Every finding on record at Golden Acres Manor

Based on record review, review of the facility reported incident (FRI) investigation, review of facility policy, and staff interviews, the facility failed to ensure residents remained free from abuse for 3 of 16 sampled residents (Resident #47, #56, and #57) who exhibited and/or were subjected to physical/verbal abuse. Failure to prevent resident-to-resident physical/verbal abuse resulted in hitting, emotional distress (crying), and fear. These actions placed all residents at risk for serious injury, pain, and mental/emotional harm. Findings include: Review of the facility policy titled Abuse and Neglect Policy and Procedure occurred on 07/29/26. This undated policy stated, . each resident has the right to be free from abuse, . Residents must not be subjected to abuse by anyone, including, but not limited to . other residents. Review of the initial FRI, dated 07/27/26, identified two nursing staff members (#2 and #3) witnessed a verbal altercation between Resident #56 and Resident #57 on 07/25/26. The staff members immediately intervened. -Review of Resident #56's medical record occurred on all days of survey. Diagnoses included borderline personality disorder, mild intellectual disabilities, Post-Traumatic Stress Disorder, major depressive disorder, and mood disorder. The current care plan stated, Post Traumatic Stress Disorder. Goal: patient will acknowledge and feel that they are safe and cannot be harmed. Interventions: acknowledge the resident's feelings and show understanding, monitor for avoidances of places, people, or situations. During an interview on 07/27/26 at 2:04 p.m., Resident #56 expressed fear for her life. During an interview on 07/27/26 at 6:19 p.m., Resident #56 verbalized fear of Resident #57 and stated she will not go to activities or places where Resident #57 is present. During an interview on 07/30/26 at 8:19 a.m., Resident #56's guardian stated the resident called to inform her of the incident on 07/26/26. The guardian indicated Resident #56 stated she was terrified to sleep, but did not mention the altercation later in the day. - Review of Resident #57's medical record occurred on all days of survey. Diagnoses included schizophrenia, psychosis, anxiety, Alzheimer's disease, bipolar disorder, and Post-Traumatic Stress Disorder. The current care plan stated, . Mood and Behavior may vary. Current behaviors of swearing, yelling out, and interrupting staff. A progress noted, dated 07/25/26 at 5:07 p.m., stated, Resident [Resident #57] was ambulating near the nurses' station toward her room when she became verbally upset with another resident [Resident #56] after believing the resident [Resident #56] was talking about her. Resident [Resident #57] stated, '[profanity] you,' to the other resident. The other resident [Resident #56] responded with the same statement, after which the resident became increasingly agitated, walked toward the other resident, and stated, 'Do you want to [profanity] fight?' Writer immediately intervened by positioning self between both residents to prevent further escalation. Resident [Resident #57] was given clear verbal redirection, instructed to stop using inappropriate language and making threats, and directed to disengage from the interaction and return to her room. Resident initially complied and began walking away. As the resident [Resident #57] was walking toward her room, the other resident [Resident #56] stated to nursing staff that she believed the resident 'should be at the state hospital.' Upon hearing this comment, the resident turned and yelled, 'If I had a knife, I will cut your [profanity] throat.' Writer immediately redirected the resident again, instructed her to stop making threatening statements, and reinforced expectations for appropriate behavior. Resident [Resident #57] complied with redirection, continued to her room, and no further verbal or physical aggression was observed. Both residents were separated for the remainder of the shift and monitored closely to prevent further interaction. No physical contact or injuries occurred. Resident [Resident #57] remained in her room following the incident, and no additional behaviors were observed during the remainder of the shift. Continued monitoring and behavioral observation will be maintained. During an interview on 07/27/26 at 5:34 p.m., a nurse (#2) stated after the incident, staff redirected Resident #57, visited with Resident #56 and her guardian, completed daily monitoring for Resident #57, and informed the next shift about the incident. The nurse also stated she has not witnessed any altercations between Resident #57 and other residents. During an interview on 07/28/26 at 1:55 p.m., a nurse (#3) stated the incident occurred in the front lobby and Resident #57 thought Resident #56 was talking about her and Resident #56 cried for a few minutes after the incident. The nurse also stated Resident #57 has shown agitation in the past but not directed towards a specific resident. - Review of Resident #47 medical record occurred on all days of survey. Diagnoses included Alzheimer's disease, anxiety, dementia with psychotic disturbance, and depression. The current care plan stated, . Alteration in mood and behaviors . Tends to wander/follow other residents at times, may attempt to hold their hand at times. Likes to hang around . front lounge. Periods of increased restlessness, delusions . Redirect as able away from other residents if appears unwanted attention attempted. When resident is anxious, take her for a walk outside . or 1:1 . Resident #47's progress note, dated 06/22/26 at 1:58 p.m., stated, . Resident was involved in a physical altercation with another resident. Writer observed both residents striking each other. Staff intervened immediately and separated the residents. Resident was assessed for injuries, no injuries was [sic] noted. During an interview on 07/29/26 at 5:30 p.m., an administrative staff member (#1) confirmed staff failed to recognize two residents striking each other as resident-to-resident physical abuse and failed to report the abuse in a timely manner.

Based on observation, record review, resident and staff interview, the facility failed to ensure that 1 of 1 sampled resident (Resident #1) with a non-pressure skin wound received treatment and care in accordance with professional standards of practice. Failure to perform regular wound monitoring and assessments and document the progression of a wound resulted in delayed healing and worsening of the wound. Findings include: Observation on 07/28/26 at 8:52 a.m. showed an open area on Resident #1's mid-back. Resident #1 stated, They think it [the open area] is from the sling [ceiling lift sling]. During an interview on 07/30/26 at 10:42 a.m., Resident #1 stated she has had the open area for about a month. Review of Resident #1's medical record occurred on all days of survey. Physician's orders included:*07/20/26, Check placement of dressing to mid/lower back-change if off or strikethrough drainage noted, every day and night shift.*07/21/26, Cleanse wound to mid/lower back with wound cleanser, pat dry. Apply xeroform [medical gauze used for wounds] dressing to wound bed and cover with gauze dressing and secure with Medi pore [brand of medical tape] tape on all 4 sides. Change 2x [times] /wk [week] on bath days (Tues [Tuesday]/Fri [Friday]) and as needed. Review of nursing progress notes identified the following:*06/30/26 at 1:08 p.m., Open area to mid back has improved slightly since yesterday. Redness present in a linear line in the fold that has decreased since yesterday. Treatment changed to sacral Mepilex [brand of medical dressing] . The medical record failed to contain documentation of a wound assessment on 06/29/26, despite the progress note referencing improvement since yesterday. *07/20/26 at 10:26 a.m., Wound committee in to assess wound to lower back. It has declined since committee last assessed. No drainage or odor present. Dressing was rolled up and not in correct position. Has two liner open areas. Left one measures 0.5 cm [centimeters] x 1.8 cm and the right one measures 1.8 cm x 4 cm. Complains of discomfort at dressing only. Area is difficult to keep a dressing on due to . constant moisture. Dressing applied to assist with friction as the skin folds rub against each other. She has limited air circulation due to area.The medical record failed to show any further wound assessments or progress notes regarding Resident #1's back wound between 06/30 and 07/19/26 (19 days). On 07/20/26, the wound committee documented the wound had declined since committee last assessed, despite the absence of documentation describing the wound's progression or ongoing assessments. During an interview on 07/30/26 at 11:33 a.m., an administrative nurse (#10) state she expected staff to document the wound status during dressing changes. The nurse (#10) confirmed the medical record lacked documentation of assessments and monitoring of Resident #1's wound, and the facility began to document the wound condition on 07/21/26 on the Treatment Administration Record (TAR). The facility failed to perform and document regular wound monitoring and assessments from 06/30/26 through 07/19/26.

