/19/14 at 5:47 p.m.: ". . . Resident had an elopment (sic) at 1645 (4:45 p.m.). He got out the main SCU dooor (sic) and walked to the area near the front reception desk. . . . It took several staff but he eventually did redirect back to SCU with multiple staff, though he was very upset. After returning to SCU he continuously was near the SCU door, setting off the alarm, and trying to get out. . . . He was able to get out again at 1730 (5:30 p.m.). Difficult to redirect, though was able to redirect him back to SCU. . . ." *08/31/14 at 1:00 p.m.: ". . . Resident's son had been up visiting for about an hour. After he left, resident wanted to go with them and was trying to get out again. At this time, I heard the alarm sound but all the staff were tied up with another resident so couldn't get to the door within the 15 sec. (seconds). As I got to the door, resident was outside and walking down the hall. . . ." *09/02/14 at 10:45 a.m.: ". . . Resident held door open until safety lock opened and went out back door of facility. Caught by (staff name) therapy, she talked him into coming back into the unit . . ." *10/11/14 at 7:21 p.m.: ". . . When resident pushed long enough on the door and was able to elope out into the hallway the other side of the unit door. Myself and another staff tried to redirect him when he postured and threatened to hit us '(expletive).' . . ." *10/19/14 at 3:50 p.m.: ". . . Resident absolutely unable to be redirected after his wife left this afternoon. . . . Resident kept pushing on door and setting alarm. He was becoming violent and pushing at staff. . . . Resident pushed on door until it opened and he was in back employee hallway. 2 CNA's and 2 kitchen staff came to assist nurse in administering 0.5 ml (1 mg) of lorazepam IM. . . ." Nurses' notes identified the following physically/verbally aggressive behaviors and exit-seeking/attempted elopements: *11/22/13 at 8:20 a.m.: ". . . Resident has been pushing on SCU door this a.m. and trying to 'get out'. . ." *12/05/14 at 1:56 p.m.: ". . . Resident is agitated, pacing around SCU. He is trying doors. Says he is 'leaving today ... going to Fargo and Gr (Grand) Forks.' . . ." *01/10/14 at 7:37 p.m.: ". . . Resident has been difficult to redirect this evening. He has been wanting to get out of the SCU and all staff interventions to promote comfort or distraction failed. Resident was aggressively pushing tables around and lifting up chairs and pushing them across table top. . . ." *01/12/14 at 1:32 p.m.: ". . . Resident has been trying to get out of SCU before and after lunchtime. Resident escalated after wife came to visit. She left after about 10 minutes due to his behavior. He was shoving chairs around and threatening to shove them through the wall. . . ." *01/12/14 at 6:00 p.m.: ". . . Resident has been extremely difficult to redirect. Resident ate supper and has been standing by SCU door pushing on it since 1800 (6:00 p.m.). He keeps stating that he needs to get out of here and is being very vulgar towards nurse and other residents. He is escalating into violent arm swinging. . . ." *02/23/14 at 4:00 p.m.: ". . . anxious, wants to leave . . ." *02/26/14 at 2:16 p.m.: ". . . Resident has been very restless since about 1230, walking back and forth and continually pushing on alarmed door to get out. Upset that they have in (sic) 'locked' in here and states the 'boss' is worthless and calling him swear words and (sic) well as saying he's going to hit him along side the head when he sees him. . . ." *03/07/14 at 6:42 a.m.: ". . . Resident's windows in SCU (room number) were both unlatched and letting in cold air. It was discovered that a brush had been thrown in the snowbank and a toothbrush was wedged in the window casing. Resident has a suitcase packed in his room. . . ." *03/08/14 at 7:04 p.m.: ". . . Resident has been anxious to get out since 1500 (3:00 p.m.) and was continuously redirected by nurses and CNA's. . . . Resident would not leave the exit door area and his agitation was escalating. . . ." *03/10/14 at 1:00 a.m.: ". . . This RN (registered nurse) called to special care unit as resident upset/anxious per LPN (licensed practical nurse). Resident peeing on door and floor, resident incontinent and had urine running down his pant leg. Resident swinging arms and attempting and threatening to hit this RN and other nursing staff. Resident charging at this RN as well. This RN attempted to find out why resident was upset and resident stated, '(expletive) you.' Resident would not take oral PRN (as needed) for agitation. This RN tried to offer multiple different distraction to resident and resident refused all attempts to redirect and continued with violent behaviors, threats, pounding, and kicking on walls and doors, and peeing on floor and self. This RN concerned about resident's safety and well being, staff safety and other residents confined in SCU. All attempts made to calm resident and not effective. (on-call physician) notified via phone and orders received for 5 mg IM Lorazepam (Ativan, an anxiolytic) and may repeat dose in one hour. (on-call physician) stated that if not effective resident would have to be transferred. . . ." *03/10/14 at 1:21 p.m.: ". . . Received orders from (primary doctor) to increase risperidone to 0.25 mg BID and in 10 days increase to 0.5 mg by mouth every AM and stay on 0.25 mg PM . . ." *03/22/14 at 7:41 p.m.: ". . . resident restless and upset. he is continuously trying to open locked doors and becomes upset with redirection. . . ." *04/16/14 at 6:48 p.m.: ". . . angry at wife after visit. standing by door tu (sic) get out. . . ." *04/22/14 at 10:53 a.m.: ". . . Made remark x 2 this a.m. that he was going to get a gun and 'shoot everyone.' . . ." *04/24/14 at 4:08 p.m.: ". . . resident at door constantly, unable to redirect. . . ." *04/30/14 at 12:16 p.m.: ". . . attempting to open doors, refused coffee, walk, reading newspaper, continues to pace. got window partially open in another room. . . ." *04/30/14 at 3:57 p.m.: ". . . resident attempting to leave, yelping, demanding to go home for supper. . . ." *04/30/14 at 6:36 p.m.: ". . . Resident anxious nd (sic) restless continues to qttempt (sic) to open door to scu. . . ." *05/02/14 at 7:23 p.m.: ". . . Resident pushed window open in SCU (room number) and threw pants and brief outside. Window had to be pushed from outside to lock again. . . ." *05/04/14 at 6:58 p.m.: ". . . Resident threw mirror and razor out the window in SCU (room number). . . ." *05/09/14 at 8:16 p.m.: ". . . kicking at staff. Trying to get out the doors. Setting off alarms. Wanting to go with the wife and combine. . . ." *05/09/14 at 9:45 p.m.: ". . . Continues to challenge the doors of the SCU. States he is going to get a gun and shoot the cops. . . ." *05/17/14 at 5:20 a.m.: ". . . This nurse was called to SCU by CNAs at about 0430 (4:30 a.m.) due to (Resident #3) being very agitated and talking about leaving. He was walking to the door and pushing it and setting off the alarm frequently. He was difficult to redirect. . . ." *05/20/14 at 2:42 a.m.: ". . . CNA's calling ststing (sic) that (Resident #3) was standing by the door to the unit trying numbers. When there to assess he was swearing, wanting to leave, stating the he needed to go to the bar and how the last time he went, he was the only one there. . . ." *05/20/14 at 2:37 p.m.: ". . . Resident wondering (sic) to doors and wanting to go out. 'I'll throw a chair through the window.' Unable to redirect. . . ." *05/20/14 at 4:20 p.m.: ". . . Continues to say he's going home. Going in to different rooms and trying to open windows. . . ." *05/20/14 at 6:37 p.m.: ". . . Resident continues to wander around and talk about going home. Tries to open windows in other resident's rooms. Did get window open a crack and threw his shirt and one shoe out. . . ." *05/25/14 at 1:50 p.m.: ". . . Resident has been wanting to leave since he got up this morning. Took all of his clothes out of the closet, and his fans, and moved them into small lounge because he was 'waiting for that door to get unlocked so I can go home.' . . ." *06/02/14 at 6:31 p.m.: ". . . Since 5 p.m., resident has been trying to open windows and doors. Swearing and wanting to leave. . . ." *06/11/14 at 6:04 p.m.: ". . . Resident up and about in hall and pushing residents by door, several attempts to get out. Says it is raining and he needs to go he was supposed to leave hours ago. Difficult to redirect. Much inappropriate verbal usage. . . ." *06/17/14 at 3:24 a.m. ". . . Res thinking he has to leave for something related to selling his car. Several attempts to go out the unit door between 7 pm & 8:30 pm. Staff directed res' attention away from door. Late entry for 06/16/14 8:30 pm. . . ." *06/27/14 at 11:01 a.m.: ". . . Patient was very anxious waiting at door to leave and would not leave door. When this nurse redirected him to go sit down in the chair he grabbed hand and squeezed tightly and started swearing. . . ." *07/25/14 at 8:17 a.m.: ". . . This am patient came out of room and went to the front exit and started kicking at door and slamming body against it trying to get out. During this time he was yelling he wanted to '(expletive) get out of here' he was talking about that he doesn't want to buy fish or eat fish, but there was no fish being served. . . ." *08/02/14 at 12:07 p.m.: ". . . Resident has been attempting to leave unit several times during morning. . . . Resident pushing on door with alarm during lunchtime. Unable to redirect. Resident