Every finding on record at Montana Mental Health Nursing Home

Based on interviews and record reviews, leadership staff failed to ensure residents were free from neglect of care and utilize or follow an effective system to identify, address, and correct concerns pertaining to staff member R's actions and failure to complete duties assigned when on shift and providing resident care, as to ensure residents were not neglected, and this failure affected 11 (#s 1, 2, 3, 4, 5, 7, 8, 9, 10, 11, and 12) of 17 sampled residents. This failure continued over several months. Findings include: Review of a facility reported incident, dated 9/23/25, reflected that staff member R had more than 50 medication errors involving residents #s 1, 2, 3, 4, 5, 7, 8, 9, 10, 11, and 12. For the residents involved, staff member R had either failed to administer medications, complete glucose checks properly, and or failed to complete skin checks. The report showed staff member R had been unavailable for interview(s) as of the completion of the report. The facility identified in the report that no harm was found for the residents affected by the physician's orders not being followed by staff member R. During an interview on 11/17/25 at 11:47 a.m., staff member I stated staff member R seemed fine the day the errors occurred and did not see a reason for the errors to have occurred. Staff member I said she had reported to staff members D and E, that over the last three to four months staff member R seemed to be confused, was asking odd questions that she would normally know (as a long term RN at the facility), she had slurred and slowed speech, was calling people by the wrong names, and on several occasions her eyes were barely open. Staff member I stated staff member R had been showing these changes in the way she acted over the past year, but she had worsened over the past three to four months.During an interview on 11/17/25 at 11:50 a.m., staff member J stated she had reported concerns about staff member R to staff member D approximately three months ago, but did not know what had happened with staff member R related to the reported concerns after that. Staff member J stated other staff were discussing the changes that had been occurring with staff member R, which included a significant weight loss, she had confusion, slurred speech, a slower gait (walking), and wandering at times.During an interview on 11/17/25 at 12:10 p.m., staff member D stated she had received concerns from staff about staff member R's cognitive status and changes and had gone to check on staff member R. Staff member D stated she asked staff member R how she was doing, and staff member R would say she was fine. Staff member D stated she had watched staff member R for a few minutes, and she seemed fine, so she did not investigate the concerns further. Staff member D stated she did not document the concerns reported by staff about staff member R, unless she herself identified concerns. Staff member D stated she had concerns one day when staff member R was found in the lounge, and it had taken several minutes to arouse the staff member. Staff member D stated staff member R had reported she had back pain, so she thought perhaps staff member R was using pain medications, based on her cognitive changes and weight loss. Staff member D stated that one day, staff member R had a resident on the memory unit who was yelling out, and staff member R was . just staring at her cart. Staff member D stated she could hear the resident down the hall behind closed doors yelling, so she went to the unit and assisted the resident while staff member R continued to stare at her cart. Staff member R was also found eating lunch on her medication cart, which was against the facility policy, while surveyors were present in the building. Staff member D stated these were not behaviors/actions she had never seen staff member R display prior. Staff member D stated she did not report these changes or concerns to her supervisor, did not investigate the events that occurred, or document the incidents.During an interview on 11/17/25 at 1:00 p.m., staff member E stated staff member R had an incident sometime in April (2025) with medication errors. Staff member R had been found in the lounge and was non-responsive. Staff member E stated staff member R finally roused and ate something, and she appeared to improve afterwards. Staff member E stated the incidents, which included more than 50 medication errors, were investigated by staff member B. Staff member E stated she was directed to review resident charts, medications, treatments, and blood glucose machines. Staff member E stated the blood glucose machines, which were to be used by staff member R, showed no glucose checks had been completed during staff member R's shift. There was also no charting completed on any residents during staff member R's shift, and it was identified that the medications and treatments had not been completed for 11 residents, which included #s 1, 2, 3, 4, 5, 7, 8, 9, 10, 11, and 12 residents. Staff member E stated she checked in with staff member R on occasion because she was concerned about her weight loss and changes in her cognition. Staff member E stated she received concerns from the licensed nursing staff regarding staff member R, which included the possibility that staff member R had an early onset of dementia and the weight loss, but staff member R seemed okay when she would check in with staff member E. Staff member E stated she did not report these concerns to a supervisor, investigate, or document the concerns about staff member R that was reported by the nurses.During an interview on 11/17/25 at 2:13 p.m., staff member L stated she had reported concerns related to staff member R's performance, after following behind staff member R (working the following shift), which included that she would find medications in different drawers, medications were not being given, and about staff member R's cognition changes. Staff member L stated staff member R had lost a lot of weight, and she believed the incidents were due to and caused by medical issues, and they were not malicious. Staff member L stated that staff member R had been having cognitive issues for three or four months before she went on a leave of absence. Staff member L stated she reported the missed medication administrations, which were not done by staff member R, to staff member I. During an interview on 11/17/25 at 2:30 p.m., staff member A stated, from her perspective, staff member R's care that she provided to the residents was good, and the medication error rate had improved, so she could not really investigate further into the situation for staff member R as it appeared as if it was personal medical issues. Staff member A stated that the concerns of staff member R's slurred speech, cognitive decline, and dementia had not been reported to her.