Based on record review, review of facility policy, and staff interviews, the facility failed to provide appropriate treatment and services to prevent the development of a pressure ulcer for 1 of 1 closed record (Resident #65) with pressure ulcers. Failure to ensure adequate monitoring and assessment by a provider resulted in the worsening of a facility acquired pressure ulcer. Findings Include: Review of the facility policy titled Pressure Injury Prevention and Management occurred on 07/29/26. The policy, dated 02/23/18 stated, . Golden Acres Manor shall establish and utilize a systematic approach for pressure injury prevention and management, starting with prompt assessment and treatment, including efforts to identify risk, stabilize, reduce or remove underlying risk factors, monitor the impact of the interventions, and modify the interventions as appropriate . Review of Resident #65's medical record occurred on 07/29/26. Diagnosis included chronic kidney disease, venous insufficiency, a pressure ulcer to the left heel, and a pressure ulcer to the sacral area. The current care plan, initiated on 03/12/26 and revised on 05/29/26, stated, Potential for impaired skin integrity related to: incontinence, impaired mobility . Prefers to lay on her back and not on her side. Unstageable pressure ulcer to left heel and to her sacrum area. Resident #65's physician's orders included the following: * 04/15/26 at 6:47 p.m., Unstageable pressure to sacrum. Cleanse with normal saline. Apply Santyl (helps to remove dead tissue) to wound bed followed by Polymer Wic (non-adhesive foam dressing that absorbs excess fluid) and Mepilex (foam dressing). Change twice weekly. * 04/30/26 at 2:51 p.m., Culture wound.* 04/30/26 at 4:38 p.m., Cleanse the wound with saline. Apply thin layer of Santyl, cover with Polymer Wic, followed by Mepilex twice a week.The progress notes identified the following:* 03/18/26 at 1:38 p.m., . Resident is dependent on staff for . toileting hygiene. She states she has no feeling when she needs to go to bathroom and is incontinent of bowel and bladder. * 03/24/26 at 8:26 a.m., . Sacral area has large red area that does blanche. Air mattress applied to her bed.* 03/30/26 at 4:44 p.m., Residents sacral area is blanchable with peeling red skin. Moderate amounts of drainage present to dressing.* 04/06/26 at 3:13 p.m., . Sacral area remains red but continues to blanch.* 04/15/26 at 2:50 p.m., . New skin Issue. Location: Sacrum. Laterality / Orientation: Middle. Pressure ulcer. new wound. Unstageable pressure ulcer . acquired in-house. Exact date: 04/15/2026. Length (cm) [centimeters]: 1 Width (cm): 1 Depth (cm): 0 Area (cm2) [centimeters squared] . 0% [percent]. Slough [dead tissue] 100%. Eschar [hardened dead tissues] 0%. Exudate [drainage] amount: None. Surrounding tissue: Erythema [skin redness]. Induration [hardening of soft tissue] < [less than] 2cm around wound. * 04/15/26 at 3:09 p.m., [physician name] here this morning and saw resident on rounds . No new orders received.* 04/16/26 at 4:09 p.m., Unstageable pressure ulcer to sacrum: Cleanse with area with normal saline. Apply thin layer of Sanyl [topical enzyme to remove dead or damaged tissue] to wound bed followed by small piece of Polymer cavity filler covered with a Mepilex every day shift every Mon [Monday], Thu [Thursday] . Wound to sacrum has no signs of infection. Resident did c/o [complain of] pain to area.* 04/21/26 at 8:58 a.m., . Sacrum. Laterality . Middle . Pressure ulcer . Improving: overall wound characteristics improved. Unstageable ulcer due to slough and / or eschar. Wound acquired in-house . 04/15/2026. Did not measure as resident wanted assessment completed in EZ stand and could not tolerate that long. Slough is lessening and becoming thinner. Area is cleaner looking. Slough: 100%. Exudate amount: None. Surrounding tissue: Normal in color . * 04/28/26 at 1:47 p.m., . Location: Sacrum. Laterality . Middle . Pressure ulcer . wound characteristics deteriorated. Unstageable ulcer due to slough and / or eschar. Size has increased. Increased exudate. Painful. Sharp [pain]. Length (cm): 2.2 Width (cm): 2.3 Depth (cm): 0.1 . Slough: 40%. Eschar: 60%. Exudate amount: Moderate. Seropurulent: mixture of purulent and serous, usually watery, yellow, green, tan or brown. Surrounding tissue: Erythema . Fragile . Excoriated [skin that has been traumatized, red, and inflamed]. Induration > [greater than] 4 cm in any area around wound. Periwound [tissue surrounding a wound] temperature: Warm. Dressing saturation: Moderate 26-75%.* 04/28/26 at 2:05 p.m., Sacrum and right buttock wounds have both deteriorated since last week when they were healing nicely. Both areas now have drainage, redness surrounding wound, moderate drainage present to Polymer [dressing] when it was changed this morning, increase in size with black eschar present . Wound committee will re-evaluate again in the morning.The wound committee failed to evaluate the next day, 04/29/26. * 04/30/26 at 12:22 p.m., Wound committee into assess wounds. They are stable since noted deterioration on 4/28/26. [physician name] will be contacted to request a wound culture of sacral area due to increased drainage, increased slough and eschar since last week.* 04/30/26 at 12:34 p.m., .Sacrum. Laterality . Middle. Pressure ulcer . Deteriorating: wound characteristics deteriorated. Unstageable ulcer due to slough and / or eschar. Wound acquired in-house . 04/15/2026 . Increased exudate. Non-healing. Length (cm): 3.1 Width (cm): 2 Depth (cm): 0.1 . Slough: 100%. Eschar: 20%. Exudate amount: Moderate. Seropurulent: mixture of purulent and serous, usually watery, yellow, green, tan or brown. Surrounding tissue: Erythema. Dressing saturation: Moderate 26-75%. The wound committee assessed Resident #65 on 04/30/26 and determined the pressure ulcer as stable. The nurse's assessment at 12:34 p.m. on the same day contradicts the wound committee's assessment as stable. * 05/02/26 at 3:57 a.m., . Dressing was changed for soilage and break through drainage. Resident tolerated procedure well.* 05/02/26 at 3:16 p.m., . wound culture results . positive for Staphylococcus Aureus [bacteria]. Ciprofloxacin [antibiotic] 500mg [milligrams] PO [oral] BID [twice a day] x 5days. [physician name] would like for resident to be re-evaluated by [physician assistant name] during rounds on Monday 5/4/26.* 05/03/26 at 3:57 p.m., . Wound Infection (Sacrum) . small amount of serosanguineous [pink and watery] drainage was observed on the previous dressing. The wound bed contains area of necrotic [dead tissue] tissue. The site is tender upon palpation .* 05/04/26 at 5:33 a.m., . Wound Infection (Sacrum) . drainage with a foul odor. The wound bed area was reddened with dark tissue to the wound bed.* 05/04/26 at 9:34 a.m., . RT [restorative therapy] did place a different cushion in wheelchair.RT assessed Resident #65 for a new cushion approximately 19 days after the pressure ulcer was first noted. * 05/04/26 at 10:12 a.m., . Sacrum. Laterality . Middle. Size has increased. Smell increased. Painful . Pain description: Sharp. Length (cm): 2.1 Width (cm): 3.5 Depth (cm). Slough: 60%. Eschar: 40%. Exudate amount: Light. Seropurulent: mixture of purulent and serous, usually watery, yellow, green, tan or brown. Odor after cleansing: Moderate. Surrounding tissue: Excoriated. Erythema. Induration > [greater than] 4 cm in any area around wound. * 05/05/26 at 5:37 p.m., . Wound Infection (Sacrum) . Resident continues on Cipro BID for treatment of wound infection to sacrum. Old dressing removed with moderate amount of serosanguineous drainage noted . Aprox [approximately] 50% of wound bed is slough and 50% has appearance of necrotic tissue that is tender with palpation.* 05/06/26 at 8:46 p.m., Wound Infection (Sacrum) . Previous dressing has a moderate amount of serosanguineous drainage with a foul odor. The wound bed area has some slough and necrotic tissue noted.* 05/10/26 at 9:53 a.m., . Wound Infection (Sacrum) . Wound has increased in size since last observed. Area is tender to touch.* 05/11/26 at 9:21 a.m., . Resident continues with unstageable pressure ulcer to sacral area with wound bed covered in slough/eschar. A New stage 2 pressure ulcer noted right below it that is a stage 2 with partial thickness skin loss with red/pink wound bed. Mepilex applied to the stage 2 pressure ulcer. She was added to [physician assistant] rounds this after [afternoon] for review due to continues [sic] worsening of wound. Antibiotics for wound infection was completed on 5/8/26. She continues to be at risks [sic] for ongoing pressure and delay in wound healing. See skin assessment for measurements. * 05/11/26 at 9:56 a.m., . Sacrum. Laterality . Middle. Pressure ulcer . Size has increased. New or satellite areas of breakdown. Length (cm): 4.3 Width (cm): 4.2 Depth (cm): 0.1 . * 05/11/26 at 10:00 a.m., . New skin Issue. Location: Right gluteus. Right upper buttock . Stage 2 Pressure ulcer / injury - partial thickness skin loss with exposed dermis [middle layer of skin]. Wound acquired in-house. Wound is new. Pain description: Sharp. Length (cm): 2.8 Width (cm):1.5 Area (cm2) . Exudate type: None. Odor after cleansing: None. Surrounding tissue: Intact. Surrounding tissue: Erythema. Induration > 4 cm inany [sic] area around wound.* 05/12/26 at 2:33 p.m., . Resident was given convoluted [pressure relieving] cushion for W/C last week to try out for comfort. She stated it feels more comfortable where her wound is when sitting in W/C. A convoluted cushion will also be placed in her recliner, so she gets out of W/C during the day for more frequent repositioning.* 05/13/26 at 10:55 a.m., . Wound Infection (Sacrum) . Foul odor present when dressing changed this shift. Copious [large] amounts of drainage present to superior sacral dressing, Polymer completely saturated. Area cleansed with Vashe [wound cleanser], dressing applied as ordered.* 05/13/26 at 4:36 p.m., [physician] here this morning and saw resident on rounds . New orders received.* 05/14/26 at 6:08 p.m., Wound Infection (Sacrum) . new abx [antibiotic] started 5/13/26. Wound assessed and has some serosanguineous drainage with slough and necrotic tissue to upper portion of wound bed. Foul odor noted. No increased warmth but redness around red edges remains.* 05/16/26 at 4:51 a.m., . Wound Infection (Sacrum) . Wound beds not visible as they are covered with slough and black eschar. Moderate yellowish drainage noted on the dressing with no granulation tissue.* 05/18/26 at 9:26 a.m., . Right upper buttock . Stage 2 Pressure ulcer . partial thickness skin loss with exposed dermis. Wound acquired in-house. Wound is new. Reason measurements not documented as part of this assessment: Area has merged with the sacral ulcer .* 05/18/26 at 9:42 a.m., . Wound Infection (Sacrum) . Wound committee into [sic] assess wounds after whirlpool. Sacral and right upper buttock have merged into one large unstageable pressure ulcer. Area has rapidly deteriorated andhas [sic] become larger and deeper. No complaints of pain during dressing change. Redness surrounds the wound but blanchable. Therapy placed a different cushion in wheelchair last week that [Resident #65] states is helping. [physician] ordered a second round of antibiotics last week with no improvement noted to wound bed. She continues withan [sic] air mattress on bed . [physician] notified with request for wound clinic referral.* 05/18/26 at 10:40 a.m., Cushion provide [sic] behind the back in W/C due to ongoing wound.* 05/19/26 at 3:05 p.m., Dressing to sacral wound changed again at this time due to drainage and 4x4 Mepilex coming off. Sacral dressing placed along with entire sheet of the Polymer cavity filler. [Resident #65] reports her nurse had already changed her dressing late this morning. She has wound clinic appointment scheduled for Thursday. * 05/21/26 at 10:31 a.m., Wound Infection (Sacrum) . wound assessed edges of wound appear macerated, wound has slough necrotic tissue in upper portion/center of wound bed no drainage noted at this time. Redness noted to be surrounding wound.* 05/21/26 Resident #65 left for the first scheduled appointment at the wound clinic. * 05/21/26 at 6:06 p.m., Received call from ER [emergency room] nurse at [hospital] as resident was sent to them from the wound clinic due to severity of her wound. Nurse reports that a CT [computed tomography] scan was done of the wound and it is in to [sic] the bone and the surgeon at [hospital] is making arrangements for [resident] [NAME] [sic] transferred via ambulance to [hospital] in Fargo.* 05/22/26 at 9:27 a.m., Call placed to [hospital] Fargo for a resident update. Nurse [name] reported she arrived on the trauma med surg [medical surgical] unit . with dx [diagnosis] of a sacral ulcer . She is currently being held as NPO [nothing by mouth] until they hear back from provider about a possible procedure.* 05/25/26 at 11:57 a.m., . Call placed to husband [name]. stated [resident] was transferred to Minneapolis to a hospital . regarding her bladder stimulator.* 05/29/26 at 10:00 a.m., Call placed to [hospital] for an update on this resident. Nurse [name] stated she is currently on IV [intravenous] antibiotics . The doctor is recommending 6 weeks of antibiotic therapy following removal of her bladder stimulator on 5/26/29.During an interview on 07/29/26 at 4:30 p.m., a nurse (#8) stated the facility was not aware of the bladder stimulator and the stimulator caused the pressure ulcer to the resident's sacrum. During an interview on 07/29/26 at 5:46 p.m., an administrative nurse (#1) stated because antibiotics were initiated on 05/02/26, the facility staff removed Resident #65 from the physician PA rounds on 05/04/26. The nurse (#1) also stated because Resident #65 was scheduled for routine rounds with the physician on 05/13/26, the facility removed the resident from the PA's rounds schedule on 05/11/26. During a phone interview on 07/30/26 at 10:42 a.m., a PA (#9) stated she sees residents on Mondays, sees any resident the physician did not see, and also sees residents with acute issues. The PA (#9) stated the facility provides a list of residents to be seen. The PA (#9) stated she expected facility staff to schedule an appointment with a provider for residents who have a decline or a significant change to a pressure ulcer. During an interview on 07/30/26 at 11:02 a.m., a nurse (#8) stated nursing staff adds a resident with concerns to the provider list or makes an appointment at the clinic. The nurse (#8) agreed Resident #65 should have been seen at the clinic for the documented decline the end of April. The facility failed to ensure a provider evaluated Resident #65's sacral ulcer between 04/15/26 and 05/13/26. (27 days) during which time the sacral ulcer worsened.

