Every finding on record at Good Samaritan Society - Park River

Based on record review, review of the facility reported incident (FRI) and investigation, review of facility policy, and staff interview, the facility failed to ensure residents remained free from abuse for 1 of 1 sampled resident (Resident #2) who displayed sexually inappropriate behaviors towards other residents. Failure to protect residents from sexual abuse placed all residents at risk for psychosocial harm and mental and emotional distress. inappropriate behaviors resulted in sexual abuse. Findings include:The surveyors determined a deficient practice existed on 09/22/25. The facility implemented and completed corrective action on 09/25/25.Review of the facility policy titled Abuse and Neglect . occurred on 12/04/25. This policy, revised 04/07/25, stated, . The resident/client has the right to be free from abuse. resident/client must not be subjected to abuse by anyone, including, but not limited to. other residents/clients.Review of the facility policy titled Abuse Definitions . occurred on 12/04/25. This policy revised 01/02/25, stated, . sexual abuse: non-consensual sexual contact of any type with a resident. Sexual abuse includes but is not limited to: 1. Unwanted intimate touching of any kind, especially of breasts and perineal area.Review of Resident #2's medical record occurred on 11/24/25. Diagnoses included dementia with other behavioral disturbance. The quarterly Minimum Data Set (MDS), dated [DATE], identified inappropriate sexual statements and sexual touching.The FRI, dated 09/22/25, stated, . resident [Resident #1] was approached by male resident [Resident #2] via w/c [wheelchair] along [Resident #1's] left side in commons area. [Resident #1] also in a wheelchair and was fidgeting with the blanket on her lap. Male resident attempted on first contact to assist with adjusting blanket. Male resident reached over to [Resident #1] where he made contact to blanket and lifted it and then lifted [Resident #1] shirt and rubbed breast abdomen region. Staff intervened and separated resident [sic]. Resident [Resident #1's] BIMS [brief interview of mental status (a cognitive screening tool)] 00 unaware of incident. There is no change from baseline.Progress notes identified the following:* 09/22/25 at 5:10 p.m., Resident was in commons room today in [sic] moving around independently in w/c. Resident approached another female resident sitting in her w/c in commons are [sic]. At this time, said resident advanced inappropriately rubbed breast, abdomen, and vaginal region. Female resident has BIMS of 0 and was not aware of what was happening. Immediately upon notification of event residents were separated and redirected. Female resident was not aware of situation when asked and had no response. Female resident . will be monitored for any changes in baseline for any post effects of event x [times] 3 days. Physician notified, DNS [Director of Nursing Services], Administrator, Social worker and MDS coordinator all notified.* 09/23/25 at 1:18 a.m., This evening the resident was self propelling in his w/c with his pants and protective underwear partially down and was exposing himself to peers but staff would intervene and bring him to his room, move peers away from him and remind him to stay covered.* 09/23/25 at 1:21 p.m., Care Plan Change . Resident 15 minute check [sic] initiated on 09/22/25 r/t [related to] resident to resident incident with documentation on observation flow sheet. Evening of 9/22/25 resident observation increased to in line of sight of staff when out of bed d/t [due to] increase in behaviors.* 09/23/2025 2:12 p.m., Contacted [hospital] regarding situation with resident. [Psychiatrists'] office verbal instructions to discontinue abilify (an antipsychotic medication) and increase trazadone (an antidepressant medication) to 50 mg [milligrams]. He also instructs to send to [hospital] for psyc [sic] [psychological] eval [evaluation]. Spoke with clinic nurse and she will call back with direction for action.* 09/23/2025 2:15 p.m., Received call from [hospital] to send resident to ER [emergency room] .* 09/23/2025 2:23 p.m., Resident left facility for a psych eval in ER .During an interview on 11/24/25 at 2:30 p.m., an administrative nurse [#1] reported Resident #1 had no injury or recall of the incident and has since passed away. She also confirmed there have been no other touching episodes in the facility since this incident occurred.Based on the following information, non-compliance at F0600 is considered past non-compliance. The facility implemented corrective actions for residents who may be affected by the deficient practice as follows:* Completed an investigation of the incident that occurred on 09/22/25 involving Resident #1 and Resident #2,* Provided staff education regarding sexual abuse and ensuring resident safety,* Educated staff to separate the residents, to stay with Resident #1, and report the incident to administration,* Directed staff to check on Resident #2 every 15-minutes, increasing to line-of-sight when out of bed, and record his behaviors per shift,* Ensured Resident #2 received a psychiatric evaluation in a timely manner,* Adjust Resident #2's medications per physician order,* Implemented audits to ensure resident safety, monitoring incident involving resident-to-resident sexual abuse.

Based on observation, review of professional reference, review of facility policy, and staff interview, the facility failed to ensure food is prepared and stored in a clean and sanitary manner in 2 of 2 kitchen/nutrition centers (main kitchen and nutrition center) observed. Failure to ensure cleanliness of the kitchen and proper food storage has the potential for contamination of food and may result in a foodborne illness to residents, visitors, and staff. Findings include: The 2022 Food and Drug Administration (FDA) Food Code, Chapter 4, Section 4-6, pages 20-21, Section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, stated, . (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (C) Non FOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. Review of the facility policy titled Food Preparation -Food and Nutrition occurred on 08/19/25. This policy, dated March 2025, stated, . Regular cleaning/sanitizing of equipment, utensils and work surfaces are performed during food preparation as needed . Observation of the main kitchen occurred on 08/18/25 at 12:55 p.m. with dietary staff member (#8) and showed the following:* An accumulation of dirt and debris on the floor, and a large, blackened area under the three-compartment sink.* An accumulation of a sticky substance on the lip of the oven hood.* An accumulation of a sticky substance on the outside of all the cabinet doors within the kitchen.* An accumulation of food residue on the back splash and walls behind the food prep area and food prep sink.* An accumulation of debris in the utensil and other storage drawers that contain food and miscellaneous dishware. * An accumulation of a sticky yellow substance around the inside rims of a silverware divider within a utensil drawer.* Visible dried particles of red colored food on pan covers on a storage shelf.* Visible food debris on the bottom of the reach in refrigeration unit, along with a sticky dark pink substance on the sides and bottom of the unit.* The reach in freezer unit contained a large unopened bag of onion rings with layers of ice buildup within the bag.* One ceiling fan with an accumulation of dust and hanging debris in the dishwashing area.The walk-in refrigerator showed:*An accumulation of grey-green mold on the underside of the two-fan condenser unit.*An accumulation of debris on all the metal wired shelving units.The walk-in freezer showed: * One open, unlabeled, and undated bag of chicken cordon blue.* One open, unlabeled, and undated bag of skinless chicken breast.* One open, unlabeled, and undated bag of hushpuppies.*Observation of the nutrition freezer on 08/19/25 at 12:52 p.m. showed a large blue gel ice pack stored beside ice cream cups.During an interview on 08/20/25 at 11:23 a.m., a dietary staff member (#8) stated he expected staff to clean all areas of the kitchen and store food properly.