swearing and threatening to throw his hot coffee at CNA and nurse. . . ." *08/03/14 at 11:44 p.m.: ". . . Earlier in the evening about 7:45 pm resident tried getting out door of unit, setting off alarm. . . ." *08/09/14 at 9:24 a.m.: ". . . continuous exit seeking, increase in agitation, threatening to 'hit the door with a hammer.' . . ." *08/19/14 at 9:24 a.m.: ". . . increased anxiety and agitation. had an elopment (sic) and has been trying to elope several times since being redirected to SCU. . . ." *08/19/14 at 6:41 p.m.: ". . . Resident continuous with another elopment (sic), and in increasingly agitated and combative, has attempted to hit staff many times. Order obtained from (provider name) for 1 mg ativan IM q2h (every 2 hours) prn up to 3 mg total for agitation (for the night of 8-19-14 only). . . ." *08/23/14 at 3:38 p.m.: ". . . Resident has been increasingly anxious and continuously exit seeking over the last hour. Nearly impossible to redirect, swears at staff and spouse when they talk to him. He is very agitated at times. Called a male staff from another wing over to see if that would help resident as he does at times responds (sic) better to male redirection. . . . (Resident #3's wife) agreeable to inquiring if it is appropriate for resident to be started on a scheduled dose of xanax or ativan. . . ." *08/25/14 at 4:19 p.m.: ". . . Has been walking almost constantly this afternoon. In other rooms, attempting to push windows open. . . ." *08/29/14 at 10:33 a.m.: ". . . Resident has been agitated all morning, attempting to get out both door and windows in residents rooms, difficult to redirect. . . ." *08/30/14 at 11:16 a.m.: ". . . Resident has been restless all morning with increased anxiety as the shift progresses. . . . Standing at the door and pushing on the handle at times, continually asking me to open the door and calls me a liar when I say I can't. . . ." *08/31/14 at 8:00 a.m.: ". . . As soon as resident was done eating, he started pushing on the door and stating he had to leave. Would push on handle until alarm would sound so staff would have to go intervene. . . ." *08/31/14 at 12:41 p.m.: ". . . Resident still restless and anxious, wanting to leave and 'get out to the farm.' . . . The last time he was at the door he was leaning against the handle so the alarm couldn't be shut of (sic) and when I told him to move away he hit me with his elbow. I asked him not to hit me and he states 'I just shoved you.' . . ." *08/31/14 at 12:45 p.m.: ". . . I have spoken with resident's wife several times over the past two days and she is aware of his anxiety/agitation. Still thinks he should be on something scheduled to even out his moods. . . ." *08/31/14 7:05 p.m.: ". . . Resident has required direct 1-1 supervision due to standing at door and trying to get out. He will hold the lever in until it opens and then get angry when we won't let him out. Struck a nurse for the second time today . . ." *09/02/14 at 4:21 p.m.: ". . . Fax from (physician name) states 'Increase risperidone to 0.5 mg BID starting tonight.' . . ." *09/16/14 at 6:09 p.m.: ". . . multiple attempts to walk out door angry with staff. . . ." *09/22/14 at 5:20 p.m.: ". . . Resident was able to open exit door by leaning on bar. Went a few steps out of the SCU. . . ." *09/28/14 at 12:00 p.m.: ". . . resident is now angry trying to get out the door, swearing at staff . . ." *10/02/14 at 3:45 p.m.: ". . . Resident has been requiring prn xanax for increased behaviors. Wife states that he gets mean and verbaly (sic) abusive when she visits. She requests meds (medications) be increased. Fax sent to (physician) requesting increase in Risperdal dose. . . ." *10/03/14 at 4:00 p.m.: ". . . swearing. exit seeking. . . ." *10/05/14 at 8:37 a.m.: ". . . resident wanting to leave, pushing on door, unalbe (sic) to redirect for any length of time . . ." *10/06/14 at 2:44 p.m.: ". . . (physician) re-faxed re: (regarding) behaviors and question if Risperdal dose can be increased. . . ." *10/06/14 at 4:04 p.m.: ". . . Wanting to leave after wife visited. Pushing on window in his room. Exit seeking. . . ." *10/08/14 at 2:09 p.m.: ". . . Call placed to Primary Physicians nurse to request response to 2 faxes for increase in medication for resident. . . ." *10/09/14 at 8:46 p.m.: ". . . res is consistently trying to leave the unit, agitated . . ." *10/10/14 at 7:23 a.m.: ". . . Res was constantly trying to open the door until he was able to open it and leave the unit. A cna was constantly with him and 2 cna were necessary to redirect him to (sic) back to the unit. . . ." *10/10/14 at 7:26 a.m.: ". . . Res has two cuts on left forearm. Res left the unit after been (sic) pushing the entrance door. After Cnas brought res back to the unit they found blood on their clothe (sic). These are small cuts 1 x 0.5 cms (centimeters) that occurred while pushing the door to exit the Unit. . . ." *10/10/14 at 9:15 a.m.: ". . . Received (sic) fax from residents PCP (primary care provider) ordering a psych (psychological) consult. Appointment scheduled with (psychologist name) . . ." *10/20/14 at 4:27 a.m.: ". . . Pacing, pushing on doors, yelling. . . ." *10/21/14 at 10:46 a.m.: ". . . Received fax from (PCP) responding to behaviors and frequent elopement attempts on 10-19-14. He would like resident to be seen by psych for med management. Resident was seen by (psychologist) on 10-14-14. No reports or recommendations received (sic) yet. Fax was sent to (psychologist) last evening requesting recommendations. . . ." *10/21/14 at 5:30 p.m.: ". . . Received (sic) call from (psych doctor). He will be visiting with (PCP) in the morning re: resident's psych eval. (evaluation). Dementia is too advanced to benefit from a therapist. Need psychiatry to manage meds. . . ." *10/23/14 at 3:24 p.m.: ". . . Author was caring for another resident, heard alarm, resident had pushed on door and was just exiting as I reached area. . . ." *10/23/14 at 3:59 p.m.: ". . . rounds made by (PCP). He will be in contact with (psych doctor) and check about possible changes with his medication regimen. . . ." *10/25/14 at 12:50 p.m.: ". . . resident held alarmed door handle until it opened up and resident wondered (sic) out into hall. . . ." *10/25/14 at 5:19 p.m.: ". . . resident going into other residents rooms and trying to open the windows. . . ." *10/26/14 4:16 p.m.: ". . . unable to redirect. hitting out. pushed on door, out in hallway. brought back. . . ." *10/26/14 at 4:20 p.m.: ". . . Pushed on door and went out. . . . Hard to redirect, brought back in to unit. Threatening. . . ." *10/28/14 at 12:52 p.m.: ". . . After lunch resident kept going to the door and setting off the alarm, stating he needed to go home because his wife and kids were waiting for him. . . ." *10/28/14 at 1:47 p.m.: ". . . Resident stood at the door and held the handle in so it would open. Staff were tied up with other resident's and by the time we get to him, he was outside the door. Resident sat in the chair at the table outside and refused to come back in. . . ." *10/28/14 at 2:59 p.m.: ". . . Resident was trying to get out the front door again (sic), holding the handle down so the door would open. CNA was unable to get him to let go off (sic) the door so I intervened. Resident hit me in the chest with his hand and swore at me. Resident was able to get out of the door and was trying to go out the door to the outside. CNA was trying to stop him from getting out and I saw the administrator so called him over to help. Administrator was not able to convince resident to come back inside so we went and found resident's nephew, who is a worker here, and he was able to get resident to come back inside. . . . After nephew left, I gave resident IM Alprazolam (sic, Ativan) . . ." *10/28/14 at 6:22 p.m.: ". . . Received a fax from (PCP) with order for Doxepin (an antidepressant) 10 mg po bid. . . ." *10/29/14 at 3:43 p.m.: ". . . 1st dose of Doxepin given at 9 am when medication arrived. Has been groggy all day but had prn medication x 3 yesterday so unable to determine if any effects from new medication. . . ." *10/30/14 at 5:27 p.m.: ". . . Woke up after spouse left, ate all of supper and then became very aggitated (sic). Pushed on exit door, out into hallway, threatened to hit me, yelling, and swearing. . . ." *10/31/14 at 9:27 a.m.: ". . . Unable to awaken resident for morning medications. . . . cannot awaken for meal at this time. . . ." *10/31/14 at 10:11 a.m.: ". . . Call back from primary physician. Order to dc (discontinue) Doxepin and to hold insulin this am . . ." *11/03/14 at 2:56 p.m.: ". . . Resident attempting to leave SCU, swearing and hitting at the staff. . . ." *11/10/14 at 2:36 p.m.: ". . . Faxed (PCP) re: possibly increasing Zoloft (an antidepressant) dose. Was started on 25 mg po daily on 9/3/14. Resident's wife feels he is still depressed. He does continue to express feelings of sadness and lonliness (sic) at times. . . ." *11/11/14 at 7:03 p.m.: ". . . increase (sic) agitation and attempts at getting off unit . . ." *11/12/14 at 2:16 p.m.: ". . . Resident agitated, attempting to leave . . ." *11/15/14 at 10:26 p.m.: ". . . Resident last few nights has been getting up during night, getting dressed and trying to get out doors. At times, CNA's might be in room then hear door alarm going off from Resident trying to get out. . . ." *11/16/14 at 9:49 a.m.: ". . . Res. crying to this nurse saying that his is going to die today on and off for about 30 mins . . ." *11/18/14 at 9:10 p.m.: ". . . increase (sic) restlessness, attempts to leave unit . . ." *11/19/14 at 10:39 a.m.: ". . . res trying to get out, threating (sic) to kill everyone here . . ." Review of Resident #3's medical record identified staff administered IM Ativan on 10/19/14 and 10/28/14 without a valid physician's orders [REDACTED]. Social services progress notes identified the following:*01/06/14 at 4:29 p.m.: ". . . Initiated (Resident #3) Annual assessment today. . . . He also noted that 2-6 days in the last 2 weeks he has had thoughts that he would be better off dead. . . . The unit manager was notified. There are no other concerns at this time. . . ." *01/16/14 at 5:21 p.m.: ". . . (Resident #3) had a Care Conference today. . . ." *02/12/14 at 11:38 a.m.: ". . . Per the Interdisciplinary Team of Eventide via Nursing, Activities, and Social Services, it is deemed in (Resident #3) best interest to continue placement in the 'Special Care Unit' of Eventide due to his exit seeking behavior. . . ." *02/12/14 at 9:58 p.m.: ". . . (Resident #3's wife) appreciated the update per this Worker providing Social Services to the residents and/or families of the SCU along with wanting to confirm her support of (Resident #3) continual placement in the Special Care Unit commenting 'it wouldn't be safe for him anywhere else right now because he's always wanting to go or get out of there; with the cold weather, it just isn't safe.' . . ." *07/11/14 at 2:14 p.m.: ". . . Care Conference was held . . . Placement on the Special Care Unit continues to be in (Resident #3) best interest due to the continual elopement attempts and/or exit seeking behaviors. . . ." *10/15/14 at 5:25 p.m.: ". . . Care Conference was held . . . (Resident #3) has made and/or experienced elopements per the SCU with the overall plan to potential (sic) reassess meds along with anticipation of (Resident #3) overall needs. . . ." *10/15/14 at 5:44 p.m.: ". . . (Resident #3's wife) met briefly with this Social Worker after the Conference reiterating the concern of (Resident #3), at times gets demanding and/or verbally aggressive per the request for (wife) to take him home. . . ." The record lacked evidence of social services involvement except for quarterly care conference/progress notes. The record lacked evidence of assessment, monitoring, and/or intervention evaluation by social services regarding Resident #3's continued behaviors. When asked to provide further evidence of social services involvement in the management of Resident #3's behaviors, the facility provided no additional information. physician progress notes [REDACTED]. *12/04/13: ". . . He also struggles with some anxiety and irritability. In fact, the nursing staff informed me he has had several more 'elopements' where he sneaks out of the special care unit. Sometimes, he will pull a chair up next to the exit door and just wait for a visitor to leave, so he can sneak out. They have noticed that there seems to be a pattern as to what time of the day this occurs. It seems to happen when he is a little more irritable and anxious. According to the nursing staff, his wife is requesting that we restart him on alprazolam during these times because it helped in the past. . . . PLAN: . . . We are going to start scheduling alprazolam. Please see orders. . . ." Review of the medical record showed staff did not receive an order for [REDACTED].#16) stated staff did not start Resident #3 on a scheduled dose of alprazolam, and failed to follow up on the physician's recommendation. *01/09/14: ". . . Lately, there has been problems with his anxiety and then agitated behavior. He also has been acting inappropriately by making sexual gestures towards some of the female residents. Last visit, I started him on scheduled alprazolam as a trial. Staff felt that maybe some of his behavior was related to times when he was anxious or maybe even a little confused and, therefore, almost paranoid. They have noticed some improvement and feel we should give it a little bit longer trial. . . . PLAN: . . . I am going to keep him on the same medications. We will give this alprazolam a little bit longer trial. . . ." Record review identified Resident #3's medication regimen did not include scheduled alprazolam. *04/02/14: ". . . His main concern lately has been inappropriate behavior. He has had several elopements from the special care unit. At times he has been a little combative. Last visit I started him on low-dose Risperdal in the morning (0.25 mg every morning initiated 02/05/14). Staff states that he has not had as much aggressive or inappropriate behavior. However, because of his dementia, he can be very time consuming. . . ." Faxes to the physician identified the following: *08/28/14: ". . . The wife was wondering if Resident could have Xanax (alprazolam) 0.25 mg PO (by mouth) scheduled twice a day. H

ELOPEMENT 1. Based on observation, record review, review of facility policy, and staff interview, the facility failed to ensure the safety of 3 of 3 sampled residents (Resident #3, #13, and #14) who wandered and exited the Special Care Unit (SCU) and/or the facility. Failure to ensure and maintain resident safety by providing adequate supervision, implementing effective interventions (a functioning wanderguard system, 15 minute checks, changes to the security code, etc.), and monitoring/reevaluating the interventions resulted in Resident #3, Resident #13, and Resident #14 eloping from the SCU and/or the facility on multiple occasions, including Resident #13 eloping a block and a half away without staff knowledge. Findings include: Review of the facility policy titled "Missing Residents" occurred on 11/20/14. This policy, dated May 2013, stated, "Policy: Eventide will assure the health, safety and welfare of all residents who are placed in our care. If a resident is missing, a search will be conducted. . . ." - Review of Resident #3's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. Current medications included Risperdal (risperidone, an antipsychotic) 0.5 milligrams (mg) twice per day (BID) (initiated 08/23/14) and Xanax (alprazolam, an anxiolytic) 0.25 mg every 4-6 hours as needed (prn), and Zoloft (an antidepressant) 25 mg every evening (initiated 09/03/14). The current MDS, dated [DATE], identified severely impaired cognition, and "other" behaviors and wandering occurring on 1-3 days of the 7-day look back period. The current care plan stated, ". . . I am an elopement risk/wanderer. I wander aimlessly, at times into other resident's rooms; demonstrate impaired safety awareness; disoriented to place, person and/or time along with a history of attempts to leave facility unattended seeking to exit via the doors and/or windows of the SCU. . . . wandergurad (sic) in place . . . Interventions/Tasks . . . Document wandering behavior and attempted diversional interventions in behavior charting . . . Distract me from wandering by offering pleasant diversions, structured activities, food, conversations, television, book. . . . Identify pattern of wandering by assessing if my wandering is purposeful, aimless or escaping and/or am I looking for something or someone. . . . refuses to wear the wanderguard at times, rips it off. Wanderguard placed on res. (resident) belt loop as he allows . . ." An interview with a staff nurse (#24) occurred on 11/17/14 at 11:40 a.m. During the interview, the nurse identified Resident #3 eloped multiple times from the SCU. The nurse stated the certified nursing assistants (CNAs) hear the door alarming, but they are often busy in a resident's room and cannot answer the alarm right away. A confidential interview occurred during the survey with two CNAs. One CNA stated, "It's tough, we could definitely use another person back here (in the SCU)." The other CNA agreed and stated, "Most of our time is spent trying to keep (Resident #3) in (the SCU)." Refer to F353. A physician's order, dated 03/14/14, stated, "Put wanderguard on back loop of jeans in the am, whenever he gets dressed, remove from jeans when he undresses and place in med (medication) cart." Nurses' notes identified the following: *11/19/13 at 6:26 p.m.: ". . . Resident followed staff member out of the SCU unnoticed at 4:40 pm, he went to the front desk area and attempted to leave through the front doors. Was stopped from going outside with some resistence (sic). Redirected back to the SCU with TLC (tender loving care). Noted resident received a 0.7 cm (centimeter) skin tear to (L) (left) forearm during this time, possibly from when he went out the SCU door. . . ." *03/07/14 at 6:42 a.m.: ". . . Resident's windows in SCU (room number) were both unlatched and letting in cold air. It was discovered that a brush had been thrown in the snowbank and a toothbrush was wedged in the window casing. Resident has a suitcase packed in his room. . . ." *03/13/14 at 1:32 p.m.: ". . . Talked with spouse at 9:25 a.m. (Resident #3) had eloped from the unit at 9:05 a.m. and was found out of rear parking lot. Discussed the use of wanderguard with her and she stated he would not wear one and that she was doubtful that we would get one on him. . . ." *05/02/14 at 7:23 p.m.: ". . . Resident pushed window open in SCU (room number) and threw pants and brief outside. Window had to be pushed from outside to lock again. . . ." *05/04/14 at 6:58 p.m.: ". . . Resident threw mirror and razor out the window in SCU (room number). . . ." *05/17/14 at 5:20 a.m.: ". . . This nurse was called to SCU by CNAs at about 0430 (4:30 a.m.) due to (Resident #3) being