1. Based on record review, review of facility policy, and staff interview, the facility failed to provide adequate supervision and/or assistance for 1 of 5 sampled residents (Resident #5) who experienced frequent falls. Failure to provide adequate supervision, assistance, and interventions to prevent falls, resulted in two transfers to the emergency room, pain, lacerations and abrasions, and lethargy. Findings include: Review of the facility policy titled Fall Policy occurred on 07/30/26. This policy, dated 2017, stated, . Falls will be discussed in morning meetings. Immediate interventions are discussed as well as any other possible contributing factors that may be mitigated by additional interventions. Weekly prn [as needed] fall reviews will be done by the fall committee in QA [quality assurance] meetings. At the monthly safety meeting, the falls are discussed and patterns evaluated and any safety issues addressed. Review of Resident #5 medical record occurred on all days of survey. Diagnoses included agitation/restlessness, dementia, and Parkinson's disease. The annual Minimum Data Set (MDS), dated [DATE], identified severely impaired cognition, more than two falls without injury, and more than two falls with injury during the assessment period. A fall assessment, dated 06/19/26, described Resident #5 as disoriented all the time, balance problems while standing/walking, chairbound, and at risk for falls. The current care plan stated, . Impaired mobility with potential for falls related to: poor safety awareness . Ambulates x2 [times two] assist with FWW [front wheeled walker] as tolerated . Bed in low position when occupied . Check on resident frequently, encourage assist with all transfers and ambulation . Do not leave unattended in . dining room [Initiated on 06/30/26 after the resident's fifth fall in the dining room] . Transfers x1-2 [times one-two] assist . Trial use of leg support on footrests [Initiated on 07/27/26 after 37 falls] . Wheelchair per staff assist . Requires assistance with daily cares . Dependent for toileting hygiene . Resident #5's progress notes identified the following dates and locations of falls: * One fall in the activity room: 07/05/26 * Six falls in the dining room: 09/09/25, 03/28/26, 04/06/26, 04/10/26, 04/19/26, 06/25/26 * Seven falls in the day, lobby, lounge, tv area: 10/15/25, 10/22/25, 10/24/25, 11/30/25, 04/13/26, 04/26/26, 05/15/26 * Two falls near the nurses' station: 03/12/26, June 2026 (day of month was not visible on report) * 16 falls in the resident's room: 08/16/25, 10/19/25, 12/01/25, 01/30/26, 02/06/26, 03/11/26, 03/13/26, 03/14/26, 03/30/26, 04/02/26, 04/03/26, 04/13/26, 05/25/26, 06/16/26, 06/30/26, 07/12/26 The progress note, dated 07/12/26 at 1:10 a.m., stated, . the resident was found partially suspended from the head of the bed. Resident's lower extremities remained on the bed, while the resident's head and upper body were hanging over the side, with the head wedged between the closet and wall . swelling and a visible red indentation to the left side of resident's head. Redness was also noted to the resident's shoulder. Skin remained intact . Resident . reported pain. Neurological checks were initiated . During the second neurological assessment, the resident appeared increasingly lethargic . with delayed response to verbal and tactile stimuli. EMS [Emergency Medical Services] . transported the resident to the local hospital for further evaluation. * Four falls in unknown locations: 01/09/26, 02/23/26, 04/12/26, 06/20/26 * 16 falls required neuro-checks (as assessment used to monitor changes or deterioration in neurologic functions): 08/16/25, 10/22/25, 10/24/25, 11/30/25, 12/02/15, 02/06/26, 03/13/26, 03/14/26, 04/03/26, 04/13/26, 04/26/26, 05/15/26, 05/25/26, 06/16/26, 06/20/26, 06/25/26 * Two falls required transfer to the emergency room: 10/22/25, 07/12/26 * One fall required an assessment by the provider: 04/13/26 During an interview on 07/30/26 at 9:10 a.m., an administrative staff member (#1) described Resident #5 as quick and can walk when he wants. When asked what interventions the facility has tried, the administrative staff member (#1) stated, He doesn't engage in a lot of activities. We've tried to toilet him more frequently. Staff have been told he can't be left in the dining room unattended. When asked about new interventions and when the interventions are added to the resident's care plan, she responded, We discuss falls during the morning meetings, to see if there is anything else we can do. When asked if staff rearranged Resident #5's room after the fall on 07/12/26 when his head was wedged between the closet and the wall, the administrative staff member (#1) stated, I don't know and We would probably have to move him to a different room. The staff member agreed Resident #5 could end up in the same position (with his head wedged between the closet and wall) again. Resident #5 experienced approximately 36 falls between 08/16/25 and 07/12/26, which resulted in two transfers to the emergency room, increased lethargy/delayed responses to stimuli, and minor injuries including an abrasion to his lower back, a laceration to his elbow, a large mark on his forehead, redness to his shoulder, hip, and knee, rib pain, scrapes/scratches to his forearms and knee. Staff repeatedly reminded Resident #5 to use the call light for assistance even though the resident had severely impaired cognition. The facility failed to provide the necessary supervision, assistance, and appropriate interventions to prevent future falls. 2. Based on observation, record review, review of facility policy, and staff and resident interviews, the facility failed to ensure the residents' environment remained as free of accident hazards as possible for 1 of 1 sampled resident (Resident #10) who kept cigarettes and a lighter in their room. Failure to safeguard the accessibility of smoking supplies from other residents, including residents known to wander, may result in injury, burns, fire, or other smoking-related accidents. Findings include: Review of the facility policy titled Smoke Free Facility occurred on 07/28/26. This policy, dated April 2025, stated, Policy: It is the policy of this facility to provide a safe and healthy environment for residents, visitors, and employees. Therefore, this facility is a 'Smoke Free Facility.' Policy Explanation and Compliance Guidelines: 1. This policy applies to all residents, visitors, and employees. 6. Residents who are cognitively intact and are determined to be safe may choose to leave facility grounds to smoke. Review of Resident #10's medical record occurred on all days of survey. The current care plan stated, Resident is alert and oriented and is known to independently leave facility grounds without notifying staff to smoke . Document any known episodes of unsafe smoking behavior . Educate resident regarding facility non-smoking policy and rationale . Encourage resident to avoid smoking near schools, churches, behind vehicles, funeral homes, or inappropriate public locations. Notify charge nurse immediately if it is suspected resident has violated facility smoking policy. The care plan failed to identify where the resident's cigarettes and lighter were to be stored to prevent access by other residents. During an interview on 07/28/26 at 9:28 a.m., Resident #10 stated he smoked and had been instructed he could smoke as long as he went off facility grounds, such as across the street. Observation showed a package of cigarettes and a lighter on the resident's bedside table. When asked whether other residents entered his room, Resident #10 stated the resident across the hall had wandered into his room during the night. Observations conducted on 07/28/26 at 8:00 a.m., the morning of 07/29/26, and on 07/30/26 at 8:38 a.m. showed Resident #10's room door open and the cigarettes and a lighter on the resident's beside table in plain view. During an interview on 07/29/26 at 4:32 p.m., an administrative nurse (#8) stated Resident #10 purchased his own smoking supplies and kept the supplies in a bag attached to the back of his wheelchair. During an interview on 07/30/26 at 8:19 a.m., Resident #10 stated he kept his smoking supplies on the table in his room. During an interview on the afternoon of 07/30/26, an administrative nurse (#1) confirmed Resident #10 should not keep cigarettes and lighter on the bedside table because the facility has residents who wander into other residents' rooms.