Based on review of facility policy, review of call light logs, and resident, family, and staff interviews, the facility failed to ensure sufficient nursing staff and related services are available at all times to meet the residents' needs for 2 of 8 sampled residents (Resident #30 and #39), one supplemental resident (Resident #26) and 1 confidential resident (Resident A) who required staff assistance. Failure to provide sufficient staffing does not promote each resident's rights, physical, mental, and psychosocial well-being, and/or provide a safe environment for the residents. Findings Include: Review of the facility policy titled Call Light occurred on 08/20/25. This policy, revised 07/08/25, stated, When residents call light is observed/heard, go to the resident's room promptly. Respond to request as soon as possible. Resident and family interviews occurred on the morning/afternoon of 08/18i25 and identified the following: * Resident A stated they are short of staff here, it takes 30 minutes to answer my call light. * Resident #26 stated it can take 30 minutes for staff to answer my call light. * Resident #30 reported it has been up to half an hour or more before staff answer the call light, identified having to wait on the toilet a long time, and “they forget about me. *Resident #30's family member identified concerns with call lights being answered timely on various shifts, and Resident #30 has waited up to an hour for staff to answer the call light and has had urinary incontinence due to waiting. *Resident #39 stated, it can take 45 minutes to get my call light answered and I talked to staff, and nothing changed. Review of the call light logs from 08/14/25 to 08/18/25 showed the following and call light response: * Resident #39 waited 25 minutes or greater on 7 occasions and the longest wait 50 minutes. * Resident #26 waited 25 minutes or greater on 6 occasions and the longest wait 53 minutes. *The call light logs from 7/17/25 to 8/18/25 showed Resident #30 waited 17 to 22 minutes or greater on 9 occasions and the longest wait 27 minutes. During an interview on the morning of 08/21/25 an administrative nurse (#1) confirmed the call light log showed staff failed to answer call lights promptly. During confidential staff interviews on 08/20/25 at 11:03 a.m., confidential staff members (B, C, D, E, F) stated the staff worked short most shifts, administration was aware, and the shortages continued in resident care areas and in the dining room with feeding assistance.

Based on observation, record review, review of facility policy, and staff interview, the facility to ensure residents received adequate supervision/assistance to prevent accidents for 1 of 1 sampled resident (Resident #30) observed during a sit-to-stand lift transfer. Failure to ensure proper use of a leg strap placed Resident #30 at risk for possible injury.Findings include:Review of the facility policy titled Safe Resident Handling Equipment-Competency Validation Checklist occurred on 08/21/25. This policy, dated December 2024, stated, . Checks resident care plan or Kardex prior to transfer for type of equipment to be used, type and size of sling and amount of assistance required . If directed by care plan or location specific procedure, uses the shin/calf strap when the resident requires additional lower extremity support . Applies the shin/calf strap when the resident is in a seated position, before rising to a standing position . Review of Resident #30's medical record occurred on all days of survey. Diagnoses included muscle weakness and orthopedic pain. The current care plan stated, . TRANSFER: The resident requires staff assist for 1 for toileting and transfers with the stand lift. The care plan failed to address the need for a shin strap.Observation on 8/19/25 at 3:58 p.m. showed a certified nurse aide (CNA) (#11) transferred Resident #30 from the wheelchair to the bathroom using the sit to stand mechanical lift. The CNA failed to attach the leg strap and place the resident's shins against the shin rests. During the transfer, the resident's legs shifted and buckled, hands failed to grip the handlebars, and his/her arms/elbows pushed outward and upward. The CNA failed to apply the leg strap during transfer and notify the nurse of the resident's unsafe transfer. During an interview on 08/21/2025 at 12:43 p.m., an administrative nurse (#5) confirmed Resident #30 transferred using a sit-to-stand lift, and she expected staff to report any resident change in transfer status.

Based on observation and staff interview, the facility failed to discard expired medications in 2 of 3 medication storage areas (100-200 Wing Medication Cart and Medication Storage Room) reviewed. Failure to discard expired medications may result in decreased effectiveness of the prescribed medication.Findings include:-Observations on 08/19/25 at 1:40 p.m. of the medication storage room showed the following:* Three saline solution laxatives expired in December 2024.* Two tubes of antimicrobial skin wound gels expired in November 2024.* One bottle of antiseptic liquid for skin wounds expired in March 2025.-Observation on 08/19/25 at 1:50 p.m. of the medication cart (100-200 wing) showed one bottle of nystatin powder expired December 2024.During an interview on 08/20/25 at 2:57 p.m., an administrative nurse (#1) confirmed expired medication should be discarded and not used.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to review and revise the comprehensive care plans to reflect the residents' current status for 2 of 14 sampled residents (Resident #12 and #28). 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 Care Plan occurred on 08/20/25. This policy, revised December 2024 stated, . The plan of care will be modified to reflect the care currently required/provided for the resident. -Observation on 8/18/25 at 4:00 p.m. showed a certified nurse aide (CNA) (#3) transferred Resident #28 from the wheelchair to the bathroom using a sit to stand mechanical lift. Review of Resident #28's medical record occurred on all days of survey. The care plan stated, Pivot transfer with one assist using the gait belt for toileting.Transfer: Resident requires AX1 [assist times one] staff to stand pivot transfer with gait belt. During an interview on 08/20/25 at 1:09 p.m. a staff nurse (#4) confirmed Resident #28 transferred using a sit-to-stand lift. -Review of Resident #12’s medical record occurred on all days of survey and showed a weight loss of greater than 10% in one month. The care plan, stated, The resident has unplanned/unexpected weight loss R/T [related to] (SPECIFY) E/B [evidenced by] (SPECIFY) Resident will maintain weight between (SPECIFY: ______ and ______ lbs.) by review date. Weigh (SPECIFY FREQ. [Frequency])” The care plan failed to include interventions and goals related to Resident #12's weight loss.