Based on observation, interviews, and record reviews, the facility failed to have an effective and accurate system in place for the identification and correction of medication administration documentation omissions for physician-ordered medications. Due to this, it was unknown if the sampled residents received the physician-ordered medications, due to the lack of documentation, or what the reasoning was for the undocumented medication administrations, and it was unknown if a medication error occurred or if the residents had an outcome from an error, since the concerns were unaddressed. Per the facility policy, these medication documentation omissions should have been identified and addressed by the facility staff as medication errors, but were not, and the ongoing concerns were not identified or addressed by the contracted pharmacy in an attempt to correct the concerns, for 14 (#s 1, 2, 3, 4, 5, 7, 8, 9, 10, 11, 12, 14, 16, and 17) of 17 sampled residents. Findings include: 1. Review of a facility reported incident, dated 9/23/25, reflected that staff member R had more than 50 medication errors involving residents #s 1, 2, 3, 4, 5, 7, 8, 9, 10, 11, and 12. The facility reported staff member R failed to administer medications, complete glucose checks properly, when insulin was given on a sliding scale, and failed to complete skin checks. The document showed staff member R was unavailable for interview as of the completion of the report. The facility reported incident showed the facility did not identify harm to the residents. This Surveyor attempted to contact staff member R on 11/18/25 at 11:10 a.m., and no response was received. The staff member was on leave. 2. Review of resident #1's medication records, dated 10/1/25 - 11/18/25, reflected that resident #1 had ten missed medication administrations, including the medications olanzapine, budes-formoterol, melatonin, triamcin, senna plus, carbidopa-levodopa, mirtazapine, and quetiapine. There was no documentation on the medication records or nursing notes to reflect why the medications were not administered to resident #1. The medical record did not address the medication errors and or potential outcomes of errors. 3. Review of resident #2's medication records, dated 10/1/25 - 10/31/25, reflected that resident #2 had two missed medication administrations, including the medications quetiapine and atorvastatin. There was no documentation on the records or nursing notes to reflect why the medications were not administered. The medical record did not address the medication errors and or potential outcomes of errors. 4. Review of resident #3's medication records, dated 10/1/25 - 10/31/25, reflected resident #3 had 25 missed medication administrations, including the medications fluticasone, hydrochlorothiazide, prednisolone, atorvastatin, lisinopril, cetirizine, aspirin, latanoprost, amlodipine, quetiapine, and lamotrigine. There was no documentation on the back of the medication record or nursing notes to reflect why the medications were not administered. The medical record did not address the medication errors and or potential outcomes of errors. 5. Review of resident #4's medication chart, dated 10/1/25-10/31/25, reflected resident #4 had missed four medication administrations, including Boost, tamsulosin, and amlodipine. There was no documentation on the back of the medication chart or in nursing notes to reflect why the medications were not administered. The medical record did not address the medication errors and or potential outcomes of errors. 6. Review of resident #5's medication record, dated 10/1/25 -1 1/18/25, reflected that resident #5 had one medication administration, and the record showed 59 fentanyl patch checks were not documented. There was no documentation on the back of the medication record or nursing notes to reflect why the medications were not administered or the patch checks were not completed. The medical record did not address the medication errors and or fentanyl patch checks. 7. Review of resident #7's medication record, dated 9/1/25 - 11/18/25, reflected that resident #7 had 48 missed medication administrations, including senna plus, a very high-calorie drink, risperidone, acetaminophen, divalproex, and olanzapine. There was no documentation on the back of the medication record or in the nursing notes to reflect why the medications were not administered. The medical record did not address the medication errors and or potential outcomes of errors. 8. Review of resident #8's medication record, dated 10/1/25 - 10/31/25, reflected that resident #8 had eight missed medication administrations, including the medications for a multivitamin, metformin, lamotrigine, famotidine, and clonazepam. There was no documentation on the back of the medication record or in the nursing notes to reflect why the medications were not administered. The medical record did not address the medication errors and or potential outcomes of errors. 9. Review of resident #9's medication record, dated 9/1/25 -1 0/31/25, reflected resident #9 had 11 missed medication administrations, including the medications olanzapine, calcium, clonazepam, and acetaminophen; and there were 17 lidocaine patch removals not documented. There was no documentation on the back of the medication record or nursing notes to reflect why the medications were not administered. The medical record did not address the medication errors and or potential outcomes of errors. 10. Review of resident #11's medication record, dated 10/1/25 - 10/31/25, reflected resident #11 had six missed medication administrations, including fluticasone, metformin, vitamin B, Boost, NovoLog, and clobetasol. There was no documentation on the back of the medication record or in the nursing notes to reflect why the medications were not administered. The medical record did not address the medication errors and or potential outcomes of errors. 11. Review of resident #14's medication record, dated 10/1/25 - 10/31/25, reflected resident #14 had four missed medication administrations, including olanzapine, vitamin B, and acetaminophen. There was no documentation on the back of the medication record or in nursing notes to reflect why the medications were not administered. The medical record did not address the medication errors and or potential outcomes of errors. 