Based on record review, review of facility policy, and staff interview, the facility failed to notify the physician and/or resident representative of a change in condition and falls for 1 of 5 sampled residents (Resident #5) reviewed for symptoms of hypoglycemia and falls. Failure to promptly notify the physician regarding low blood glucose readings and failure to notify the resident representative regarding the falls limited the physician's ability to alter treatment and limited the resident representative's ability to make informed decisions regarding Resident #5's care. Findings include: Review of the facility policy titled Notification of Change occurred on 07/30/26. This policy, dated 2017, stated, . An accident involving the resident which results in injury and has the potential for requiring physician intervention. A significant change in the resident's physical, mental, and psychosocial status. These changes may include a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications. Review of the facility policy titled Hypoglycemia occurred on 07/30/26. This policy, dated, 2017, stated, . Hypoglycemia is defined as a blood glucose less than 70 mg/dl [milligrams per deciliter], with or without symptoms and requires immediate treatment. Notify physician of blood glucose levels below 60 mg/dl . BLOOD GLUCOSE Review of Resident #5's medical record occurred on all days of survey and identified blood glucose levels less than 60 mg/dL on five occasions. Review of Resident #5's blood glucose readings from April - May, 2026 showed the following:* 04/03/26, 45 mg/dL and 46 mg/dL* 04/14/26, 54 mg/dL* 04/28/26, 45 mg/dL* 05/01/26, 35 mg/dL* 05/08/26, 58 mg/dL Review of Resident #5's progress notes identified the following:* 04/03/26 at 6:43 a.m., . Given Breeze, Root Beer, and a cookie at 0615 [6:15 a.m.] for a blood sugar of 45 taken by night nurse at 0515 [5:15 a.m.]. Blood sugar did not increase much at this time, so was given more Breeze and cookie. * 04/03/26 at 6:57 a.m., Resident had blood glucose of 45 mg/dL at 0525 [5:25] am and he was asymptomatic. He was given fortified high calorie drink and a few wafers by the AM nurse. Recheck at 0640 [6:40 a.m.] and BGL [blood glucose level] is now 69 mg/dL. Will continue to monitor.* 04/03/26 at 7:05 a.m., . Administration was: Effective Blood sugar up to 93 at this time.* 04/14/26 at 4:56 a.m., . attempted to provide Resident with chocolates and orange juice to increase blood glucose levels resident refused. Resident sated [sic] repeatedly 'leave me the [profanity] alone' This writer informed and educated resident that his glucose was out of normal range and that it needed to be addressed immediately to prevent potential injury. Resident stated 'Get the [profanity] out of my room you [profanity].'* 05/01/26 at 6:04 a.m., . Checked blood glucose at 4:00 AM blood sugar was 37 Gave resident snack as he stated 'I am not drinking no [profanity] orange juice' but agreed to nutri-grain bar Rechecked and it was 35 resident not agreeable to any attempts to raise glucose.* 05/08/26 at 4:21 a.m., . 240 ml of boost offered and resident drink it all.* 05/17/26 at 10:02 a.m., [pharmacist entry] Resident with recurrent fasting hypoglycemia including BG as low as 35 mg/dL. Recommend reducing insulin glargine dose to decrease severe hypoglycemia risk. The facility failed to notify the provider about Resident #5's low blood glucose readings and failed to address the resident's low blood glucose level on 04/28/26. FALLS Review of Resident #5's progress notes identified approximately 36 falls between 08/16/25 and 07/12/26. The medical record lacked documentation the facility notified the resident's representative of approximately 10 of the 37 falls. During two interviews on 07/30/26, an administrative staff member (#1) indicated she expected staff to document any physician and/or resident representative contact in the resident's progress notes and confirmed staff failed to notify the physician about Resident #5's low blood glucose readings.

Based on record review and review of facility policy, the facility failed to ensure residents remained free from unnecessary psychotropic medications for 1 of 1 sampled resident (Resident #22) reviewed for as needed (PRN) psychotropic medication. Failure to limit PRN psychotropic medication orders to 14 days or obtain physician documentation supporting clinical rationale for extending the order beyond 14 days placed the resident at risk of receiving unnecessary psychotropic medication and potential adverse effects associated with its use.Findings include:Review of the facility policy Use of Psychotropic Drugs occurred on 07/29/26. This policy, dated 2017, stated, Policy: It is the policy of Golden Acres Manor that each resident's drug regiment is free from unnecessary drugs . Policy Explanation and Compliance Guidelines: 1. Resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used: . b. For excessive duration . 6. PRN orders for psychotropic drugs are limited to 14 days, except as provided if the attending physician or prescribing practitioner believe that it is appropriate for the PRN order to be extended beyond 14 days. He or she should document their rationale in the resident medical record and indicate the duration for the PRN order.Review of Resident #22's medical record occurred on all days of survey. Physician's orders included lorazepam (an anti-anxiety medication) every four hours as needed for restlessness/anxiety, initiated 06/18/26. Review of Resident #22's electronic medication administration record (EMAR) showed the facility administered PRN lorazepam on July 23, 25, and 26, 2026. These dates were beyond the acceptable duration of 14 days. The medical record failed to show physician documentation supporting the clinical rationale to extend the PRN lorazepam order beyond 14 days.

Based on record review, review of facility policy and staff interview, the facility failed to report incidents of abuse to the State Survey Agency (SSA) within the required time frames for 3 of 16 sampled residents (Resident #47, #56 and #57) reviewed for resident-to-resident abuse. Failure to ensure incidents of potential abuse are reported to the SA immediately, but no later than 2 hours after the allegation is made, may result in continued abuse, fear, anxiety, and psychosocial harm. Findings include: Review of the facility policy titled Resident to Resident Altercation occurred on 07/29/26 and 07/30/26. This revised policy, dated 05/25/26, stated, . 4. If a Resident-to-Resident Altercation is suspected or alleged, the facility will take the following actions: . e. Notify the administrator or Director of Nursing. f . 2.If there is no serious bodily injury, report no later than 24 hours to the State Survey Agency . - Review of Resident #56's medical record occurred on all days of survey. Diagnoses included borderline personality disorder, mild intellectual disabilities, Post-Traumatic Stress Disorder, major depressive disorder, and mood disorder. The current care plan stated, Post Traumatic Stress Disorder. Goal: patient will acknowledge and feel that they are safe and cannot be harmed. Interventions: acknowledge the resident's feelings and show understanding, monitor for avoidances of places, people, or situations. A progress noted, dated 07/25/26 at 5:07 p.m., stated, Resident [Resident #57] was ambulating near the nurses' station toward her room when she became verbally upset with another resident [Resident #56] after believing the resident [Resident #56] was talking about her. Resident [Resident #57] stated, '[profanity] you,' to the other resident. The other resident [Resident #56] responded with the same statement, after which the resident became increasingly agitated, walked toward the other resident, and stated, 'Do you want to [profanity] fight?' Writer immediately intervened by positioning self between both residents to prevent further escalation. Resident [Resident #57] was given clear verbal redirection, instructed to stop using inappropriate language and making threats, and directed to disengage from the interaction and return to her room. Resident initially complied and began walking away. As the resident [Resident #57] was walking toward her room, the other resident [Resident #56] stated to nursing staff that she believed the resident 'should be at the state hospital.' Upon hearing this comment, the resident turned and yelled, 'If I had a knife, I will cut your [profanity] throat.' Writer immediately redirected the resident again, instructed her to stop making threatening statements, and reinforced expectations for appropriate behavior. Resident [Resident #57] complied with redirection, continued to her room, and no further verbal or physical aggression was observed. Both residents were separated for the remainder of the shift and monitored closely to prevent further interaction. No physical contact or injuries occurred. Resident [Resident #57] remained in her room following the incident, and no additional behaviors were observed during the remainder of the shift. Continued monitoring and behavioral observation will be maintained. During an interview on 07/27/26 at 6:38 p.m., two administrative staff members (#1 and #4) confirmed the facility failed to report the altercation that occurred on 07/25/26 to the SSA until the morning of 07/27/26. - Review of Resident #47 medical record occurred on all days of survey. Diagnoses included Alzheimer's disease, anxiety, dementia with psychotic disturbance, and depression. The current care plan stated, . Alteration in mood and behaviors . Tends to wander/follow other residents at times, may attempt to hold their hand at times. Likes to hang around . front lounge. Periods of increased restlessness, delusions . Redirect as able away from other residents if appears unwanted attention attempted. When resident is anxious, take her for a walk outside . or 1:1 . Resident #47's progress note, dated 06/22/26 at 1:58 p.m., stated, . Resident was involved in a physical altercation with another resident. Writer observed both residents striking each other. Staff intervened immediately and separated the residents. Resident was assessed for injuries, no injuries was [sic] noted. During an interview on 07/29/26 at 5:30 p.m., an administrative staff member (#1) confirmed staff failed to report the incident that occurred on 06/22/26 to the SSA.