Based on observation, record review, policy review, review of a professional reference, and staff interview, the facility failed to provide appropriate toileting for 2 of 4 sampled residents (Resident #4 and #5) and 1 closed record (Resident #1) who required staff assist with toileting. Failure to provide toileting may result in a loss of dignity and placed the residents at risk for skin breakdown, poor grooming/hygiene, decreased self-esteem, urinary tract infections, and risk for fall and/or injuries. Findings include: Review of the facility policy titled Activities of Daily Living occurred on [DATE]. This policy, dated [DATE], stated, . Any resident who is unable to carry out activities of daily living [ADLs] will receive necessary services . ADLs are those necessary tasks conducted in the normal course of a resident's daily life. Included in these are the following .Toileting . Kozier & Erb's Fundamentals of Nursing: Concepts, Process and Practice, 11th Edition eText, 2021, Pearson, Boston, Massachusetts, page 892, stated, Fecal and Urinary Incontinence: Moisture from incontinence promotes skin maceration [tissue softened by prolonged wetting or soaking] and makes the epidermis [skin] more easily eroded and susceptible to injury. Digestive enzymes in feces, urea in urine . also contribute to skin excoriation [area of loss of the superficial layers of the skin] . Any accumulation of secretions . is irritating to the skin, harbors microorganisms, and makes an individual prone to skin breakdown and infection. Page 1221 stated, Managing Urinary Incontinence . Habit training, also referred to as timed or prompted voiding and scheduled toileting, attempts to keep clients dry by having them void at regular intervals, such as every 2 to 4 hours. The goal is to keep the client dry . - Review of Resident #1's medical record occurred on all days of survey and identified an admitted [DATE]. The resident expired on [DATE], approximately 48 hours after admission. The current care plan stated, . The resident has an ADL deficit r/t [related to] weakness . TOILET USE: . Resident requires a full lift and 2 assist with toileting . Review of Resident #1's toileting log, dated [DATE] through [DATE], identified the following: * [DATE] staff assisted with toileting at 2:35 p.m. and not again until 8:38 p.m. (6 hours later). * [DATE] staff assisted with toileting at 8:38 p.m. and not again until 12:57 a.m. (4 hours later). [DATE] staff assisted with toileting at 9:25 a.m. and not again until 8:41 p.m. (11 hours later). - Review of Resident #4's medical record occurred on all days of survey. The current care plan stated, . The resident has an ADL self care performance deficit . TOILET USE . Toilet per assist of one on arising . Observation on [DATE] at 4:45 p.m. showed two certified nurse aides (CNAs) (#4 and #5) assisted Resident #4 to the bathroom. The resident's saturated incontinent product leaked urine through the resident's pants. The toileting log showed the resident last toileted at 1:48 p.m. - Review of Resident #5's medical record occurred on all days of survey. The current care plan stated, . The resident has an ADL deficit . TOILET USE: . Resident uses assist of one and gaitbelt to toilet. Toileting schedule: Assist of one to toilet between ,d+[DATE] [3:,d+[DATE]:30 p.m.] . and prn [as needed]. Observation on [DATE] at 3:50 p.m. showed two CNAs (#2 and #3) transferred Resident #5 from the recliner to the wheelchair and then to the commons area in the facility. The CNAs failed to offer toileting assistance to the resident. During an interview on [DATE] at 12:36 p.m., an administrative staff member (#1) stated she expected staff to assist residents with toileting per the care plan.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to follow standards of infection control and prevention for 1 of 3 sampled residents (Resident #6) observed during cares. Failure to practice infection control standards related to hand hygiene has the potential to spread infection throughout the facility. Findings include: Review of the facility policy titled Hand Hygiene occurred on 02/19/25. This policy, dated March 2022, stated, . Policy: . All employees in patient cares areas . will adhere to . Hand Hygiene . 3 After bodily Fluid/Glove Removal . according to standard precautions . 2. Hand hygiene should be performed after glove removal . Procedure: HCW [Health Care Workers] will use waterless alcohol-based hand sanitizer or soap and water to clean their hands: . After removing gloves regardless of task completed . After contact with a patient's excretions . Review of Resident #6's medical record occurred on all days of survey. The Minimum Data Set (MDS), dated [DATE], identified dependent on staff for toilet hygiene. Observation on 02/18/25 at 4:04 p.m. showed two certified nurses aides (CNAs) (#2 and #3) donned gloves and transferred Resident #6 with the sit to stand lift from the wheelchair to the bed. The CNA (#3) cleaned the sit to stand lift with sanitizing wipes, checked and changed the resident's brief, obtained the tube of barrier cream left on the resident's bed, and placed it in the resident's top dresser drawer. The CNAs (#2 and #3) then transferred the resident back to the wheelchair using the sit to stand lift. The CNA (#3) cleaned the lift with the same gloves she donned at the start of the cares. CNA (#3) failed to change gloves and complete hand hygiene between tasks and after completing personal resident care. During an interview on 02/19/25 at 12:32 p.m., an administrative nurse (#1) confirmed she expected staff to remove gloves and perform hand hygiene after perineal cares.

Based on observation, record review, and review of facility policy, the facility failed to provide activities of daily living (ADLs) for 1 of 4 sampled residents (Resident #2) and 1 closed record (Resident #1) dependent on staff for personal hygiene and bed mobility. Failure to assist residents who cannot perform personal hygiene and bed mobility independently may result in poor hygiene, skin issues, and decreased self-esteem. Findings include: Review of the facility policy titled Activities of Daily Living occurred on [DATE]. This policy, dated, [DATE], stated, . Any resident who is unable to carry out activities of daily living (ADL's) will receive necessary services to maintain . grooming and personal hygiene . ADLs are those necessary tasks conducted in the normal course of a resident's daily life. Included in these are the following: 1. General Personal, Daily Hygiene/Grooming: Care of hair . nails . - Review of Resident #1's medical record occurred on all days of survey and identified an admitted [DATE]. The resident expired on [DATE], approximately 48 hours after admission. The current care plan stated, . The resident has an ADL self care performance deficit R/T [related to] weakness . Bed mobility . Assist of one . Review of Resident #1's bed mobility/repositioning log, dated [DATE] through [DATE], identified the following: * [DATE] staff assisted with bed mobility at 2:34 p.m. and not again until 7:01 p.m. (4.5 hours later). * [DATE] staff assisted with bed mobility at 7:01 p.m. and not again until 12:57 a.m. (almost 6 hours later). [DATE] staff assisted with bed mobility at 9:25 a.m. and not again until 8:41 p.m. (11 hours later). - Review of Resident #2's medical record occurred on all days of survey. The current care plan stated, . The resident has an ADL self care performance deficit . PERSONAL HYGIENE . Resident requires assist of one with personal hygiene. Observation on [DATE] at 4:26 p.m. showed Resident #2 in a wheelchair in the hallway with uncombed hair and long, dirty fingernails. Observation on [DATE] at 11:50 a.m. showed Resident #2 in the dining room wearing a shirt soiled with food and long, dirty fingernails. The facility failed to assist dependent residents with personal hygiene and bed mobility.

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 5 of 12 sampled residents (#1, #3, #13, #15, and #25). Failure to accurately complete the MDS does not allow each resident's assessment to reflect their current status/needs and may affect the development of a comprehensive care plan and the care provided to the residents. Findings include: SECTION GG: FUNCTIONAL ABILITIES AND GOALS The Long-Term Care Facility RAI Manual, revised October 2023, pages GG-14, GG-15, and GG-21, states . Individualized care plans should be based on an accurate assessment of the resident's self-performance and the amount and type of support being provided to the resident. Steps for Assessment 1. Assess the resident's self-care performance based on direct observation, incorporating resident self-reports and reports from qualified clinicians, care staff, or family documented in the resident's medical record during the assessment period. CMS [Centers for Medicare & Medicaid Services] anticipates that an interdisciplinary team of qualified clinicians is involved in assessing the resident during the assessment period. A dash (-) indicates 'No information.' CMS expects dash use to be a rare occurrence. - Review of Resident #3's medical record occurred all days of survey and included diagnoses of hemiplegia (partial or total paralysis on one side of the body) and hemiparesis (one-sided muscle weakness caused by brain, spinal cord, or nerve problems) following cerebral infarction (stroke) affecting left dominant side. Resident #3's quarterly MDS, dated [DATE], showed Section GG with dashes in the areas of oral hygiene, upper and lower body dressing, putting on footwear, and transfers. The MDS failed to identify the resident's ability or assistance required in these areas. - Review of Resident #13's medical record occurred all days of survey. The record identified diagnoses of Parkinson's disease (progressive disorder that affects the nervous system and causes tremors, stiffness, and slow movement) with dyskinesia (uncontrolled, involuntary movements of the face, arms or legs) and dementia. Resident #13's quarterly MDS, dated [DATE], showed Section GG with dashes in the areas of oral hygiene, toileting hygiene, showering/bathing, upper body dressing, lower body dressing, and putting on/taking off footwear. The MDS failed to identify the resident's ability or assistance required in these areas. - Review of Resident #15's medical record occurred on all days of survey and included diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. Resident #15's annual MDS, dated [DATE], showed Section GG with dashes in the areas of oral hygiene, toileting, upper and lower body dressing, putting on footwear, personal hygiene, and transfers. The MDS failed to identify the resident's ability or assistance required in these areas. - Review of Resident #25's medical record occurred on all days of survey and included diagnoses of pain in left shoulder, polyneuropathy (damage to multiple peripheral nerves), and abnormalities of gait and mobility. Resident #25's quarterly MDS, dated [DATE], showed Section GG with dashes in the areas of oral hygiene, bathing, upper and lower body dressing, putting on footwear, and transfers. The MDS failed to identify the resident's ability or assistance required in these areas. During an interview on 07/10/24 at 2:12 p.m., an administrative nurse (#6) agreed staff failed to code the MDS correctly for Residents #3, #13, #15, and #25. SECTION K: SWALLOWING/NUTRITIONAL STATUS The Long-Term Care Facility RAI Manual, revised October 2023, page K-10, states, . K0520. Nutritional Approaches: Check all of the following nutritional approaches that apply . Performed while a resident of this facility and within the last 7 days . B. Feeding tube . C. Mechanically altered diet - require change in texture of food or liquids (e.g., pureed food, thickened liquids) D. Therapeutic diet (e.g. low salt, diabetic, low cholesterol) . Review of Resident #1's medical record occurred all days of survey. The physician's orders identified a feeding tube, Osmolite (type of tube feeding formula), and a pureed (mechanically altered) diet. Resident #1's quarterly MDS, dated [DATE], identified a therapeutic diet, and failed to identify a feeding tube or a mechanically altered diet. During an interview on 07/11/24 at 9:20 a.m., a dietary manager (#3) agreed staff failed to code the MDS correctly for Resident #1. 46963 46259