very agitated and talking about leaving. He was walking to the door and pushing it and setting off the alarm frequently. He was difficult to redirect. . . ." *05/20/14 at 2:42 a.m.: ". . . CNA's calling ststing (sic) that (Resident #3) was standing by the door to the unit trying numbers. When there to assess he was swearing, wanting to leave, stating the he needed to go to the bar and how the last time he went, he was the only one there. . . ." *05/20/14 at 6:37 p.m.: ". . . Resident continues to wander around and talk about going home. Tries to open windows in other resident's rooms. Did get window open a crack and threw his shirt and one shoe out. . . ." *06/17/14 at 3:24 a.m. ". . . Res thinking he has to leave for something related to selling his car. Several attempts to go out the unit door between 7 pm & 8:30 pm. Staff directed res' attention away from door. Late entry for 06/16/14 8:30 pm. . . ." *07/08/14 at 11:38 a.m.: ". . . Resident had an elopement attempt at 1115 Am (11:15 a.m.). He got out the back door in SCU by room SCU-11. Walked around parking lot for several minutes stating 'I need to find my car. I am tired of this (expletive).' . . ." *08/10/14 at 2:05 p.m.: ". . . Elopment (sic) attempt - Resident had not had any attempts to open any SCU doors until after lunch. At approx (approximately) 1215 (12:15p.m.), he was able to open the main SCU door by holding the bar long enough. Staff heard door alarm and wanderguard alarm going off and immediately came to assess situation. Nurse noted resident shadow outside of main SCU door, and ran out door to redirect resident. . . ." *08/19/14 at 9:25 a.m.: ". . . Resident had an elopement from SCU at 0845 (8:45 a.m.). Got out main SCU door, unable to be redirected by staff, would become agitated with redirection attempts. Walked from SCU door to offices near front reception desk. . . ." *08/19/14 at 5:47 p.m.: ". . . Resident had an elopment (sic) at 1645 (4:45 p.m.). He got out the main SCU dooor (sic) and walked to the area near the front reception desk. . . . It took several staff but he eventually did redirect back to SCU with multiple staff, though he was very upset. After returning to SCU he continuously was near the SCU door, setting off the alarm, and trying to get out. . . . He was able to get out again at 1730 (5:30 p.m.). Difficult to redirect, though was able to redirect him back to SCU. . . ." *08/31/14 at 1:00 p.m.: ". . . Resident's son had been up visiting for about an hour. After he left, resident wanted to go with them and was trying to get out again. At this time, I heard the alarm sound but all the staff were tied up with another resident so couldn't get to the door within the 15 sec. (seconds). As I got to the door, resident was outside and walking down the hall. . . ." *09/02/14 at 10:45 a.m.: ". . . Resident held door open until safety lock opened and went out back door of facility. Caught by (staff name) (from) therapy, she talked him into coming back into the unit . . ." *09/22/14 at 5:20 p.m.: ". . . Resident was able to open exit door by leaning on bar. Went a few steps out of the SCU. . . ." *10/10/14 at 7:23 a.m.: ". . . Res was constantly trying to open the door until he was able to open it and leave the unit. A cna was constantly with him and 2 cna (sic) were necessary to redirect him to (sic) back to the unit. . . ." *10/10/14 at 7:26 a.m.: ". . . Res has two cuts on left forearm. Res left the unit after been (sic) pushing the entrance door. After Cnas brought res back to the unit they found blood on their clothe (sic). These are small cuts 1 x 0.5 cms (centimeters) that occurred while pushing the door to exit the Unit. . . ." *10/11/14 at 7:21 p.m.: ". . . When resident pushed long enough on the door and was able to elope out into the hallway the other side of the unit door. Myself and another staff tried to redirect him when he postured and threatened to hit us '(expletive).' . . ." *10/19/14 at 3:50 p.m.: ". . . Resident absolutely unable to be redirected after his wife left this afternoon. . . . Resident kept pushing on door and setting alarm. He was becoming violent and pushing at staff. . . . Resident pushed on door until it opened and he was in back employee hallway. 2 CNA's and 2 kitchen staff came to assist nurse in administering 0.5 ml (1 mg) of lorazepam IM. . . ." *10/25/14 at 12:50 p.m.: ". . . resident held alarmed door handle until it opened up and resident wondered (sic) out into hall. . . ." *10/26/14 at 4:16 p.m.: ". . . unable to redirect. hitting out. pushed on door, out in hallway. brought back. . . ." *10/26/14 at 4:20 p.m.: ". . . Pushed on door and went out. . . . Hard to redirect, brought back in to unit. Threatening. . . ." *10/28/14 at 1:47 p.m.: ". . . Resident stood at the door and held the handle in so it would open. Staff were tied up with other resident's and by the time we get to him, he was outside the door. Resident sat in the chair at the table outside and refused to come back in. . . ." *10/28/14 at 2:59 p.m.: ". . . Resident was trying to get out the front door agian (sic), holding the handle down so the door would open. CNA was unable to get him to let go off (sic) the door so I intervened. Resident hit me in the chest with his hand and swore at me. Resident was able to get out of the door and was trying to go out the door to the outside. CNA was trying to stop him from getting out and I saw the administrator so called him over to help. Administrator was not able to convince resident to come back inside so we went and found resident's nephew, who is a worker here, and he was able to get resident to come back inside. . . . After nephew left, I gave resident IM Alprazolam (sic, Ativan) . . ." *10/30/14 at 5:27 p.m.: ". . . Woke up after spouse left, ate all of supper and then became very aggitated (sic). Pushed on exit door, out into hallway, threatened to hit me, yelling, and swearing. . . ." *11/15/14 at 10:26 p.m.: ". . . Resident last few nights has been getting up during night, getting dressed and trying to get out doors. At times, CNA's might be in room then hear door alarm going off from Resident trying to get out. . . ." Observations in the SCU during the survey showed a fire exit door located in the SCU which led directly outside into a parking lot. The main exit door led to a hallway within the facility. Observation showed an exit door approximately 25 feet away from the main SCU door which led directly outside into a parking lot. During an interview on 11/19/14 at 4:25 p.m., a supervisory nurse (#16) stated the door in the SCU which leads to the parking lot is not equipped with a wanderguard alarm system, nor is the exit to the parking lot located in the hallway outside the SCU. She stated only the main entrance to the SCU is equipped with a wanderguard alarm system; however, all three of these doors are equipped with a lock that must be released by pushing on the door for 15 seconds. The nurse stated that these three doors will open after 15 seconds, but an alarm will sound, alerting staff the doors are open. - Review of Resident #14's medical record occurred on 11/20/14. [DIAGNOSES REDACTED]. Resident #14's quarterly MDS, dated [DATE], identified long and short term memory problems. Physician's orders stated, "Check wanderguards daily." Resident #14's care plan stated, ". . . Focus: I have hx (history) of elopement attempts/wandering d/t (due to) impaired safety awareness and/or disoriented to place. . . . Goal: I will not leave facility unattended. My safety will be maintained. . . . Interventions/Tasks: 1:1 supervision PRN (as needed), Assist res. (resident) to sit closer to nurse's station prn to monitor whereabouts, Distract me from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Resident prefers to sit in the recliner by the birds or look out the big windows in the Lounge. Document wandering behavior and attempted diversional interventions. Husband/family request to be involved and will come and sit with res. as needed. Staff to notify family as needed for assistance. Identify pattern of wandering: Is wandering purposeful, aimless, or escapist? Am I looking for something or someone? Does it indicate the need for more exercise? Intervene as appropriate. Medications reviewed prn, wanderguard placed and checked daily by staff to ensure that it is working. . . ." Review of Resident #14's progress notes identified the following: * 03/16/14 at 2:24 a.m. - "Resident up and wandering. Going door to door. got out dorrs (sic) x 2 with staff coming right behind her. walking hand in had (sic) in facility. Questioned if having pain and shakes head yes. Refuses when offerred (sic) tylenol. * 03/16/14 at 1:45 p.m. - "CNA responded to sounding alarm at 10am, found resident standing on the sidewalk by front entrance, resident had gone out the door by the Wing 3+5 nurses station. Redirected easily. Assisted to her room, laid down on her bed at 10:30 am, CNA sat with her until she fell asleep, at 11:30 resident up walking, assisted to dining room, ate 100% of lunch. . . . Dr. (doctor) on call, notified of elopement. Husband . . . also notified. Rsident (sic) placed on 15 min (minute) checks." * 04/01/14 at 5:30 p.m. - "Resident has been wandering since 1200 (12:00 p.m.) and has made multiple attempts to go outside. Comes back in with staff without resistance but then just walks to a different door. Had med aide (medication aide) give resident her 2 pm Lorazepam (an antianxiety medication) at 1pm. Resident settled down by 1330 (1:30 p.m.) and was resting