Based on record review, review of the facility reported incident (FRI) investigation, review of facility policy, and staff interviews, the facility failed to investigate incidents of verbal and physical abuse for 3 of 16 sampled residents (Resident #47, #56 and #57) reviewed for resident-to-resident abuse. Failure to investigate alleged violations of resident-to-resident abuse, ensure residents were protected during investigation, implement corrective actions, and evaluate the effectiveness of the actions, placed Resident #47, #56, and #57, and all residents at risk for possible mental/emotional distress and injury. Findings include: Review of the facility policy Abuse and Neglect Policy and Procedure occurred on 07/29/26 and 07/30/26. This undated policy stated, , . Investigation must include: Date, time and place of incident, adverse reactions, results of interviews, and actions taken. - Review of Resident #56's medical record occurred on all days of survey. Diagnoses included borderline personality disorder, mild intellectual disabilities, Post-Traumatic Stress Disorder, major depressive disorder, and mood disorder. The current care plan stated, Post Traumatic Stress Disorder. Goal: patient will acknowledge and feel that they are safe and cannot be harmed . Interventions: acknowledge the resident's feelings and show understanding, monitor for avoidances of places, people, or situations. A progress noted, dated 07/25/26 at 5:07 p.m., stated, extra space Resident [Resident #57] was ambulating near the nurses' station toward her room when she became verbally upset with another resident [Resident #56] after believing the resident [Resident #56] was talking about her. Resident [Resident #57] stated, '[profanity] you,' to the other resident. The other resident [Resident #56] responded with the same statement, after which the resident became increasingly agitated, walked toward the other resident, and stated, 'Do you want to [profanity] fight?' Writer immediately intervened by positioning self between both residents to prevent further escalation. Resident [Resident #57] was given clear verbal redirection, instructed to stop using inappropriate language and making threats, and directed to disengage from the interaction and return to her room. Resident initially complied and began walking away. As the resident [Resident #57] was walking toward her room, the other resident [Resident #56] stated to nursing staff that she believed the resident 'should be at the state hospital.' Upon hearing this comment, the resident turned and yelled, 'If I had a knife, I will cut your [profanity] throat.' Writer immediately redirected the resident again, instructed her to stop making threatening statements, and reinforced expectations for appropriate behavior. Resident [Resident #57] complied with redirection, continued to her room, and no further verbal or physical aggression was observed. Both residents were separated for the remainder of the shift and monitored closely to prevent further interaction. No physical contact or injuries occurred. Resident [Resident #57] remained in her room following the incident, and no additional behaviors were observed during the remainder of the shift. Continued monitoring and behavioral observation will be maintained. During an interview on 07/27/26 at 6:38 p.m., two administrative staff members (#1 and #4) verified the resident-to-resident altercation occurred on 07/25/26 and the facility had not started an investigation. - Review of Resident #47 medical record occurred on all days of survey. Diagnoses included Alzheimer's disease, anxiety, dementia with psychotic disturbance, and depression. The current care plan stated, . Alteration in mood and behaviors . Tends to wander/follow other residents at times, may attempt to hold their hand at times. Likes to hang around . front lounge. Periods of increased restlessness, delusions . Redirect as able away from other residents if appears unwanted attention attempted. When resident is anxious, take her for a walk outside . or 1:1 . Resident #47's progress note, dated 06/22/26 at 1:58 p.m., stated, . Resident was involved in a physical altercation with another resident. Writer observed both residents striking each other. Staff intervened immediately and separated the residents. Resident was assessed for injuries, no injuries was [sic] noted. During an interview on 07/29/26 at 5:30 p.m., an administrative staff member (#1) confirmed the facility failed to thoroughly investigate the incident that occurred on 06/22/26.

Based on record review, review of facility policy, review of the North Dakota Provider Manual for Preadmission Screening and Resident Review (PASARR) and Level of Care Screening Procedures for Long Term Care Services, and staff interview, the facility failed to complete a status change assessment for 1 of 1 sampled resident (Resident #5) with a newly diagnosed mental illness. Failure to complete a change in status assessment may result in the delivery of care and services that are inconsistent with residents' needs. Findings include:Review of the facility policy titled Resident Assessment - Coordination with PASARR Program occurred on 07/30/26. This undated policy stated, . Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or a related condition will be referred promptly to the state mental health or intellectual disability authority for a level II resident review.The North Dakota PASARR Provider Manual, revised 07/19/22, page 13 states, . Change in Status Process . Whenever the following events occur, nursing facility staff must contact Maximus to update the Level I screen for determination of whether a first time or updated Level II evaluation must be performed. These situations suggest that a significant change in status has occurred: . If an individual with MI, ID, and/or RC (mental illness, intellectual disability, and conditions related to intellectual disability [referred to in regulatory language as related conditions or RC]) was not identified at the Level I screen process, and that condition later emerged or was discovered.Review of Resident #5's medical record occurred on all days of survey. The record showed an initial PASARR completed 02/28/24, and included diagnoses of depression, persistent mood disorder and major neurocognitive disorder due to Parkinson's disease with behavioral disturbances. The medical record showed a new diagnosis of psychosis on 09/24/24. The record lacked evidence the facility notified Maximus when Resident #5 received the diagnosis of psychosis. During an interview on 07/30/26 at 3:29 p.m., an administrative staff member (#4) confirmed the facility failed to contact Maximus with the diagnosis of psychosis.

Based on record review, review of professional reference, and resident and staff interviews, the facility failed to ensure provision of care and services consistent with accepted professional standards of practice for 1 of 1 sampled resident (Resident #10) on hemodialysis. Failure to routinely assess and monitor the resident's hemodialysis vascular access site (fistula) may delay the identification of complications, including infection, clotting, bleeding, or loss of vascular access. Findings include:Review of the Core Curriculum for the Dialysis Technician - A Compressive Review of Dialysis, Fifth Edition, page 121 and 127 states, . Vascular access makes chronic hemodialysis (HD) possible . An access is an HD patient's lifeline. Access problems can cause hospital stays, surgery illness, limb loss, and death. Examine the fistula [vascular access] . listen for Bruit - the sound and pitch of whooshing) . Feel for: skin temperature - more warmth (could be infection) or cold (could mean less blood flow). Thrill - should be present and constant, . A fistula should have a strong flow of blood. Teach . patients to feel their thrill at least once a day . a change in the thrill (or the volume of the bruit) can mean blood flow through the access is slowing down. Types of Accesses. The three main types of access are 1. Fistula. 2. Grafts 3. Central venous catheters.- During an interview on 07/27/26 at 9:23 a.m., Resident #10 stated he had a fistula in his left arm for hemodialysis. When asked whether staff checked the fistula site, the resident stated, nobody looks at my arm. Review of Resident #10's medical record occurred on all days of survey. The current care plan stated, Alteration in health maintenance related to: . end stage renal disease . Receives Dialysis outside of facility. The care plan failed to identify the resident's vascular access type (left arm fistula), interventions for routine fistula assessment, address potential fistula complications, or provide instructions for ongoing monitoring and care. Review of Resident #10's nurses' progress notes and nursing assessments from admission on [DATE] through 07/29/26, failed to show documentation regarding assessment of the residents left arm fistula, including the presence or absence of a bruit or thrill, condition of the access site, or any other vascular access assessment.During an interview on 07/29/26 at 2:30 p.m., an administrative staff member (#1) stated the facility does not have a policy or process regarding the care and monitoring of residents receiving hemodialysis.

Based on observation, review of facility policy, and staff interview, the facility failed to ensure safe and secure storage of medications in 1 of 3 units (100-unit) observed. Failure to secure medications may result in unauthorized access to medications. Findings include:Review of the facility policy titled Medication Administration occurred on 07/29/26. This policy, revised 04/28/26, stated, . Lock cart when not attended to.Observation on 07/28/26 at 7:40 a.m. showed an unlocked medication cart in the 100-unit hallway with a medication cup containing two pills on the top of the cart, and the computer screen open and displaying resident information. Observation showed facility staff left the medication cart unattended for over 3 minutes with residents present in the hallway. During an interview on 07/29/26 at 3:38 p.m., an administrative nurse (#1) confirmed she expected staff to lock the medication cart, not leave medications unattended, and close out of the computer screen when the medication cart is left unattended.

Based on observation, review of facility policies, and staff interviews, the facility failed to serve beverages at palatable temperature in 1 of 2 dining rooms (Dining room [ROOM NUMBER]) observed. Failure to serve breverages at palatable temperatures to residents may result in decreased intake, weight loss, and inadequate nutrition. Findings include:Review of the facility policy titled Policy for Temperature Control of Foods occurred on 07/29/26. This undated policy stated, Goal: To provide food that is palatable, attractive, and at the proper temperature . Cold foods will be refrigerated until the appropriate time to be served. Food temperatures will be periodically monitored. If temperature control standards are not consistently met. Procedures will be reviewed, with recommendations made for change.Review of the facility policy titled Policy on Food Handling occurred on 07/29/26. This undated policy stated, . Appropriate food temperatures are maintained during food preparation and serving to protect against food borne illness: . Observation in the 300-dining room occurred on 07/27/26 at 11:45 a.m. and showed an unidentified dietary staff member filled milk glasses and placed on the dining room tables. At 12:40 p.m. (55 minutes later), Resident #16 and Resident #22 arrived at their dining tables. Resident #16 took a sip of the milk and stated it was warm. A dietary staff member (#5) measured the temperature of Resident #16's milk, and the reading showed 64.9 degrees Fahrenheit. The dietary staff member confirmed the temperature of the milk should be 40 degrees or lower, removed Resident #16 and Resident #22's milk and replaced it with freshly poured milk. The dietary staff member (#5) did not check the temperature of Resident #22's milk, stating I am sure it is the same temperature.