Based on observation, record review, review of facility policy, and staff interview, the facility failed to follow standards of infection control for 2 of 2 sampled residents (Resident #1 and #3) observed with enhanced barrier precautions (EBP). Failure to practice infection control standards by ensuring staff use the proper personal protective equipment (PPE) has the potential to transmit infections to residents, staff, and visitors. Findings include: Review of the facility policy titled Standard and Transmission-Based Precautions, All Service Lines occurred on 07/11/24. This policy, revised 04/02/24, stated, . Purpose . To prevent the spread of infection . Enhanced Barrier Precautions . Enhanced barrier precautions expand the use of PPE beyond situations in which exposure to blood and body fluids is anticipated and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs [multi drug resistant organisms] . Enhanced barrier precautions are needed for . Residents with Indwelling Medical devices (. indwelling urinary catheters, feeding tubes .) . - Review of Resident #1's medical record occurred on all days of survey. Current physician's orders included tube feeding formula/water flushes and gastrostomy (artificial opening into the stomach) tube site care daily and as needed (PRN). Observation on 07/09/24 at 3:11 p.m. showed Enhanced Barrier Precautions signs on Resident #1's doorframe and on top of the supply cart in the room. A nurse (#4) performed hand hygiene and gloved, flushed Resident #1's feeding tube, administered a PRN medication, then flushed and capped the tube. The nurse removed the soiled dressing from the gastrostomy tube site, cleansed the area, applied a new dressing, and performed hand hygiene and glove changes where indicated. The nurse (#4) failed to wear a gown as required. 46259 -Review of Resident #3's medical record occurred on all days of survey. The current care plan stated, . The resident requires Enhanced Barrier Precautions (EBP) R/T [related to] indwelling medical device suprapubic catheter . Don gown and gloves when performing high contact care activities including: dressing, bathing, transferring, providing hygiene such as shaving or brushing teeth, changing linens, repositioning, checking and changing, device care and/or use, and wound care. Observation on 07/09/24 at 10:45 a.m. showed Resident #3 completing exercises with a restorative nursing aide (#7) in the therapy room. The aide proceeded to complete exercises with the resident's hands, shoulders, and feet. The aide (#7) failed to donn the appropriate PPE as required. Observation on 07/09/24 at 3:50 p.m., showed two certified nurse aides (CNAs) (#2 and #8) emptied Resident #3's catheter bag. The CNAs donned gloves, performed cares, doffed their gloves, sanitized their hands, and exited the room. The CNAs failed to don gowns as required. During an interview on 07/11/24 at 10:26 a.m., an administrative staff (#1) confirmed staff should don PPE as required.

Based on observation, review of facility policy, and staff interview, the facility failed to ensure accurate labeling of medications in 1 of 2 medication carts (300/400 cart) observed during medication administration. Failure to obtain a label for an insulin pen and identify an open date may result in a resident receiving an incorrect or ineffective dose of insulin. Findings include: Review of the facility policy titled Medication: Insulin Administration, Insulin Pens, Insulin Pumps occurred on 07/11/24. This policy, dated 12/14/23, stated, . Insulin Pen . Insulin pens must be clearly labeled with the name or other identifiers to verify that the correct pen is used on the correct person. Verify provider order, the expiration date and the number of days the pen has been open. - Observation on 07/10/24 at 8:17 a.m. showed a nurse (#5) prepared Resident #15's Humalog insulin pen for administration. The nurse obtained the pen from a bin labeled with the resident's name. The pen lacked a label with the resident's name or other identifying information and lacked an open date. - Observation on the morning of 07/10/24, during a check of insulin pens in the 300/400 wing medication cart, identified Resident #136's Tresiba (long-acting) insulin pen lacked an open date. During an interview on 07/10/24 at 8:30 a.m., a nurse (#5) stated, Whoever opens a pen is supposed to date it when opened.

Based on observation and review of facility policy, the facility failed to ensure a medication error rate of less than five percent for 1 of 7 residents (Resident #7) observed during medication administration. Two medication errors occurred during staff administration of 25 medications, resulting in an eight percent error rate. Failure to properly prepare and administer medications may result in residents receiving an ineffective dose and experiencing adverse reactions. Findings include: Review of the facility policy titled Medication: Insulin Administration, Insulin Pens, Insulin Pumps occurred on 07/11/24. This policy, dated 12/14/23, stated, . Insulin Pen . Remove the protective pull tab from the needle and screw it onto the pen . Remove both the plastic outer cap and inner needle cap. 10. Turn the dosage knob to '2' units to prime pen. 11. Holding the pen with the needle pointing upwards, press the button until at least a drop of insulin appears. Inject the dose into the chosen site. Be sure to wait about 6 seconds to ensure that the full dose has been delivered. Observation of medication administration on 07/10/24 at 7:43 a.m. showed a nurse (#9) prepared a Levemir (long-acting) insulin pen and a Fiasp (rapid-acting) insulin pen for Resident #7. The nurse applied a needle, dialed each pen to two units, and held each pen horizontally to prime the insulin pen. After injecting the insulin, the nurse (#9) removed the needle from the skin immediately. Failure to prime an insulin pen correctly and inject the insulin with proper technique may result in the resident receiving less than the full dose.