on her bed. Husband and Dr. made aware. Husband came up around 1500 (3:00 p.m.) and spent time with her but after he left, she again went out the front door and had only her pj's (pajamas) on now. Came in with CNA without resistance." * 04/01/14 at 7:00 p.m. - "At 7 pm tonight staff went running down hall and out the door saying, '(Resident #14) is outside'. CNA states she saw her walking on the street from end of wing 1 hallway and went out our back door and ran to catch her. At that time (name of staff member), our driver was returning from taking someone to an activity, saw staff member and resident, stopped and picked them up. That's when w/c (wheelchair) and blanket obtained and resident brought back into bldg (building). No injury noted. Since it was her bath night, another CNA initiated her bath. Vitals taken after that. She had no shoes on and feet were wet, toes pink. Skin normal color since her bath. Husband notified and came to sit with her until she goes to sleep. (Name of Resident #14's step-daughter) here as well. Administer (sic) and nurse manager notified. Dr. on call notified and ER (emergency room ) Dr. also noted incident and had no new orders. She has been noted to have 9 elopement attempts today." * 04/04/14 at 10:31 a.m. - "All doors in facility were checked per maintenance for proper functioning alarms and locking. Res. accutech (wanderguard) is checked daily by nursing for proper functioning. Res. has made no further attempts to exit seek. Res. has been more content. Husband continues to visit every day as he did before and sits with res. and attends activities." * 04/17/14 at 3:01 p.m. - "Resident went out door at the end of Wing 1 at 2:20 pm. Was easily brought back indoors by staff. Resident's husband here shortly after so aware of elopement. Dr. . . . faxed." * 05/23/14 at 8:00 a.m. - "At 750 (7:50 a.m.) patient was spotted outside on sidewalk. Administrator went out and redirected her back into the building. When patient came back in the alarms went off, but when went outside nothing alarmed. Patient not hurt during incident. Left message with family about calling back. PCP (primary care provider) notified." * 06/07/14 at 6:27 a.m. - "Resident up and dressed at 0530 (5:30 a.m.) this am. I noticed her walking rapidly toward lobby. I immediately followed her and caught her ready to go out front exit door. Taken to CNA and told needed to be watched close. At 0600 (6:00 a.m.) while in SCU giving med, received (sic) call we needed to look for her. She was found in back parking lot by staff coming to work. Husband notified and Dr faxed condition report." * 06/07/14 at 5:23 p.m. - "At 1315 (1:15 p.m.) patient was seen trying to leave the building through the front door. Staff saw patient walk out first set of doors, and the alarm went off. Staff redirected resident back into building. Family aware." * 06/18/14 at 9:31 a.m. - "Resident observed to be exit seeking this a.m. Will apply a second wanderguard to opposite wrist with plan to transfer to our SCU/locked unit when bed available. . . ." During an interview on 11/20/14 at 1:00 p.m., an administrative staff member (#28) said the doors to the back parking lot and the main door were secured (equipped with an alarm) following the 04/01/14 incident. The doors were tested and worked properly and another wanderguard was placed on the resident on 05/23/14. The administrative staff member (#28) said the elopement investigations had been destroyed per policy. - Review of Resident #13's medical record occurred on November 19-20, 2014. [DIAGNOSES REDACTED]. Physician's orders included a wanderguard, initiated on 07/18/14, and placement in the SCU, dated 09/15/14. Resident #13's current care plan stated, "Focus: The resident has impaired cognitive function/dementia or impaired thought processes r/t (related to) Disease Process *8/27/14 left facility unattended Resident believes at times he is waiting for the doctors order to go home and will pack his bags and ask to go home. 9/20/14 elopement from SCU; elopement from SCU noon on 10/29/14. Punched in code 10/2/14 . . . 10/2/13 (sic) Elopement from SCU x 2 (twice) *tearful at times thinking his wife is divorcing him and taking his money. Knows how to read code to activate door and needs to be redirected when he is there. Attempted to leave 11/3/14 Stopped. 11/17/14 Exited SCU . . . Interventions/Tasks: *Administer meds as ordered . . . *Cue, reorient, and supervise as needed . . . *Enc. (Encourage) Diversional act. (activity) . . . visiting about the past, walks, snacks, etc . . . *Patient has wander guard (sic) in place for wandering. Focus: I have a mood problem r/t (related to) Dementia. I get agitated and wander and have tried to leave the unit . . . Interventions/Tasks: *Medication as ordered *monior (sic) increased aggression and wandering." Review of Resident #13's progress notes identified the following: *08/27/14 - "Resident has had an elopement tonight. Wife called at 2035 (8:35 p.m.) stating that resident was standing outside their house, which is 1 1/2 blocks north of Eventide. This writer told wife that two CNAs would be over to bring resident back via wheelchair. CNAs were able to bring resident back with some convincing that he needed to come back for his safety. Resident returned at 2100 (9:00 p.m.) with two CNAs. Resident was last seen by a CNA on Wing 2 at 2020 (8:20 p.m.) when he was sitting at the nurse's desk. Resident does have a wandergaurd (sic) on but no alarms were heard in the building. New wandergaurd (sic) was placed on resident upon return. It was checked and is working. . . ." *09/06/14 at 5:16 p.m. - "Resident has been up out of his room for the majority of the day. Has gotten through first set of doors to go outside three times today. Wanderguard alarm has gone off all three times and resident was able to get redirected . . ." *09/10/14 at 11:00 p.m. - "Res (resident) was very agitated this evening. Res was trying to leave the building saying that he was kidnapped. . . ." *09/12/14 - "At 1340 (1:40 p.m.) resident eloped despite wanderguard. Resident was walking home, staff were unable to redirect resident, staff walked with resident home, . . . Staff were able to get resident back to facility. . . ." *09/20/14 at 9:18 a.m. - ". . . Resident got out of the locked SCU, resident wanderguard alarm went off. . . ." *09/30/14 at 5:42 p.m. - Resident read exit #'s (numbers) and left unit x 2 (twice) within 30 minutes . . ." *10/02/14 - "Resident exited the SCU x 2 this morning at 0930 (9:30 a.m.) and again at 1005 (10:05 a.m.) Did not set door alarm off. Was able to open door using code. Wanderguard alarm sounded when door opened. . . ." *10/25/14 at 5:17 p.m. - "resident was pleasant and visiting with staff prior to evening meal. after eating resident went through the SCU door and sounded alarm. . . ." *10/29/14 at 12:39 p.m. - "Apparently punched code in following meal and exited unit. Was brought back to unit, from main part of facility. . . ." 11/10/14 at 2:25 p.m. - ". . . Did go to the door x 1 and attempt to punch in exit code. Did not get door open. . . ." A careplan review/update progress note, dated 11/03/14, regarding Resident #13's elopement stated, ". . . Able to read code numbers on unit door and will punch in code and leave. Also very quick and staff needs to be aware of where he is when they exit unit as he will be right there. . . ." Although Resident #13 eloped multiple times from the SCU by entering the security code, facility staff failed to provide evidence they changed the security code in response to Resident #13's elopements. The facility failed to provide adequate supervision and effective interventions to prevent Residents #3, #13, and #14 from eloping from the facility and/or the SCU. HOT WATER TEMPERATURES 2. Based on observation, review of professional literature, and staff interview, the facility failed to maintain safe water temperatures at hand washing sinks in resident rooms in 4 of 6 units (200, 300, and 400 wings, and the Special Care Unit). Failure to ensure safe water temperatures may result in injury/burns to residents of the facility. Findings include: The Centers for Medicare and Medicaid Services (CMS) has outlined standards of practice regarding hot water temperatures which states water may reach hazardous temperatures in hand sinks, showers, and tubs. Many residents in long-term care facilities have conditions that may put them at increased risk for burns caused by scalding. These conditions include: decreased skin thickness, decreased skin sensitivity, peripheral neuropathy, decreased agility (reduced reaction time), decreased cognition or dementia, decreased mobility, and decreased ability to communicate. Third degree burns can occur after five minutes of exposure to water at 120 degrees Fahrenheit (F), three minute exposure at 124 degrees F, one minute exposure at 127 degrees F, and 15 second exposure at 133 degrees F. On 11/18/14 at approximately 11:45 a.m., a surveyor noted the water in the bathroom between the 200 wing and the Special Care Unit (SCU) as hot, obtained a thermometer, and measured the temperature. The temperature measured 129 degrees F. On 11/18/14, between 11:55 a.m. and 12:20 p.m., the water temperatures measured in residents' bathroom sinks revealed the following hot water temperatures: *Room 1 (SCU) - 134 degrees F *Room 2 (SCU) - 133 degrees F *Room 4 (SCU) - 130.9 degrees F *Room 13 (SCU) - 120 degrees F *Room 208 - 120.4 degrees F *Room 303 - 130.6 degrees F *Room 404 - 122.3 degrees F An interview with the director of environmental services (#25) occurred on 11/18/14 at 12:40 p.m. This staff member stated he expected the hot water temperature in residents' rooms to measure about 110 degrees F. He stated the maintenance staff do random measurements of the hot water in residents rooms weekly and make adjustments if the temperature measures over 110 degrees F. The staff member (#25) agreed the above noted temperature measurements were high and would make adjustments immediately. During an interview on 11/18/14 at 3:45 p.m., a staff member (#25) and a maintenance staff member (#26) stated they checked the hot water temperatures throughout the facility and they are measured below 110 degrees F at this time. The staff member (#25) also stated adjustments were made to the mixing valves (hot and cold water mixed) and the water heater.