Based on review of the North Dakota Department of Health, Division of Health Facilities provider files, record review, review of facility policy, survey findings, and staff interview, the facility failed to maintain a Quality Assurance (QA) process, which identified and implemented preventative actions and mechanisms to decrease or prevent adverse events. Findings include: Review of the facility policy Quality Assurance and Performance Improvement (QAPI) occurred on 07/30/26. This policy, revised 04/30/26, stated, . It is the policy of this facility to develop, implement, and maintain an effective, comprehensive, data-driven QAPI program that focuses on indicators of the outcomes of care and quality of life. 2. The QAA [Quality Assessment and Assurance] Committee shall be interdisciplinary and shall: . c. Develop and implement appropriate plans of action to correct identified quality deficiencies. d. Regularly review, and . act on available date to make improvements. The QAPI plan will address the following elements . Developing and implementing corrective action or performance improvement activities. v1. Monitoring and evaluating the effectiveness of corrective action/performance improvement activities and revising as needed. Review of the North Dakota Department of Health, Division of Health Facilities Provider files identified the facility failed to maintain compliance in the following area previously cited on 04/30/26:*F600-Free from Abuse and Neglect Review of medical records showed the facility failed to protect Resident #47, #56 and #57 and all other residents from verbal/physical abuse. Review of the Behavior Documentation Tool used by the facility failed to identify potential triggers causing resident behaviors or suggest any new interventions after behaviors occurred. The facility failed to utilize the QAPI process for resident-to-resident altercations and behaviors which resulted in resident abuse and continued noncompliance at F600.

Based on observation, review of facility policy, review of professional reference, and staff interview, the facility failed to follow standards of infection control and prevention for 3 of 3 sampled residents (Resident #1, #24, and #15) observed during wound care and medication administration. Failure to practice infection control standards related to medication administration (Resident #15) and dressing changes (Resident #1 and #24) has the potential to spread infection throughout the facility. Findings Include: DRESSING CHANGES Review of Kozier & Erb's Fundamentals of Nursing, Concepts, Process and Practice, 11th Edition eText, 2021, Pearson, Boston, Massachusetts, Chapter 28 stated, . Skills 28.1 .Standard Precautions. 1. Perform proper hand hygiene after contact with . contaminated objects . a. Perform proper hand hygiene immediately after removing gloves. 2. Wear clean gloves when touching . contaminated items. Gloves. The hands are cleansed each time gloves are removed for two primary reasons: (1) The gloves may have imperfections or be damaged during wearing so that they could allow microorganism entry and (2) the hands may become contaminated during glove removal. -Observation on 07/28/26 at 10:30 a.m. showed a nurse (#6) donned gloves and placed wound care supplies, including tape, a bottle of wound cleanser, packaged gauze, and packaged dressing directly on top of Resident #24's bedspread. The nurse cleansed the wound with a gauze soaked with wound cleaner and then dried the area. Without changing gloves, the nurse opened the dressing package and applied the dressing to the wound. The nurse failed to place wound supplies on a clean surface and failed to change gloves and perform hand hygiene before applying the new dressing. -Observation on 07/28/26 at 10:49 a.m. showed a nurse (#6) donned a gown and gloves and placed wound care supplies, including tape, a bottle of wound cleanser, unpackaged gauze, and a packaged dressing, directly on top of Resident #1's bedspread. The nurse applied wound cleanser to the gauze and cleansed the resident's wound. The nurse reached into the pocket of a jacket worn beneath the gown, removed a pair of scissors, cut the Xeroform dressing, applied it to the wound, and attempted to cut the tape. The nurse failed to cut the tape, so he/she removed the dressing from the wound, removed the gloves, cut the tap, reached into the jacket pocket to answer a portable radio, and applied tape to the gauze. The nurse reached into the jacket pocket again to answer the portable radio. Without performing hand hygiene, the nurse donned new gloves and applied the dressing. After removing the gloves, the nurse returned the scissors to the jacket pocket and used hand sanitizer before leaving the room. The nurse (#6) failed to place wound care supplies on a clean surface; perform hand hygiene and change gloves after cleansing the wound and before applying the new dressing; disinfect the scissors before cutting the Xeroform and tape; and change gloves and perform hand hygiene after handling the portable radio. MEDICATION ADMINISTRATION Review of the facility policy titled Medication Administration occurred on 07/29/26. This policy, revised 04/28/26, stated, . Wash/Sanitize hands prior to administering medication. -Observation on 07/27/26 at 11:30 a.m. showed a nurse (#7) prepared medications for Resident #15. The nurse opened the medication cart with a key, retrieved the medication card, and removed two pills from the medication card. One of the pills fell on top of the medication cart and the nurse picked it up with bare hands and placed it in the medication cup. During an interview on 07/29/26 at 3:38 p.m., an administrative nurse (#1) stated she expected nursing staff to discard any medication that fall on the top of the medication cart.