THIS IS A REPEAT DEFICIENCY FROM THE COMPLAINT SURVEY COMPLETED ON 03/12/24. Based on observation, record review, review of facility policy, and staff interview, the facility failed to review and revise care plans to reflect residents' current status for 2 of 12 sampled residents (Resident #17 and Resident #25). Failure to update care plans limited staffs' ability to communicate needs and ensure continuity of care. Findings include: Review of the facility policy titled Care Plan-R/S [rehab/skilled], LTC [long-term care], Therapy & Rehab occurred on 07/11/24. This policy, dated November 2023, stated, . POLICY . Each resident will have an individualized, person-centered, comprehensive plan of care . Any problems, needs and concerns identified will be addressed through the use of departmental assets, the Resident Assessment Instrument (RAI) and review of the physician's orders. This plan of care will be modified to reflect the care currently required/provided for the resident. - Review of Resident #17's medical record occurred on all days of survey. The current care plan stated, The resident has an ADL [activities of daily living] self care performance deficit only in bathing, otherwise, is independent. Date Initiated: 11/03/2023 Revision on: 11/21/2023 . A quarterly Minimum Data Set (MDS), dated [DATE], identified the resident required setup or cleanup assistance for eating and partial/moderate staff assistance for oral hygiene, toileting hygiene, upper and lower body dressing, putting on/taking off footwear, and personal hygiene. The facility failed to updated Resident #17's care plan to reflect the care needs and staff assistance required. During an interview on 07/11/24 at 10:20 a.m., an administrative staff member (#1) confirmed staff failed to revise the care plan to reflect the changes in ADLs. - Review of Resident 25's medical record occurred on all days of survey. The current care plan, dated 04/26/24, stated, . The resident is at risk for falls R/T [related to] Osteoporosis and abnormalities of gait and mobility E/B [evidenced by] history of falls, hx [history] of femur fracture prior to admit. Modify to maximize safety. Observations on 07/09/24 and 07/10/24 showed a fall mat placed on the floor beside the resident's bed. Review of progress notes showed the following: *10/09/23 at 3:37 p.m., . Encouraged to wait for staff to help to prevent another fall. Falls mat @ [at] bedside. *02/22/24 at 10:59 p.m., . Found resident sitting on the floor by her bed on top of the mat by her bed. *05/29/24 at 4:42 a.m., . Steady on feet and will attempt to self transfer. Falls [sic] mat @ [at] bedside. Resident #25's care plan failed to address the use of a fall mat at bedside. During an interview on 07/11/24 at 10:26 a.m., an administrative staff member (#1) confirmed staff failed to revise the the care plan to reflect the use of a fall mat. 46963

Based on record review, review of Medicare Part A letters/notices, and staff interview, the facility failed to ensure the resident and/or their representative completed the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN) for 1 of 3 supplemental residents (Resident #16) discharged from Medicare Part A in the past six months. Failure to ensure the completion of the SNFABN limited the resident/representative's ability to exercise their rights regarding Medicare Part A services. Findings include: Review of Medicare Part A beneficiary notices identified Resident #16 discharged from Medicare Part A on 04/03/24. The SNFABN failed to identify if the resident and/or her representative chose to continue or discontinue services or request a demand bill. Review of Resident #16's medical record occurred on 07/11/24. The record lacked documentation the resident and/or representative was informed of options related to billing and services when Medicare Part A coverage ended. During an interview on the morning of 07/11/24, an administrative staff member (#1) confirmed staff failed to document whether staff informed Resident #16 and/or her representative of their options related to billing and services when Medicare Part A coverage ended.

THIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED ON 06/08/23. Based on observation, record review, review of facility policy, and staff interview, the facility failed to ensure residents received adequate supervision/assistance to prevent accidents for 1 of 1 sampled resident (Resident #15) observed during a sit-to-stand lift transfer. Failure to ensure proper use of a leg strap as care planned placed Resident #15 at risk for possible injury. Findings include: Review of the facility policy titled Safe Resident Handling Equipment-Competency Validation Checklist occurred on 07/11/24. This policy, dated March 2023, stated, . Checks resident care plan or Kardex prior to transfer for type of equipment to be used, type and size of sling and amount of assistance required . If directed by care plan or location specific procedure, uses the shin/calf strap when the resident requires additional lower extremity support . Applies the shin/calf strap when the resident is in a seated position, before rising to a standing position. - Review of Resident #15's medical record occurred on all days of survey. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, muscle spasm, and polyneuropathy. The current care plan stated, . TRANSFER - Transfer Between Surfaces: Use SS-M [sit-to-stand lift with medium sling] with leg strap, assist of 1 for transfers. Observation on 07/09/24 at 11:10 a.m., showed a certified nurse aide (CNA) (#2) transferred Resident #15 from the bed to the toilet using the sit-to-stand lift. The CNA applied the sling to the resident and fastened the buckle then attached the sling to the lift. The CNA cued the resident to hold onto the lift bars and to place their feet on the platform. The CNA lifted the resident to a standing position, transferred to the bathroom and lowered to the toilet. After toileting, the CNA lifted the resident to a standing position, completed cares, and transferred the resident to the wheelchair. The CNA failed to apply the leg strap during transfers between surfaces. During an interview on 07/11/24 at 10:26 a.m., an administrative staff member (#1) confirmed the staff should apply the leg strap as care planned for the resident.

Based on record review and review of facility policy, the facility failed to follow physician's orders for 1 of 3 sampled residents (Resident #17) and 1 closed record (Resident #86) reviewed who experienced high and/or low blood sugars. Failure to notify the physician of blood sugar results above and/or below the ordered parameters may result in complications to the resident and prevent the physician from evaluating the need to alter treatment. Findings include: Review of the facility policy titled Blood Glucose Monitoring, Disinfecting and Cleaning occurred on 07/11/24. This policy, dated 01/31/24, stated, . If the medical provider has identified a low and high blood sugar for a resident . when the blood sugar varies from the baseline entered. the nurse will notify physician if necessary, per parameters. - Review of Resident #17's medical record occurred on all days of survey. Diagnoses included type two diabetes mellitus. Medications included, Insulin Aspart Injection Solution 100 UNIT/ML [milliliter] . related to TYPE 2 DIABETES MELLITUS WITH UNSPECIFIED COMPLICATIONS . For BS [blood sugar] > [greater than] 451 call MD [medical doctor]. Review of the January-July 2024 blood sugars log showed the following: * 01/03/24 - 453 mg/dL (milligrams per deciliter) * 01/07/24 - 458 mg/dL Review of the medical record showed the facility failed to notify Resident #17's physician of the blood sugar readings greater than 451. - Review of Resident #86's medical record occurred on all days of survey. Diagnoses included type two diabetes mellitus with hypoglycemia (low blood sugars) and insulin use. Medications included 10 milligrams (mg) Glipizide extended release one time a day, 20 units Humalog (short-acting insulin) two times a day (start date 03/29/24), 25 units Humalog one time a day (start date 03/30/24), 80 units Lantus (long-acting insulin) one time a day, and 500 mg Metformin HCI (Hydrochloride) (oral medication used to control high blood sugar) twice a day. The physician's orders included, Call MD when blood sugars < (lesser than) 70 mg/dL or > 400 mg/dL. Review of the December 2023 blood sugars log identified a reading of 67 mg/dL on 12/27/23. The progress notes identified, * 04/24/24, . Residents blood sugar was 62 [mg/dL] this morning. * 04/26/24, . Residents blood sugar was 65 [mg/dL] this morning. A progress note, dated 04/27/24, further identified the facility transferred Resident #86 to the emergency room after she received Glucagon (medication used to treat low blood sugar) for a blood sugar reading of 42 mg/dL. Review of the medical record showed staff failed to notify Resident #86's physician of the low blood sugar readings on 12/27/23, 04/24/24, and 04/26/24. 27221

Based on observation, review of facility grievances, review of the North Dakota Long Term Care Ombudsman Program's Guide to Resident Rights, and staff interview, the facility failed to treat residents with respect and dignity and failed to provide resident care in a manner and an environment that promotes, maintains, or enhances their quality of life on 1 of 1 days of survey. Failure to treat residents with dignity and speak respectfully has the potential to affect the residents' psychosocial wellbeing. 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. Observation on 03/12/24 at 8:05 a.m. showed three unidentified certified nurse aides (CNAs) and three unidentified residents sitting at a table in the dining room. The three staff members conversed amongst themselves and failed to interact with the three residents. At 8:15 a.m., one of the three unidentified CNAs started to pound two fingers loudly on the table and stated, [Resident's first name]. [Resident's first name]. Hey you better wake up and eat. Another unidentified resident at a different table with the same first name stated, I am eating. The unidentified CNA stated, No not you [Resident's first and last] but this [Resident's first name] at this table. Review of facility grievances filed in the last 6 months included: * On 10/04/23, Resident didn't feel attitude of facility staff were encouraging to him. * On 12/01/23, Facility staff not approachable. * On 12/20/23, Resident stated when he/she puts the call light on, the facility staff come in and say in an unpleasant tone, What do you want? The resident stated on a grievance he/she does not feel like he/she should be treated like this. During an interview on 03/12/24 at 4:50 p.m., an administrative nurse (#1) stated she expected staff to treat all residents with respect and dignity.