Based on observation, record review, policy review, and staff interview, the facility failed to ensure that a resident with a pressure ulcer received the necessary treatment and services to promote healing, prevent infection, and prevent new ulcers from developing for 1 of 1 sampled resident (Resident #10) with deteriorating pressure ulcer requiring hospitalization . Failure to protect Resident #10's left heel during transport in the wheel chair had the potential to cause injury, pain, or worsening of the pressure ulcer; failure to apply the protective heel boot to the right foot as ordered had the potential for new ulcers to develop; failure to identify a worsening pressure ulcer, as evidenced by increased pain, redness and swelling of the leg, and foul smelling drainage and failure to notify the physician of the worsening pressure ulcer resulted in Resident #10's hospitalization for surgical intervention of the pressure ulcer. Findings include: Review of the policy "Skin Assessment" occurred on 12/19/13. This policy, dated May 2013, stated, "Purpose: The purpose is to inspect and assess all areas of the resident's skin to identify current and potential problems. A resident who is admitted to the facility will receive the necessary treatment and services to promote healing, prevent infection and prevent new ulcers from occurring. It is Eventide's goal that residents who enter the facility without pressure ulcers do not develop them unless the clinical condition demonstrates the pressure sore was unavoidable. . . . Policy: . . . The nurse is responsible for: . . . Identifying and evaluating risk factors and changes in residents' conditions. . . ." Review of Resident #10's medical record occurred on all days of survey. Resident #10's medical [DIAGNOSES REDACTED]. Review of Resident #10's care plan identified a Focus area of "Hx (history) of Stage 2 pressure ulcer to coccyx. I have un-stageable pressure ulcers to left heel. . . . Interventions: Administer treatments as ordered and monitor for effectiveness. Assess/record/monitor wound healing weekly and prn. . . . Assess and document status of wound perimeter, wound bed and healing progress. Report improvement and declines to the MD." Review of Resident #10's Nursing Progress Notes identified the following: *11/30/13 - "Resident has a 4.8 by 3.6 cm (centimeter) fluid filled area to outer left heel. Heelers are now in place, MD (medical doctor) notified. . . ." NOTE: This is the first time staff identified the blister area on the left heel in the medical record. *12/02/13 - "Skin asst (assessment) done and has left heel fluid like filled area and is on TX (treatment) to check. . . ." *12/03/13 - 8:49 a.m. - ". . . note still a fluid lilled (sic) area present and skin dark. 1:15 p.m. - To wlak (sic) - in clinic via bus and dtr (daughter) met her there to have left heel checked. . . . Culture obtained after opening blister. No puss noted. Will await culture results before starting antibiotics. Suspect pressure ulcer, to keep moist with [MEDICATION NAME] and non-adherent dressing. Change BID (twice a day) Continue with heel protectors." NOTE: Physician's Progress note dated 12/03/13 stated, ". . . There is a handwritten note stating that on November 30 they noticed a blister on her left heel. It was 4.8 x 3.6 cm in size. . . . Plan: . . . I would like them to keep this area moist and covered with a nonadherent dressing. It should be changed twice a day to make sure the area is examined. . . . It is important to use heel protectors as I feel this is most likely a pressure ulcer. We will prescribe appropriate antibiotics based upon culture results." *12/08/13 - ". . . note small amt (amount) of dry blood on old drsg (dressing). " *12/10/13 - ". . . some areas dark and another fluid filled area present and intact. . . . Dr. . . . faxed an update on current pressure areas and status of healing. . . . Final culture results returned and faxed it to Dr. . . ." *12/11/13 - ". . . note the 1 area still open where Dr. opened up and the other area still fluid filled. Heel is odorous. . . ." *12/12/13 - ". . . Area on left heel has loose skin where Dr. opened up it up and has another loosely fluid filled pockt (sic). Tx done as per order." *12/13/12 at 4:01 p.m. - "Tylenol with [MEDICATION NAME] #3 . . . complaints of left foot pain." 10:02 p.m. - "Tylenol with [MEDICATION NAME] #3 . . . left heel" *12/14/13 - "Tylenol with [MEDICATION NAME] #3 . . . pain in left foot. resident states that it hurts really bad." *12/15/13 - "Tylenol with [MEDICATION NAME] #3 pain in left foot. resident states it hurts real bad." *12/16/13 - "Tylenol with [MEDICATION NAME] #3 . . . resident crying out asked if she was having pain stated yes unable to give me a number." *12/17/13 - "Tylenol with [MEDICATION NAME] #3 . . . pain in back/heel unable to say number but resident crying. . . . Cleansed with normal saline and [MEDICATION NAME] applied and wrapped with Kling. Did not apply [MEDICATION NAME] as too moist and has a very foul odor to it . . . " 4:25 p.m. - "Dr. . . . faxed at 6:40 am this am re: left heel wound and update. 9:40 am. very sleepy probably from pain pill earlier . . . This afternoon received fax Dr . . . to send to walk-in clinic. . . . resident went via bus . . ." 5:33 p.m. - "Nurse on wing 3 notified at approximately 1625 (4:25 p.m.) that (name of resident) was being admitted to (name of local hospital) . . . ." Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The nurses notes identify the resident complained of foot pain. Review of Resident #10's Wound Care Flow Sheets identified the following: *11/30/13 - "Site: Left heel . . . Type: blister . . . Units of Measure: Length 4.8 cm Width 3.6 cm . . . Stage: N/A" *12/02/13 - "Site: Left inner heel . . . Type: pressure . . . . Length 3.5 cm Width 4.0 cm . . . Stage: Unstageable . . .Wound Bed Tissue: Raised, dark fluid filled blister" *12/03/13 - "Site: Left heel outer . . . Type: pressure. . . Length 3.1 cm Width 3.1 . . . Stage: Unstageable. . . Drainage: none - raised fluid filled blister" *12/09/13 - "Site: Left heel. . . Type: Blister . . . Length 4.8 cm Width 4.0 cm. . . . Stage: N/A" *12/10/13 - "Site: L inner heel . . . Type: Pressure . . . Length 3.1 cm Width 3.5 cm . . . Stage: Unstageable . . . Site: L outer heel . . . Type: Pressure. . . Length 4.0 cm Width 6.5 . . . Drainage: Left inner heel has small amount of bloody drainage. Left outer heel continues to have a fluid filled blister. . . . Odor: Foul odor present . . . Wound Bed Tissue: Left inner heel with dark red area, difficult to determine tissue bed d/t (due to) scab beginning to form. Left outer heel continues to have a blister intact." *12/16/13 - "Site: Left inner heel . . . Length 3.5 cm Width 4.1cm . . . Site: Left outer heel . . . Type: Pressure . . . Length 7.5 cm Width 6.0 cm . . . Drainage: Left inner heel area has mod (moderate) amt of bloody tinged drainage from it this am and area that is open is large then (sic) last week as more of the skin as (sic) come off. Area is very dark. Left outer heel has a fluid filled area intact the size of 7.5 by 6 which is larger area then (sic) last week. . . . Odor: foul smell to wound . . . Wound Bed Tissue: slough present" Observation of two staff members (CNA #5 and CNA #6) assisting Resident #10 out of bed occurred on 12/16/13 at 4:35 p.m. The resident stated "don't touch my leg" and complained of pain when the CNAs lifted the resident's leg. Observation showed the gauze dressing around the heel saturated with a dark colored drainage, and a very foul odor permeated throughout the room. Resident #10's left lower leg was reddened, swollen, and approximately twice the size of the right lower leg. The CNA (#5) stated "her leg is really swollen." The CNAs stated they would notify the nurse about the resident's leg and the saturated dressing. Observation showed Resident #10 wearing a soft protective booty on her left heel while in bed and in the wheelchair, but not on the right heel. While transporting the resident in the wheelchair down the hall, the left foot (the foot with the heel ulcers) repeatedly fell or slipped back off the foot pedal, towards the wheel of the chair. The CNA notified the nurse about the resident's leg pain and of the foot slipping off the chair and the nurse placed a work order for a support board. At 5:00 p.m., Resident #10 stated "I don't know if I can sit up anymore." Observation showed the resident's left foot slipped off the back of the foot pedal towards the floor and wheel during transport back to her room. Observation on 12/17/13 at 7:50 a.m. showed Resident #10 in bed with a blue protective