Based on record review, review of the facility reported incident (FRI) investigations, observations, review of facility policy, and resident and staff interviews, the facility failed to ensure residents remained free from abuse for 5 of 5 sampled residents (Resident #2, #3, #4, #5, #6) who were subjected to verbal and physical abuse by Resident #1. Failure to protect residents from verbal and physical abuse may result in injury, fear, anxiety, mental anguish, emotional distress and resulted in retaliatory abuse to Resident #1.Findings include:Review of the facility policy titled Resident to Resident Altercation occurred on 04/30/26. This policy, dated 04/20/26, stated, . Resident to Resident Altercations can include: Verbally aggressive behaviors 1. Screaming 2. Cursing . Physically aggressive behaviors 1. Hitting 2. Kicking, grabbing . 4. Pushing/shoving . Touching or rummaging through other resident's property h. wandering into other resident's room/space .Review of the facility policy titled Resident Abuse and Neglect occurred on 04/30/26. This policy, dated 07/01/11, stated, Residents have the right to be free from verbal . physical and mental abuse .Review of Resident #1's medical record occurred on 04/30/26. Diagnoses included dementia, restlessness and agitation. The care plan stated, . Alteration in mood and behaviors related to . restless and agitation, and dementia with psychotic disturbances. Current indicators . History of entering other rooms, rummaging, verbal and physical behaviors. The quarterly Minimum Data Set (MDS), dated [DATE], indicated severely impaired cognition. -Incident between Resident #1 and #3Review of the FRI investigation, dated 04/09/26, stated, . [Resident #3] was sitting in common area/TV [television] in a recliner. [Resident #1] was by one of the other recliners in the TV area and [Resident #3] told him to leave the cords alone. [Resident #3] then got up and went to [Resident #1]. [Resident #1] started to mess with [Resident #3's] bag that was sitting on his recliner, and [Resident #3] proceeded to hit [Resident #1] on the left side of the head. [Resident #1] then hit [Resident #3] on the left side of the arm.Observation on 04/30/26 at 11:16 a.m. showed Resident #1 seated in a recliner in the front lobby area. When asked how he was, Resident #1 stated, Comfortable right now. When asked if he remembered being any physical altercations with other residents, he stated, No, I wouldn't hit anyone.During an interview on 4/30/26 at 8:51 a.m. when asked about the above incident, Resident #3 stated, I did not get hurt. [Resident #1] has dementia so bad. Review of Resident #3's medical record occurred on 04/30/26. The care plan stated, . Alteration in mood and behaviors related to: depression, anxiety, mental disorder, mild cognitive disorder . History (sic) verbal and physical behaviors involving others . The annual MDS, dated [DATE], indicated intact cognition. -Incident between Resident #1 and #4Review of the FRI investigation, dated 04/19/26, stated, . [Resident #1] followed [Resident #4] into the TV area. [Resident #1] was seen hitting [Resident #4] on the left side of the face. On 4/20/26 [Resident #4] reported to [social service designee] that [Resident #1] came up and hit him and asked [Resident #4] if he had his wallet. [Resident #4] then stated to [Resident #1] 'I don't have your [explicit] wallet' and then [Resident #1] hit him. Upon reviewing video footage of the altercation, it showed [Resident #4] ambulating with his walker past the nurse's station and turning into the TV area with [Resident #1] ambulating behind him. [Resident #1] was seen standing right behind [Resident #4] and it appeared he made a comment to [Resident #4]. [Resident #4] was seen swatting at [Resident #1] and then [Resident #1] hit [Resident #4] on the left chin area.Resident #1's progress note, dated 04/19/26 at 9:35 p.m., stated, . Resident physically assaulted another resident at 2004 [8:04 p.m.]. [Resident #4] was returning to a seat in the common area and [Resident #1] tried to engage him in conversation. When [Resident #4] did not respond to [Resident #1], he suddenly punched [Resident #4] on the left cheek. Writer had heard the raised pitch and arrived just as he was striking the other resident. Writer intervened and [Resident #1] was informed that such behavior was unacceptable.Review of Resident #4's medical record occurred on 04/30/26. The quarterly MDS, dated [DATE], indicated moderately impaired cognition. During an interview on 4/30/26 at 11:50 a.m. when asked if he remembered the altercation with Resident #1, Resident #4 stated, Yes, but I don't know why he would do that. I was just sitting here; I didn't do anything. -Incident between Resident #1 and #2Review of the FRI investigation, dated 04/26/26, stated, . Staff report that on 4/26/26 at around 1645 [4:45 p.m.] they witnessed [Resident #2] and [Resident #1] wrestling around on a reclining chair while another resident was sleeping on it. CNA [certified nurse aide] reports being called to the front to assist the nurse with [Resident #1] and [Resident #2]. She states that she helped the nurse separate the individuals but did not know what led to the altercation and did not know what was said prior. LPN [licensed practical nurse] reports that she was alerted by another resident that [Resident #1] and [Resident #2] were fighting. Upon entering the TV area, she saw both residents engaged in physical contact with each other and laying on their sides in a recliner on top of another resident. She states that her and [a CNA] were able to get the residents apart and separate them. [The LPN] completed an assessment and found that [Resident #2] had a small light red spot noted on the center of her head with no lump present. She also had a light red mark to her upper inner arm which she was unsure was due to the altercation or from the nurse attempting to assist resident from the recliner. Both areas resolved after time. Review of video footage . of the incident between [Resident #2] and [Resident #1] at around 1652 [4:52 p.m.] showed as follows: [Resident #1] was standing in front of the TV in the lounge area fidgeting with the control box. [Resident #1] was sitting in the recliner. After about 5 minutes [Resident #1] walked over to [Resident #2] and grabbed her by the arm which appeared as if he was trying to guide her away from the TV. [Resident #2] then turned around and hit [Resident #1] in the left arm. [Resident #1] then hit [Resident #2] back in the right arm. Both residents grabbed each other and had their arms around one another and then fell onto a reclining chair which was occupied by [Resident #7] who was reclined back in the chair. Staff immediately intervened and separated the residents.Review of Resident #2's medical record occurred on 04/30/26. The quarterly MDS, dated [DATE], indicated severely impaired cognition. -Incident between Resident #1 and #5Review of Resident #1's progress notes, dated 04/24/26 at 3:54 p.m. stated, . Activity director was walking residents down to the dinner tables and [Resident #1] kicked [Resident #5] who was walking in front (sic) him and he chuckled. Activities director corrected [Resident #1] and said that was not very nice and that we don't kick people. The [Resident #5] then turned around that he kicked and told him not to (sic) that again. During an interview on 4/30/26 at 11:20 a.m. when asked about the incident when [Resident #1] kicked [Resident #5,] an administrative staff member (#2) stated, I think [Resident #1] thought it was a joke and [Resident #5] did not take it that way.Review of Resident #5's medical record occurred on 04/30/26. The quarterly MDS, dated [DATE], indicated severely impaired cognition. During an interview on 4/30/26 at 11:30 a.m. when asked if she remembered when Resident #1 kicked her, Resident #5 stated, Yes, when I was standing and talking, she just let me have it. She's not 100 percent though.-Incident between Resident #1 and #6Review of Resident #1's progress notes, dated 04/20/26 at 2:03 p.m., stated, . Writer heard [Resident #6] yelling from Social Services office 'Get out here. Let it alone. Get out here you [explicit] Piece of slop' writer walked out to the front lobby sitting area to see what was going on. [Resident #1] was lifting up [Resident #6's] cushion in her chair looking for his wallet. writer got in between the two residents. AS [sic] writer was distracting resident, he raised his voice back and called her [Resident #6] a [explicit] bitch. [Resident #6] was still yelling and cursing and was going to take her shoe off to use towards Resident #1. Writer had this resident go for walk and look for his wallet in his room. After that resident and writer walked to prairie and he is sitting in recliner in Prairie dining room watching tv. Resident is calm sitting on prairie.Review of Resident #6's medical record occurred on 04/30/26. The quarterly MDS, dated [DATE], indicated intact cognition. During an interview on 04/30/26 at 11:35 a.m. when asked if she remembered the above incident, Resident #6 stated, Yes, he said he was looking for his keys or wallet. He's never had any keys or wallet. When asked if Resident #1 hit her she stated, No, but he wanted to hurt me. He gets me so mad. He hits my friend [Resident #4] for no reason. He hit [Resident #4] on the chin and [Resident #4's] glasses were crooked from it. I really wanted to hit him, but [Social Services Designee] told me that would not be a good idea, I'd probably end up in jail. I'm worried about my friend [Resident #4] though.During an interview on 04/30/26 at 12:00 p.m., when asked what she would do if she witnessed a resident hit another resident, the staff member (#3) stated, I'd get the RNs (Registered Nurses). When asked if there was anything else she would do, the staff member stated, I'd try to get a hold of someone.During an interview on 04/30/26 at 12:15 p.m., an administrative staff member (#1) stated Resident #1 has not been seen by psychiatry since 2024.The facility failed to protect Resident #2, #3, #4, #5, and #6 from Resident #1's abusive behaviors which resulted in retaliatory abuse to Resident #1.

Based on observation, review of professional reference, review of facility policy, and staff interview, the facility failed to maintain a clean and sanitary kitchen environment for 1 of 1 kitchen and 1 of 1 refrigerator on a nursing unit (Prairie Unit). Failure to clean fans in areas where food is stored and prepared, failure to ensure sanitizer test strips are not expired, and failure to store resident cold packs in an area separate from food has the potential for contamination of food and may result in a foodborne illness. Findings Include: The 2022 Food and Drug Administration (FDA) Food Code, Chapter 3 Food, Section 3-305 Preventing Contamination From the Premises, Section 3-305.11 states, A. Food shall be protected from contamination by storing the food: . 2) Where it is not exposed to . dust, or other contamination. Review of the facility policy Dietary Sanitation and Housekeeping Policy occurred on 05/29/25. This undated policy, stated, Goal: To provide all dietary employees with adequate training and education on sanitary requirements . and to assure that the requirements are maintained in the storage, preparation, distribution of foods . The dietary manager and assistant dietary manager are responsible to monitor sanitary conditions within the dietary department and make corrections and re-education staff as necessary. Cleaning schedules are posted and followed for routine cleaning of all equipment and work areas. Sanitizing solution concentration is periodically checked for adequate dispensing of sanitizer . Observation of the kitchen on 05/27/25 at 12:29 p.m. with an administrative dietary staff member (#14) showed the following: *Quaternary Ammonia Sanitizer test strips, used by staff to test the concentration of sanitizer solution, with an expiration date of December 2023. * An accumulation of dust on the hood above the oven. When asked how often the hood is cleaned, the dietary staff member (#14) stated a company cleans the hood every six months, but did not know when it was last cleaned. * An accumulation of dust/dirt on the grate below the front door of a reach-in refrigerator. * Walk in Cooler with an accumulation of black dust/dirt on a total of four fans located on two separate condenser units. During an interview on 05/27/25 at 10:45 a.m., the administrative dietary staff member (#4) confirmed staff should not use expired sanitizer test strips and should clean the dust/dirt from the exhaust hood, grates, and fans. Observation of the refrigerator/freezer on the Prairie Unit occurred on 05/27/25 at 1:00 p.m. The freezer contained two resident cold packs, used on the body, stored next to food items. During an interview on 05/29/25 at 10:22 a.m. an administrative nursing staff member (#7) confirmed staff should not store resident cold pack in the food freezer and identified a separate refrigerator designated for resident cold packs.