Based on observation, review of facility policy, review of facility call light logs, resident interviews, and staff interview, the facility failed to promptly respond to residents' call lights for 4 of 4 confidential residents (Residents A, B, C, and D) who required staff assistance. Failure to promptly respond to resident calls for assistance may result in residents experiencing unmet needs and may negatively affect the residents' physical, mental, and psychosocial well-being. Findings include: Review of the facility policy titled Call Light occurred on 03/12/24. This policy, dated 08/01/23, stated, . 2. When resident's call light is observed/heard, go to the resident's room promptly. 3. Respond to request as soon as possible. Turn call light off and inquire about resident's request. Observations on 03/12/24 at 2:39 p.m. showed Resident C activated the call light and stated to the surveyor he/she needed to be changed. At 2:56 p.m., a certified nurse aide (CNA) (#5) entered the resident's room, inquired about the resident's needs, and stated she would return shortly. At 3:00 p.m., the CNA (#5) and an unidentified CNA returned to the resident's room and began to assist the resident with toileting needs (21 minutes after the call light initially activated). During an interview on 03/12/24 at 2:35 p.m., when asked about sufficient staff/response to call lights, Resident A stated, It depends on who is working for call lights to be answered. I have waited 30 minutes or a little longer. Review of the facility call light logs from 02/01/24 through 02/03/24 identified length of time between resident call light activated and deactivated for the following: * On 02/01/24, Resident B = 34 minutes. * On 02/02/24, Resident B = 27 minutes. * On 02/02/24, Resident C = 54 minutes. * On 02/03/24, Resident D = 74 minutes. During an interview on 03/12/24 at 4:15 p.m., an administrative staff member (#1) indicated staff should answer call lights within ten minutes. 40489

Based on observation, review of facility policy, and staff interview, the facility failed to provide reasonable accommodation of needs regarding call lights for 1 of 1 sampled resident (Resident #2) observed during cares. Failure to ensure residents can reach/access the call light may result in unmet needs and the inability to call for help. Findings included: Review of the facility policy titled Call Light occurred on 03/12/24. This policy, dated 08/01/23, stated, . When leaving the room, place call light within easy reach of resident. Observations on 03/12/24 in Resident #2's room showed the following: * At 8:42 a.m., a certified nurse aide (CNA) (#2) completed cares, assisted the resident into his/her recliner, exited the room, and failed to place the call light within the resident's reach. * At 9:03 a.m., asleep in the recliner and the call light out of reach. * At 9:20 a.m., remained in the recliner with the call light out of reach. During an interview on 03/12/23 at 4:15 p.m., an administrative staff member (#1) stated she expected staff to ensure all residents' call lights are within their reach prior to exiting the resident's room. 40489