booty on her left heel, but not on her right heel. Observation showed a nursing staff member (#4) changed the dressing on Resident #10's left heel. During the dressing change, Resident #10 moaned out in pain. The nurse (#4) stated she had given the resident Tylenol with [MEDICATION NAME] #3 one hour prior to the dressing change. Observation showed a large area of black tissue over the inner heal and a large fluid filled blister on the outer heal. The heel had a strong, foul odor which permeated the room. Observation showed Resident #10's left leg was reddened and swollen. At 8:05 a.m., a CNA (#7) assisted Resident #10 from the bed to the bathroom with a mechanical standing lift. Observation showed a soft, protective booty on the left heel, but not on the right heel. The resident moaned and cried of pain in her leg when the CNA moved the resident to the side of the bed for placement in the lift. After using the bathroom, the CNA transferred the resident to her wheelchair with the mechanical lift. Observation showed the resident's left foot falling backward off the foot pedal when transported down the hall to the dining room. Observation on 12/17/13 at 9:30 a.m., showed a staff member (#8) transported Resident #10 back to her room in her wheelchair after breakfast. Observation showed the resident's left foot falling off the back of the foot pedal. The resident stated "My shoe came off, I lost my shoe" and the CNA placed her foot back on the pedal. After using the standing lift to transfer Resident #10 to the recliner, the CNA (#8) removed the shoe from the resident's right foot. The CNA stated "she is supposed to have another booty for her right foot." The CNA looked around the room, and then found the booty in the bag on the back of the wheelchair. The CNA then placed the protective booty on the right heel. Facility nursing staff faxed the physician on 12/10/13 the following information: "(Name of resident) went to walk-in clinic on 12-3-13 and she opened up a blister on (L) heel and this is the culture results. Also has another large blister on same heel noted yesterday. Is this a significant culture result? Please fax back." The Physician's responded, "Likely not significant." Facility staff notified the physician regarding the culture result and the development of a new blister area on the heel on 12/10/13, however did not describe the size, appearance, or the foul odor as identified on the Wound Care Flow Sheet dated 12/10/13. The next day, 12/11/13, the nurses notes again identified the heel as odorous. The Wound Care Flow Sheet, dated 12/16/13, identified the foul odor to the wound and the enlargement of the pressure areas on the heel. Resident #10 began to complain of foot pain on December 13-17, requiring administration of Tylenol with [MEDICATION NAME] #3. Observations on 12/16/13 identified redness and swelling of Resident #10's left leg, pain in the left leg, and a strong, foul odor in the resident's room, yet the facility did not notify the physician until the following day, 12/17/13. On 12/17/13, facility nursing staff faxed the physician the following information: "Re: L heel wound (s) - went to walk-in clinic on 12-3-13 with large fluid filled area on L heel. Seen Dr. (name of physician) . . . opened the area with small slit and did C&S (culture and sensitivity) of drainage. Results came back negative. . . . ordered [MEDICATION NAME] and dressing change BID. Then on 12-11-13 another lg (large) fluid filled area next to the open one. As of yesterday noted the 1st area most of top layer of skin gone and now has very dark (necrotic area?) present and very, very foul odor to it. Redness around wound(s), having a lot of pain with some warmth around area also needs it looked at at clinic? Please fax back." Physician Response: "Take to walk in clinic today." Facility staff transported Resident #10 to the clinic the afternoon of 12/17/13, and nurses notes later identified Resident #10's admission to the Jamestown Regional Medical Center. On the morning of 12/18/13, a staff nurse stated Resident #10 would be having surgery for [REDACTED]. The facility failed to: * Recognize and identify Resident #10's deteriorating pressure ulcer as evidenced by increased pain, redness and swelling of the leg, and the development of a foul smelling drainage. * Promptly notify/consult the physician when Resident #10's heel ulcer began to deteriorate. * Identify the pressure ulcer until it was a 4.8 cm by 3.6 cm fluid filled area. * Promptly protect Resident #10's left heel/pressure ulcer area when staff identified her foot continued to fall off the back of the foot pedal. * Implement the heel protector booty on Resident #10's right foot.

Based on observation, record review, policy review, review of a professional reference, and staff interview, the facility failed to establish and implement individualized behavioral interventions, monitor the effectiveness and make necessary changes/revisions as indicated for 3 of 4 sampled residents (Resident #6, #9, and #21) receiving antipsychotic and antianxiety medications for behavior management and 1 supplemental resident (Resident #25) who received both antianxiety and antipsychotic medications to control behaviors and had a dosage increase without attempts by the facility to minimize the behavior through other approaches/interventions. Failure to administer [MEDICAL CONDITION] medication with adequate indications for use (Resident #9 and #21) resulted in Resident #21 experiencing a fall, pelvic fracture and head injury. Failure to consider a gradual dose reduction (GDR) (Resident #6) and failure to ensure an adequate indication for increased medication dosage (Resident #25) resulted in residents receiving unnecessary medications with adverse and potential adverse consequences. Findings include: Review of facility policy titled "[MEDICAL CONDITION] Medication Monitoring and Review for Sedatives/Hypnotics and Anxiolytics" occurred on 02/09/12. This policy, dated 03/10/09, stated, "POLICY: A [MEDICAL CONDITION] medication review will be completed on any resident receiving sedative/hypnotics and/or anxiolytics. PURPOSE: To review the [MEDICAL CONDITION] medications on a quarterly basis attempting to evaluate harmful side effects and promote the use of the lowest possible dose. . . . " Review of facility policy titled "[MEDICAL CONDITION] Medication Monitoring and Review for Antipsychotics" occurred on 02/09/12. This policy, dated 03/10/09, stated, "POLICY: A [MEDICAL CONDITION] Medication Review will be completed on any resident receiving antipsychotic medications. PURPOSE: To review the [MEDICAL CONDITION] medications on a quarterly basis attempting to evaluate harmful side effects and promote the use of the lowest possible dose. . . ." PROCEDURE: . . . 2. Review diagnostic list for appropriate diagnosis. Antipsychotic drugs should not be used unless the clinical record documents that the resident has one or more of the following "specific conditions"": a. [MEDICAL CONDITION] . . . 3. Antipsychotics should not be used if one or more of the following is/are the only indication: a. Wandering b. Poor self-care c. Restlessness d. Impaired memory e. Unsociability f. Indifference to surroundings g. Fidgeting h. Nervousness i. Uncooperativeness j. Unspecified agitation that does not represent a danger to others . . . 5. Document frequency of target behaviors displayed during each shift using code as identified on the Mood/Behavior Data Sheet . . . 6. Document side effects as observed and at least quarterly with care plan review. 7. Continue to utilize non-drug approaches as determined by the behavior team. . . ." The 2011 Nursing Drug Handbook, page 696 and 697, identified indications for [MEDICATION NAME] ([MEDICATION NAME]) as ". . . Anxiety . . . [MEDICAL CONDITION] from anxiety . . ." and dosages for elderly patients as "1 to 2 mg (milligrams) P.O. (by mouth) daily in divided doses. . . ." for anxiety usage. The handbook identified adverse reactions including drowsiness, sedation and unsteadiness. - Review of Resident #21's record occurred on February 08-09, 2012. Resident #21's admission to the Special Care Unit (SCU) occurred in October 2010. Resident #21's medical [DIAGNOSES REDACTED]. Resident #21's current medication regimen included the following: * [MEDICATION NAME] (generic for [MEDICATION NAME]) (antianxiety medication) 0.5 milligrams (mg) oral (po) three times a day (tid) prn * [MEDICATION NAME] 1 mg IM every 8 hours prn * [MEDICATION NAME] (antipsychotic medication) 0.5 mg po every day in the morning (decreased on 01/24/12 to 0.25 mg) * [MEDICATION NAME] 0.5 mg po every day at 2 p.m. (decreased on 01/24/12 to 0.25 mg) * [MEDICATION NAME] 0.25 mg po every day at 7 p.m. Review of Resident #21's PRN medication log from 08/23/11 through 09/13/11 prior to hospitalization for the pelvic fracture and head injury showed nursing staff administered [MEDICATION NAME] or [MEDICATION NAME] (po and IM) 17 times for anxiety/agitation. Between 09/22/11 and 10/13/11, after Resident #21's return from her hospitalization , nursing staff administered [MEDICATION NAME] 24 times (six times intramuscularly) for the following reasons: anxiety, worried about kids, wants to go home, hitting, yelling, and trying to get out of the wheelchair. Review of Resident #21's nurses notes identified nursing staff failed to implement measures including engaging the resident in an activity, reapproaching later or with another staff member, analyzing the resident's behavior, and