Based on observation, review of facility policy, and staff interview, the facility failed to follow standards of infection control and prevention for 4 of 15 sampled residents (#16, #20, #32, and #40) and 1 supplemental resident (Resident #45) observed during personal cares. Failure to practice infection control standards related to hand hygiene, glove use, and disinfecting equipment has the potential to spread infection throughout the facility. Findings include: Review of the facility policy titled Golden Acres Manor Infection Prevention and Control Program occurred on 05/29/25. This policy, revised 05/20/21, stated, . 8. Equipment Protocol: . All reusable items and equipment requiring special cleaning or disinfection shall be cleaned in accordance with our current procedures governing the cleaning and disinfecting of soiled or contaminated equipment. Review of the facility policy titled Golden Acres Manor Hand Hygiene occurred on 05/29/25. This policy, dated 11/28/17, stated, . All facility employees will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. Hand hygiene is indicated and will be performed . Between resident contacts . After handling contaminated objects . before applying and after removing personal protective equipment . including gloves . When, during resident care, moving from a contaminated body site to a clean body site . After assistance with personal body functions (e.g. [example] elimination .) . - Observation on 05/28/25 at 1:25 p.m. showed two certified nurse aides (CNAs) (#5 and #6) performed hand hygiene, applied gloves, and transferred Resident #16 to bed with a mechanical ceiling lift. One CNA (#6) removed the resident's soiled brief, and without removing her gloves, obtained a clean brief from a drawer in the bedside dresser. Both CNAs (#5 and #6) performed perineal cares, then one CNA (#6) applied the clean brief to the resident. Both CNAs (#5 and #6) removed their gloves, and without performing hand hygiene, applied new gloves, and transferred Resident #16 into the wheelchair with a mechanical ceiling lift. The CNA (#5) placed the oxygen cannula back in the resident's nose. The CNAs (#5 and #6) adjusted the resident's clothing, blanket, and lift sling. The CNAs removed their gloves, performed hand hygiene, and exited the room. The CNAs (#5 and #6) failed to perform hand hygiene after removing gloves and before applying new gloves, and failed to remove gloves and perform hand hygiene before touching other surfaces. - Review of Resident #20's medical record occurred on all days of survey. The current care plan stated, . Potential for impaired skin integrity related to: Pressure ulcer to right shoulder. History of several to sacro-coccygeal area. Observation on 05/28/25 at 1:36 p.m. showed two CNAs (#3 and #4) provided Resident #20's perineal cares. One CNA (#3) removed her gown/gloves and exited the room without sanitizing her hands. A few minutes later, the CNA gowned/gloved and re-entered the room with a full body mechanical lift. After the CNAs (#3 and #4) transferred Resident #20 into the wheelchair, one CNA (#3) removed her gown/gloves, exited the room without performing hand hygiene, and transported the resident to the lounge. The other CNA (#4) removed her gown/gloves, exited the room with a garbage bag and the mechanical lift, placed the lift in the hallway and the garbage in a bin in the soiled utility room, and then performed hand hygiene. The CNAs (#3 and #4) failed to perform hand hygiene after removing their soiled gloves and prior to exiting the room, and failed to sanitize the mechanical lift after use. - Observation on 05/27/25 at 4:24 p.m. showed two CNAs (#5 and #8) performed hand hygiene, applied gloves, removed the oxygen cannula from Resident #32's nose, and transferred the resident from the recliner to the bed using a mechanical ceiling lift. One CNA (#5) performed perineal care and applied a protective skin cream. The other CNA (#8) removed the soiled brief and applied a new brief. The CNAs removed their gloves, and without performing hand hygiene applied new gloves, and transferred Resident #32 from the bed to the wheelchair using the ceiling lift. The CNAs (#5 and #8) removed their gloves. One CNA (#8) covered the resident with a blanket, tied and removed the garbage bag, performed hand hygiene, and exited the room. The other CNA (#5) placed the oxygen cannula in the resident's nose, adjusted the over the bed table, placed the call light, performed hand hygiene, and exited the room. The CNAs (#5 and #8) failed to perform hand hygiene after removing gloves, before applying new gloves, and prior to touching other surfaces. - Observation on 05/28/25 at 4:15 p.m. showed two CNAs (#11 and #12) provided Resident #40 with perineal cares, adjusted the resident's clothing, removed the heel protector boots, applied shoes, assisted to transfer from the bed to the wheelchair, and covered the resident with a lap blanket. The CNAs failed to perform hand hygiene after completing perineal cares and prior to touching the resident and other items. - Observation on 05/27/25 at 12:10 p.m. showed Resident #45 rested in bed. Two CNAs (#9 and #10) entered the room, performed hand hygiene, and applied gloves. One CNA (#9) provided incontinent bowel movement cares, removed the soiled gloves, applied new gloves, applied a clean brief and a protective skin cream, and placed supplies back into the bedside dresser. The CNA (#9) failed to perform hand hygiene after removing gloves and before applying new gloves and failed to remove soiled gloves and perform hand hygiene prior to touching other surfaces. During an interview on 05/29/25 at 8:38 a.m., an administrative nurse (#7) confirmed she expected staff to perform hand hygiene after removing gloves, before applying new gloves, prior to touching other surfaces, and when exiting the room. The nurse (#7) also confirmed she expected staff to sanitize the lifts prior to the lifts.

Based on record review, review of a facility reported incident (FRI), policy review, and staff interview, the facility failed to ensure residents remained free from misappropriation of funds for 1 of 1 closed record (Resident #52). Failure to protect residents from misappropriation of funds may result in anxiety, mental anguish, and financial loss. This citation is considered past non-compliance based on review of the corrective action the facility implemented immediately following the incident. Findings include: Review of the facility policy, Abuse and Neglect Policy and Procedure occurred on 05/29/25. This undated policy stated, POLICY: . Residents must not be subjected to abuse by anyone, including, but not limited to facility staff . DEFINITIONS OF ABUSE: . MISAPPOPRIATION OF RESIDENT PROPERTY: Means the deliberate . exploitation or wrongful, temporary or permanent use of a resident's belongings or money without resident's consent. Review of Resident #52's closed medical record occurred on May 28-29, 2025. The Minimum Data Set (MDS), dated [DATE], showed severe cognitive impairment. Review of the FRI, dated 07/12/24, identified the family of Resident #52 contacted the facility about a significant amount of money that had been spent from the resident's checking account. The resident told family she bought an item from an employee (#16) for $40.00 and had given the employee a signed blank check for the purchase. The family stated the employee wrote the check for $550.00 and cashed it. The family stated the employee told the resident she had lost the initial check, and the resident then gave the employee (#16) another check for $40.00. The check was later altered to $340.00. The facility obtained photocopies of the checks, which appeared altered. The facility administration contacted the local police department. Facility staff interviewed Resident #52 and the resident and acknowledged buying two items from the employee. Facility staff interviewed the employee (#16) twice. During the initial interview, the employee acknowledged she had sold Resident #52 two items but could not recall what price he/she had charged. When facility staff told the employee the resident has dementia and is considered a vulnerable adult, the employee stated he/she was unaware of that. During a second interview, the employee acknowledged the transactions made with the resident and stated he/she was not 100% sure of the amount he/she received, but stated one check was around $500.00 and another check around $400.00 When facility staff asked about the value of the items, the employee (#16) stated he/she did not know and that he/she made the price up. The employee acknowledged the problem and apologized. During an interview on 05/29/25 at 9:30 a.m., an administrative staff member (#15) stated the facility investigated the incident and terminated the employee on 07/12/24. Based on the following information, non-compliance at F602 is considered past non-compliance. The facility implemented corrective actions to ensure the deficient practice does not recur by the following actions: * Immediately placed the employee on suspension * Reported the incident to the ND Department of Health and Human Services * Completed an investigation following the incident * Contacted the police department *Terminated the employee after the investigation

Based on record review, review of facility policy, and resident and staff interview, the facility failed to review and revise the comprehensive care plans to reflect the residents' current status for 1 of 15 sampled residents (Resident #24). Failure to update care plans limited staffs' ability to communicate needs and ensure continuity of care for each resident. Findings include: Review of the facility policy titled Golden Acres Comprehensive Care Plan Policy and Procedure occurred on 5/29/25. This policy, revised January 2023 stated, . The care plan will include: Identified problems, risk factors, strengths, choices, and preferences . measurable goals . interventions to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being . the care plan will be periodically reviewed and revised by a team of qualified persons . as the resident condition changes . if a condition has not resolved within approximately two weeks, or as based on clinical judgement and resident needs, further evaluation will be completed . -Review of Resident #24's medical record occurred on all days of survey. Diagnoses included benign prostatic hyperplasia with lower urinary tract symptoms. The resident's current Minimum Data Set (MDS) indicated intact cognition. During an interview on 5/27/25 at 2:39 p.m., Resident #24 stated staff do not assist him regularly with urinary incontinence cares during the evening and night, and stated he voiced his concerns and asked to be assisted at least every 3-4 hours, and as needed. Review of Resident #24's bowel and bladder documentation for the months of March, April and May 2025, identified check and change times of 11:00 p.m., 2:00 a.m., and 4:00 a.m. Resident #24's current care plan stated, . toileting assistance: Extensive assist with incontinence cares upon demand . do not disturb at night . change at night upon request . The care plan failed to reflect the resident's preferences for urinary incontinence cares. During an interview on 5/29/25 at 9:00 am, two administrative nurses (#7 and #13) confirmed staff failed to update and individualize Resident #24's care plan.

Based on observation, review of professional reference, review of manufacturer's instructions, and staff interview, the facility failed to ensure staff followed standards of practice for 2 of 9 supplemental residents (Residents #13 and #39) observed during medication administration. Failure to clarify, accurately transcribe, and reconcile new physician's orders (Resident #13) may result in residents receiving the wrong medication and failure to correctly prime an insulin pen (Resident #39) may result in residents receiving an inaccurate dose of insulin, and/or result in adverse health consequences. Findings include: Kozier & Erb's Fundamentals of Nursing, Concepts, Process and Practice, 11th Edition eText, 2021, Pearson, Boston, Massachusetts, page 63, stated, . Carrying Out a Physician's Order. Nurses are expected to analyze . medications ordered by the physician or primary care provider. It is the nurse's responsibility to seek clarification of ambiguous or seemingly erroneous orders from the prescriber. Page 833, stated, There is evidence that medication discrepancies can affect patient outcomes. Medication reconciliation is intended to identify and resolve discrepancies - it is a process of comparing the medications a patient is taking (and should be taking) with newly ordered medications. Review of manufacturer's instructions for the NovoLog Flexpen occurred on 05/29/25. These instructions, dated 2023, stated, . Before each injection small amounts of air may collect in the cartridge during normal use. To avoid injection of air and to ensure proper dosing: E. Turn the dose selector to select 2 units F. Hold your NovoLog FlexPen with the needle pointing up. Tap the cartridge gently with your finger a few times to make any air bubbles collect at the top of the cartridge. G. Keep the needle pointing upwards, press the push-button all the way in . A drop of insulin should appear at the needle tip. - Observation on 05/28/25 at 7:56 a.m. showed a nurse (#2) prepared medications for Resident #13. The nurse pulled out a medication card labeled Metoprolol Succinate ER [extended release] 50 mg [milligrams] from the medication cart. The order in the Medication Administration Record (MAR) showed Metoprolol Tartrate 50 mg. The nurse (#2) confirmed a discrepancy between the card label and MAR, did not administer the medication, and stated she would follow up on the discrepancy. On 05/28/25 at 9:00 a.m., the nurse (#2) stated the resident has been receiving the correct medication and dose, but confirmed nursing staff failed to clarify the order when it was written and incorrectly transcribed the metoprolol as tartrate instead of succinate on the MAR. - Observation on 05/27/25 at 5:30 p.m. showed a staff nurse (#2) prepared Resident #39's insulin pen for administration. The nurse (#2) held the insulin pen horizontally instead of upright when priming the pen. During an interview on 05/29/25 at 10:22 a.m. two administrative staff (#7 and #13), confirmed nursing staff should clarify medication orders when there is a discrepancy.