Based on record review, policy/procedure review, resident interview, and staff interview, the facility failed to ensure residents are free from abuse for 2 of 2 sampled residents (Resident #3 and Resident #8) who were subjected to verbal abuse by another resident (Resident #5). Failure to ensure residents are free from verbal abuse from other residents, which includes disparaging and derogatory terms, resulted in avoidable psychosocial harm and Resident #3 being removed from his own room to appease/calm Resident #5 thereby not having access to his own room and belongings, and resulted in Resident #8 feeling angry and upset about his roommate. Findings include: Review of the facility policy "Abuse and Neglect (Number II.A.1)" occurred on 07/23/14. This policy, revised September 2013, stated, ". . . Policy - The resident has the right to be free from verbal . . . physical and mental abuse . . . Residents must not be subjected to abuse by anyone, including, but not limited to . . . other residents. . . ." Review of the facility policy "Abuse and Neglect (Number II.A.1a)" occurred on 07/23/14. This policy, revised June 2012, stated, "Purpose: * To ensure that the center has in place an effective system that, regardless of the source, prevents mistreatment, neglect and abuse of residents . . . * To ensure that residents are not subjected to abuse by anyone, including . . . other residents. . . . * To identify and remedy any abusive situations. . . . To ensure that a complete review of existing incidents is documented. . . . Procedure: 1. If a staff member receives an allegation of abuse . . or witnesses suspected abuse . . . the staff member will immediately report this to a supervisor and complete . . . Incident Report. . . . b. If it is an allegation of resident to resident abuse, the residents will be immediately separated and both assured a safe environment. . . ." - Review of Resident # 5's medical record occurred on all days of survey. Medical [DIAGNOSES REDACTED]. Resident #5's admission Minimum Data Set ((MDS) dated [DATE] and his quarterly MDS dated [DATE], identified extensive assistance for bed mobility, transfers, and locomotion on and off the unit. Resident #5's Progress Notes identified the following: *10/29/13 at 9:26 p.m. - " . . . resident (#5) had his wheelchair parked behind the door and was not allowing any staff to enter the room stating multiple times 'get the (expletive) out of here.' Nurse tried taking (sic) to resident to see what was bothering him but he wouldn't say. Nurse tried to explain that staff need to get into the room to put his roommate (Resident #3) to bed but he stated 'he doesn't need to get in here, he doesn't pay a (expletive) dime.' . . . Nurse went back to residents room to see if he would let staff in yet and he had the door closed again and backed his wheelchair up against the door again. . . . Once able to get roommate (Resident #3) in he continued to state 'he doesn't pay a (expletive) dime to be here. I'm not going to be (expletive) babysitting him' . . . He then stated "(Expletive) right I'm not, he's not (expletive) sleeping with me he can go sleep with them.' CNA (certified nursing assistant) and nurse able to get roommate into bed . . . Resident (#5) has shut door again to room." (Resident #3 left alone in room with Resident #5. The next progress note is dated 10:43 p.m., which stated "CNA poked head into room to check on resident and roommate, . . . he stated '. . . get the (expletive) out of here and close the (expletive) door.' Later the nurse went to check on resident . . . just barley (sic) had the door open and he stated 'get the (expletive) out and shut the (expletive) door.'" *10/30/14 at 10:46 p.m. - ". . . when staff tried to bringing (sic) his roommate (Resident #3) into the room to give him his evening NEB Tx (nebulizer treatment) He (Resident #5) said 'What the (expletive) are you bringing him in here for.' Staff stated that (Resident #3) was his roommate and they are going to (sic) him a NEB Tx. He said 'Get him the (expletive) out of here and your (sic) not going to do anything with him in here get the (expletive) out NOW . . . Staff brought resident (#3) and NEB machine out to the TV area and gave roommate his TX there. . . . Later staff brought the roommate to the room to put him to bed, resident (#5) must have heard him coming (sic) because when staff got to the room resident (#5) had self transferred himself halfway into his WC (wheelchair). He started yelling obsinities (sic) at the staff and roommate. Then when staff was toileting roommate he tried to lock them into the bathroom. He was very irate. Staff state that they are concerned for the roommate's (Resident #3's) safety." (Resident #3 left alone in room with Resident #5) *10/31/13 at 6:48 a.m. - "CNA came and informed writer that resident (#5)was calling his roommate (Resident #3) names and wanted him out of the room. Went down to room . . . resident (#5) started in agin (sic) saying 'Get him out of here' 'He is nothing but a (expletive) retard' Over and over agin (sic). 'All that he can say is 'Yep' ' Pulled the curtain and asked CNA to get resident (#3) up and dressed and out of the room. Will pass this information to Social Services." *10/31/13 at 11:08 a.m. (Social Service Note) - ". . . talked to the resident (#5) re: his roommate (Resident #3) and his behavior toward him. This resident said that no matter what happens that he is going to hate him (Resident #3) 'till the day that I die.' LSW (licensed social worker) said that this is his roommate's room as well & he needs to respect his roommate's space. 'It's my room and I can do with it as I like. He is a f. . . retard.' " 10/31/13 at 10:01 p.m. - ". . . Later when staff went into room to give roommate (Resident #3) his HS (evening) medications he (Resident #5) began cussing . . . 'I don't give a (expletive) about that (expletive) retard' . . and on and on he ranted and raved. Then when staff gave roommate his neb treatment he (Resident #5) got mad again because it was too noisy . . ." *11/01/13 at 2:12 a.m. - "Resident (#5) was cussing using the f word and wanted his roommate (Resident #3) off his property. Stated ' . . . that retard off his property' 'If we didn't get that retard off his property right now he is going to kill him.' Removed resident's roommate (Resident #3) to a different room. Resident (#5) calmed down as soon as we removed resident (#3)." *11/01/13 at 10:51 a.m. - Resident (#5) was sent to clinic for medical evaluation R/T (related to) aggressive behavior to R/O (rule out) medical condition which may be causing increased episodes of aggressiveness." (Resident #5 returned to the facility on [DATE] after being hospitalized for [REDACTED]. *11/10/13 at 6:30 p.m. - "While wheeling resident's roommate (Resident #3) to bed, roommate states 'this isn't it.' Resident (#5) stated 'yeah this isn't it.' Writer tells resident (#5) that its his roommates room too and resident (#5) starts calling roommate a '(expletive) retard).' . . . 'well its true, he's a (expletive) retard.' Asked resident (#5) to keep his thoughts to himself. Resident states 'I can say what I want'. . ." *11/10/13 at 8:56 p.m. - ". . . He (Resident #5) also is making comments regarding his roommate (Resident #3) again, as staff was walking out of room after giving roommate his HS medicine, he (Resident #5) started to talk quietly . . . He said 'You should stop giving him any medicine' Staff asked why and he replied 'Because then he won't be around much longer.'" *11/11/13 at 10:46 a.m. (social service note) - "Resident (#5) has been having a hard time adjusting to being in a NF (nursing facility) with a roommate. . . . He has been encouraged that when he can't stand it anymore he can come into the SS (social service) office and talk it out. He said that he felt somewhat better . . . Because of this, a new goal change has been added to his care plan. . . . A new focus re: his verbal behavioral symptoms toward his roommate (Resident #3) has been added. Please notify SS and charge nurse for any improvements or any decline." *11/19/13 at 4:05 a.m. - "CNA was taking resident's roommate (Resident #3) to the bathroom and resident (#5) stated 'Get him the (expletive) out of here,' Resident (#5) would not be redirected. Brought resident's roommate back out to the TV room." *11/19/13 at 12:51 p.m. - (social service note) - ". . . Resident (#5) remains much the same. . . . He is still having adjustment issues from being in the nursing home and having a roommate. . . ." *11/19/13 at 2:22 p.m. (social service note) - "Resident (#5) stated that his roommate (Resident #3) need (sic) to get out of the room and hates him. . . ." *11/19/13 at 11:01 p.m. - ". . . He (Resident #5) wanted to get into his wheelchair. Stated that he was going to lock his door so that retard wouldn't be able to get into the room. At this time resident (#5) is still up, going to make sure that his roommate (Resident #3), the retard, doesn't get into the room tonight. He mentioned that he was going to look into getting a lock for the door to keep the 'retard' out. . . ." *11/29/13 at 9:55 p.m. - CNA reports hearing resident (#5) yelling at his roommate (Resident #3) while she is standing at a hall kiosk charting, resident (#5) was calling roommate names and swearing at him telling roommate to get out, CNA entered residents room slowly and attempted to redirect. . . resident (#5) refused and became even more agitated, resident (#5) was attempting to get out of bed unassisted to get to his roommate, resident (#5) threatened CNA and grabbed her arm squeezing attempting to hurt her. . . CNA left resident (#5) in room alone to give him time to calm down, as she walked out of room resident (#5) was threatening to come find her and hurt her. . . ." *12/02/13 at 1:21 p.m. (social service note) - "Updated (Resident 5's wife) on the recent behavior incident. SS explained that a room change was discussed, but because the resident feels that the room he is in is all his, no one else's, the same situation may reoccur. The option of (psychiatric hospital) was discussed to see what could be done to help the resident . . . (Wife) is ok with the move to the (psychiatric hospital). . . ." (Resident #5 was hospitalized from [DATE] to 12/20/13 for his behaviors.) Resident #5's care plan during the above time period, October - November 2013, identified "The resident has adjustment issues to