developing an individualized care plan. In addition, staff agitated the resident with threats of a pill or injection. On 09/10/11, Resident #21 experienced a fall at 9:15 p.m. without injury one half hour after a two mg dose of IM [MEDICATION NAME]. In addition, the resident received a scheduled 4:00 p.m. dose of [MEDICATION NAME] (total of 3 mg within 6 hours). On 09/13/11, Resident #21 sustained a pelvic fracture and a head injury five hours after nursing staff administered three oral doses and one two mg injection of [MEDICATION NAME] within an eight hour period (total of 4.5 mg). The suggested daily dosage is 1-2 mg in divided doses. Nurses notes also identified three and four staff members were required to hold Resident #21 in order for staff to administer injections on four occasions: 09/05/11, 09/07/11, 09/25/11, and 10/02/11. Review of the behavior teams weekly meetings from 08/16/11 through 11/01/11 identified the date/time of each behavior and any medication adjustments, however, evidence is lacking the facility assessed factors affecting/contributing to Resident #21's behavior and developed/implemented appropriate interventions to modify/control the behaviors and provide alternatives to drug therapy. - Review of Resident #9's record occurred on all days of survey. Resident #9's [DIAGNOSES REDACTED]. Resident #9's current medication regimen included: * [MEDICATION NAME] 0.5 mg IM ordered 07/28/11 prn and 0.5 to 1 mg every two hours prn for agitation * [MEDICATION NAME] 0.5 mg po ordered 08/24/11 prn for agitation * [MEDICATION NAME] 0.125 mg po bid ordered on [DATE] * [MEDICATION NAME] 0.5 mg po bid ordered 09/27/11 Nurses notes identified Resident #9 received [MEDICATION NAME] one mg IM on 07/28/11 at 4:35 p.m. for "con't (continues) to be very verbally aggressive. Has hit staff & con't to yell out" and four hours later "Resident found on floor lying on her back in linen room - had been in merrywalker - admits to hitting her head on the back . . . unable to assess symptoms due to resident's cognition. Resident assisted to bed refuses any [MEDICATION NAME]. Cooperative (with) staff." Review Resident #9's of the PRN Medication Log showed nursing staff administered 14 PRN doses of [MEDICATION NAME] in September 2011. Resident #9 began receiving scheduled doses of [MEDICATION NAME] on 09/27/11, however the resident received 20 doses of PRN [MEDICATION NAME] in October 2011; 11 doses in November 2011; 10 doses in December 2011; three in January 2012 and so far one in February 2012. The record failed to identify interventions attempted or implemented prior to staff administering the [MEDICATION NAME]. Resident #9's Mood/Behavior Data Sheets for December and January lacked evidence of physical behaviors or verbal behaviors toward staff or other residents. The February data sheet showed two episodes of verbal behavior toward other people however, the nurse's notes and PRN medications log failed to identify the specific behavior. Review failed to show adequate indications for nursing staff to administer the PRN [MEDICATION NAME]. During interview on 02/09/12 at 11:10 a.m., an administrative staff nurse (#2) when informed of Resident #9 and #21's falls and resulting injuries following the administration of [MEDICATION NAME] by the nursing staff, agreed the medication likely caused the fall. In addition, the facility failed to develop appropriate behavior intervention plans to prevent the frequent use of [MEDICATION NAME] on the SCU. - Review of Resident #25's record occurred on 02/09/12. Resident #25's [DIAGNOSES REDACTED]. An admission MDS, dated [DATE], identified physical behavior symptoms directed toward others on 1 to 3 days of the past 7 days, trouble falling asleep or staying asleep 2 to 6 days of the past 14 days, and limited assistance of one person with transfers and walking in the room and corridor. A quarterly MDS, dated [DATE], identified physical behavior symptoms directed toward others, verbal symptoms directed toward others, other behavioral symptoms not directed toward others, and wandering on 1 to 3 days of the past 7 days, trouble falling asleep or staying asleep 2 to 6 days of the past 14 days, and supervision of one person with transfers and walking in the room and corridor. The record identified the facility admitted Resident #25 on 09/04/11 with physician's orders [REDACTED]. The record showed the physician added [MEDICATION NAME] (an antianxiety) 0.5 mg every six hours as needed for agitation on 09/07/11 and initiated a 12 noon dose of [MEDICATION NAME] 25 mg on 11/10/11. Resident #25's care plan, dated 12/02/11, stated, " I have mood/behavior issues . . .anxiety s/s (signs symptoms), poor sleep, . . . both verbal/physical and ELOPEMENT RISK/wander, looking for a paticular (sic) person or way to get home/fidgety, feeling bad/crying, poor appetite and short tempered." Approaches to the problem included, "Communicate with family/caregivers . . . Placement in SCU 09/15/11. Cue, reorient, and supervise as needed, Keep the resident's routine consistent . . . Present one thought, idea, question or command at a time. Reminisce with the resident . . . Review medications and record possible causes of cognitive defecit (sic) . . . Medications as ordered. Mood/behavior monitoring sheets in place. LSW (Licensed Social Worker) to visit prn (as needed) and assess for any needs/concerns . . ." Resident #25's care plan lacked individualized interventions staff should implement to address the resident's anxiety symptoms, including her verbal and physical behaviors directed toward others, sleep issues, wandering, and elopement risk. The lack of planned individualized interventions for Resident #25 resulted in staff consistently administering antianxiety medication without first considering factors that may have been causing the [MEDICAL CONDITION] and/or anxiety (as per facility policy) and attempting to alleviate the behavior through non-pharmacological interventions. Resident #25's Physician's progress notes identified the following: * 11/03/11 - "(Resident #25) is seen on routine nursing home rounds today. She had a team meeting recently where her behavior was discussed. She has had some isolated episodes of walking/wandering and 1-2 episodes of being short tempered. Reviewed her mood/behavior data sheet for Oct. (October) shows no episodes of physical behavior towards caregivers or towards other people. She's also had no verbal behavior towards other people. There are several days marked where she did have wandering although nursing staff admits that she does walk frequently about the wing . . . No consistent patterns identified with respect to behavior at this time. Continue current dose of [MEDICATION NAME] . . ." Resident #25's progress notes identified: * 11/08/11 at 11:55 a.m. - "Unit meeting held today . . . Faxed request for possible increase in [MEDICATION NAME] due to continued inappropriate behaviors this week. fidigity (sic) x (times) 4, short tempered x 3, verbal with care givers x 2, little interest x 1, verbal to others x 1, [MEDICAL CONDITION] x 2, physical with cares x 1, disruptive x 1." * 11/10/11 at 9:15 a.m. - "Order rec'd (received) via fax from (physician's name) to give [MEDICATION NAME] 25 mg po @ (12 noon) in addition to the (8:00 a.m.) dose. . . ." The record lacked evidence the facility attempted non-pharmacological behavior interventions prior to requesting an increase in the [MEDICATION NAME] dose. The facility failed to assess factors affecting/contributing to the behavior of Resident #25 and develop/implement appropriate interventions to modify/control behaviors and provide alternatives to drug therapy. An interview with an administrative nurse (#2) occurred on 02/09/12 at 11:30 a.m. regarding the lack of planned interventions for Resident #25's anxiety, sleep issues, and exit seeking behaviors which resulted in staff administering [MEDICATION NAME] for anxiety symptoms and increasing the [MEDICATION NAME] dose for behaviors without prior attempts to alleviate those anxiety symptoms and behaviors through non-pharmacological means. The nurse provided no additional information. - Review of Resident #6's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. Medications included [MEDICATION NAME] (antianxiety) 0.5 mg every morning (AM) and 1 mg every hour of sleep (hs), [MEDICATION NAME] (antipsychotic) 50 mg every AM and 75 mg every hs, and [MEDICATION NAME] (antidepressant) 75 mg TID. Resident #6's annual Minimum Data Set (MDS), dated [DATE], and quarterly MDS, dated [DATE], indicated only one item in the Mood section (feeling tired or having little energy nearly every day) and no items in the Behavior section. The Mood/Behavior Data Sheets for January-February 2012 showed episodes of sleepiness, feeling down, depressed, and short tempered/annoyed. A psychiatric progress note, dated 12/02/11, stated, ". . . There are no reports of behavioral concerns. . . . By her report and report of staff, the client is doing fairly well. There are no reports of side effects with her medications. . . . [DIAGNOSES REDACTED]. . . . Based on our discussion the client will continue: 1. [MEDICATION NAME] 0.5 mg per tube q (every) AM and 1 mg per tube hs. 2. [MEDICATION NAME] 50 mg per tube AM and 75 mg per tube hs. 3. [MEDICATION NAME] 75 mg per tube tid." Review of the psychiatric progress notes, dated 09/02/11, 06/03/11, and 03/04/11 showed Resident #6 on the same dose of medication. The progress notes failed to identify why a GDR was clinically contraindicated.