admission E/B (evidenced by) verbal behavioral symptoms towards his roommate." Interventions included "Resident will receive daily opportunities for social contact. . . Observe for stressors which may be early warning signs of problem behavior." - Review of Resident #3's medical record occurred on all days of survey. Medical [DIAGNOSES REDACTED]. The admission MDS, dated [DATE], identified short/long term memory deficits, severely impaired reasoning, [MEDICAL CONDITION], depression (feeling down/bad about self ), and required limited-to-extensive assistance with all activities of daily living (ADLs). Resident #3's care plan, dated October-December 2013, identified the following: * ". . . Interventions: . . . Resident does self transfer at times (11/04/13) . . ." * ". . . Interventions: . . . RESOLVED: PERSONAL ALARM: Wander Guard used to alert staff to residents movement and to assist staff in monitoring movement (11/01/13) . . ." The care plan failed to address the known conflict between Resident #3 and his roommate (#5) which occurred during the time period they shared a room (October 16-December 2, 2013). A progress note, dated 10/15/13, identified, ". . . talked (with) (son) to inform him his Dad would be getting a roommate tomorrow. He was okay with this information. Stated 'I hope this will work out.'" Review of nursing/social service progress notes failed to identify the known conflict between Resident #3 and his roommate (Resident #5) which occurred during the time period they shared a room (October 16-December 2, 2013). During an interview on July 23, 2014 at 12:00 p.m., when asked if the facility was aware of the conflict between Resident #3 and his roommate (Resident #5), a managerial social services staff member (#8) stated, "We were aware it was not a great situation. We were fairly full at the time. Neither one of those guys made a good roommate." When asked what types of behaviors Resident #5 displayed towards Resident #3, the managerial social services staff member (#8) stated, "All verbal, no physical. Staff were real good. They would take (Resident #3) out, so he didn't have to listen to that." When asked how Resident #3 responded to his roommate's disparaging or derogatory comments, she stated, "(Resident #3) didn't seem to be bothered by it." When asked if Resident #3's family was aware of the conflict between Resident #3 and his roommate (Resident #5), the managerial social services staff member (#8) stated, "Can't say that for sure." The medical record identified Resident #5: * Yelled and/or swore at Resident #3 on multiple occasions, * Threatened "to kill" Resident #3 * Blocked their room, so Resident #3 could not enter, * Prevented Resident #3 from receiving his NEB treatments in the privacy of his room, * Attempted to prevent Resident #3 from sleeping and/or receiving toileting cares in the privacy of his room. Resident #3's medical record provided no evidence the facility addressed the known conflict between these two residents, even though staff reported they were "concerned for (Resident #3) safety." The facility also failed to notify Resident #3's family of the ongoing verbal abuse (numerous disparaging and derogatory statements made by Resident #5) or of the staffs' concerns for his safety. During interview on 07/22/14 at 4:35 p.m., administrative staff members (# 5, #8, #9, and #10) provided information that Resident #5 was in a room by himself after he returned from his hospitalization (12/20/13) until 12/27/13 when he became roommates with Resident #8. Resident #5's Progress Notes identified the following: *12/28/13 at 2:58 p.m. - "(Resident #5) Stated to CNA that roommate (sic) (Resident #8) would have to leave the room, because he pays the rent for the whole room. . . . He continued to say roommate (sic) needed to get out." *12/28/13 at 7:18 p.m. - "(Resident #5) Pulled all the bedding off roomates (sic) bed and told CNA that roommate (sic) needed to get out. CNA assisted roommate (sic) (Resident #8) out of the room while nurse spoke to resident (#5) letting him know that his behavior would not be tollerated (sic). . . . Resident (#5) stated he would not share the room with this man (using inappropriate language as he addressed him). " *12/30/13 at 9:09 a.m. (social service note) - "Talked to resident (#5) to see how it's going with his roommate (Resident #8). He is not too happy about having a roommate, saying that he wishes that the whole room could be his. . . . He wants to have a private room. . . ." *01/02/14 at 9:29 a.m. - "(Resident #5) Sitting in doorway of room in W/C and would not allow roommate (sic) (Resident #8) to enter. Nurse asked him to please move out of doorway. He stated . . . it was his room. . . . (Resident #5) was told that . . . he shared the room . . . and needed to allow him (Resident #8) entrance. He finally backed his chair out of the way and allowed roommate (sic) to enter." *01/02/14 at 5:20 p.m. (social service note) - ". . . He (Resident #5) has had some behaviors since returning from the Center. He believes that he has his entire room to himself because his (sic) is paying for the room, not his roommate (Resident #8). He has not said anything to his roommate like to the previous roommate (Resident #3), but the resident has made it quite evident that he does not want any kind of roommate. Staff will continue to educate him that he and his roommate both pay for the room. . . ." *01/08/14 at 11:40 p.m. "This resident's roommate (Resident #8) up at this time to the bathroom when this resident (#5) started hollering 'you dumb (expletive)' multiple times. When staff entered room to see what was going on, roommate was in bathroom and staff told this resident that he did not need to talk to anybody like that he stated 'he's on my property and he needs to get off' . . ." *01/16/14 at 10:22 p.m. - "resident (#5) became upset and short tempered when rommate (sic) (Resident #8) got up to go to the bathroom." *01/17/14 at 1:06 p.m. (social service note) - "Spoke with resident (#5) about giving his roommate (Resident #8) a hard time about using the bathroom. Administered resident education re: the bathroom being shared between the two roommates." *02/18/14 at 8:37 a.m. - "Resident (#5) was yelling 'Get this guy out of my room.' Writer informed resident (#5) he did not have a private room and that was his roommate. Writer was talking to roommate (Resident #8) about his cataract surgery and roommate (Resident #5) stated 'He has surgery? Good I hope he dies.' Reminded resident (#5) that this kinda (sic) talk was inappropriate." *02/20/14 at 4:50 p.m. - "Resident (#5) was yelling obscenities at roommate (Resident #8) when staff entered room. He was in his wheelchair on the roommates side of the room, their wheelchairs were locked together. Roommate had his back scratcher in hand and was about to hit resident (#5) when staff entered the room to intervene." *02/20/14 at 7:15 p.m. - "When staff wheeled residents roommate (Resident #8) into the room after supper, resident (#5) started in again with the obscenities, staff reminded him this was inappropriate." *03/04/14 at 6:53 p.m. - "Resident (#5) in room yelling and swearing at roommate (Resident #8), not letting roommate go by him and use the bathroom. Was calmer a few moments later." *03/09/14 at 1:40 p.m. - "Nurse started roomates (sic) (Resident #8) nebulizer treatment, and resident (#5) yelled at nurse, 'shut that (expletive) thing off. It's too loud' 'If you don't stop that thing, I'll come over there and stop it myself.' Sat with roommate (sic) until treatment was finished. . . . explained . . . needed to be respectful to roommate (sic) and his needs." *03/10/14 at 7:52 a.m. - CNA reported resident (#5) was saying "Look at that Dum (sic) (expletive), he sure thinks he's smart even though he ain't. '(expletive, expletive)' When writer went in to give his roommate (Resident #8) a treatment resident (#5) states 'Turn that (expletive) thing off x 4.' Resident (#5) repeated it x3. . . ." *3/10/14 at 1:00 p.m. - "CNA walked into residents room to find him (Resident #5) grabbing onto the back of roommate's (Resident #8) shirt shaking him saying 'you (expletive), get out of here, I don't want you in my room.' When staff turned on neb treatment for [REDACTED].#5) stated, 'I am not going to listen to that (expletive) either.' " *03/10/14 at 1:30 p.m. - "Spoke to family regarding private room availability.(Wife) would like to have resident (#5) moved into the private room that is now open. Housekeeping will move resident (#5) . . . today." - Review of Resident #8's medical record occurred on 07/23/14. Medical [DIAGNOSES REDACTED].#8's quarterly MDS, dated [DATE], identified the resident as cognitively intact, and required supervision with bed mobility, transfers, and locomotion on and off the unit. Review of Resident #8's Progress Notes identified the following: *02/20/14 - "Resident's roommate (Resident #5) had been yelling obscenities at him, he argued back some and roommate went to his side of the room, when staff intervened their wheelchairs were locked together and resident (#8) had his back scratcher in hand ready to hit roommate. Stated that he no longer wanted this guy for a roommate and wants his own room." During interview on 07/23/14 at 11:15 a.m., Resident #8 stated his former roommate (Resident #5) was "mean with me, he stood by the door so I couldn't use the restroom." Resident #8 also stated "he took my bedding off" the bed and "he was always giving me the finger," which the resident stated "made me mad." Resident #8 stated he was not afraid of his roommate and "if they would have let me, I would beat the (expletive) out of him." Resident #8 stated he was "waiting and waiting, and finally they moved him (the roommate)." Resident #5's medical record identified he yelled and swore at his roommate, Resident #8, on multiple occasions. The record also identified Resident #5 blocked the room and bathroom Resident #8 could not enter. After the incident on 02/20/14, a Progress Note stated Resident #8 no longer wanted to have Resident #5 as a roommate. Although Resident #8 expressed his desire to no longer share a room with Resident #5, the facility failed to separate these residents until 03/10/14, 18 days later. Resident #8's medical record provided no evidence staff addressed the known conflict between these two residents during the time period of December 27, 2013 to March 10, 2014.