12. Review of resident #16's medication records, dated 10/1/25 -1 1/18/25, reflected resident #16 had 11 missed medication administrations, including the medications bisacodyl suppositories and acetaminophen. There was no documentation on the back of the medication records or in the nursing notes to reflect why the medications were not administered. The medical record did not address the medication errors and or potential outcomes of errors. 13. Review of resident #17's medication records, dated 11/1/25 -1 1/17/25, reflected resident #17 had eight missed medication administrations, including the medications atorvastatin, tamsulosin, melatonin, and trazadone. There was no documentation on the back of the medication records or in the nursing notes to reflect why the medications were not administered. The medical record did not address the medication errors and or potential outcomes of errors. During an interview on 11/17/25 at 11:47 a.m., staff member I stated she had not had any recent concerns for missed medication doses or diversion, and staff member I was an integral part of the facility's pharmacy services and identification of concerns needing to be corrected. During an interview on 11/17/25 at 2:13 p.m., staff member L stated if a resident refused a medication or if a medication was not given, the nurse was required to circle the box (for that medication) on the medication administration record, initial it, and write an explanation on the back of the medication administration page. During an observation and interview on 11/18/25 at 9:48 a.m., staff member I was completing a resident's medical record chart review. Staff member I stated she reviewed the medications listed on the medication records, and compared the information to the physician's order, to ensure accuracy. Staff member I stated she did not review holes (undocumented medication administrations) on the medication administration records, unless it was for a narcotic medication, and there had been a discrepancy in the medication count. Staff member I stated she did not consider the holes on the medication administration records to be medication errors. Staff member I stated she only considered a medication error to be when she received a medication error report from a nurse, or medications were returned to the pharmacy, and the medications were not accounted for. Staff member I stated if a medication was declined or not given for a specific reason, the box on the medication record should be circled, initialed, and then a progress note was to be documented by the nurse on the back of the medication administration record, which would explain the missed dose. Staff member I stated she was not sure who reviewed the medication records for missed doses or holes (undocumented administrations). Review of a facility policy, Medication Error Reporting and Prevention, dated 8/14/25, reflected:- . 4. Examples of Medication Errors: Incorrect dose, route, dosage form, or time, Medication omission .Review of a facility policy, Medication Administration & Safe Handling, Principles of, revised 3/20/25, reflected:- . 3. DOCUMENTATIONa. Document on the MAR immediately after the administration of each patient's medication.b. Document on the MAR refusals, PRN's reason and response, STAT medications, medications administered at times other than prescribed.

Based on observations, interviews, and record reviews, facility administrative staff failed to act timely and thoroughly to address concerns brought forth related to a staff member providing resident care and services, and to ensure neglect of care was not occurring, for 11 (1, 2, 3, 4, 5, 7, 8, 9, 10, 11, and 12); and administrative staff did not identify or act on concerns related to the medication administration policy, procedures, or system, and implement corrections, so concerns were ongoing, and this affected 12 (#s 1, 2, 3, 4, 5, 7, 8, 9, 11, 14, 16, 17) of 17 sampled residents. Findings include:1. Review of a facility reported incident, dated 9/23/25, reflected staff member R had more than 50 medication errors involving residents #s 1, 2, 3, 4, 5, 7, 8, 9, 10, 11, and 12. The staff member involved had failed to administer medications, complete glucose checks properly, and failed to complete skin checks. The document showed it was identified there was no harm found for the residents involved. During an interview on 11/17/25 at 11:47 a.m., staff member I stated she had reported concerns to staff members D and E, that staff member R seemed to be confused, had slurred speech, and was calling people by the wrong name. Staff member I stated this had been going on for three to four months; therefore, staff member I reported the concerns to the administrative staff to address. During an interview on 11/17/25 at 11:50 a.m., staff member J stated she had reported concerns several months prior to staff member D, concerns related to staff member R when she was working and providing resident care and services. She stated she was unsure if the concerns she reported were addressed, although an extended period of time had passed. She stated some staff noticed changes with staff member R, such as she had an obvious weight loss, displayed confusion and wandering, had slurred speech, and was walking more slowly.During an interview on 11/17/25 at 12:10 p.m., staff member D stated she had received concerns from facility staff about staff member R's cognitive status. Staff member D stated she checked on staff member R, and she said she was fine. Staff member D stated she watched staff member R for a few minutes, she seemed fine, so she did not investigate further. Although the concerns had been ongoing, staff member D stated she did not document the concerns reported about staff member R. Staff member D stated she thought maybe staff member R was using pain medications which may have affected her weight and cognition. Staff member D stated staff member R did not address a resident's concern when a resident was yelling out, and she had not been following the facility policies, which was not typical for staff member R. Staff member D stated she did not report these concerns to her supervisor, investigate the incidents, or document the incidents related to the licensed staff member and the concerns she was aware of, to ensure resident safety. During an interview on 11/17/25 at 1:00 p.m., staff member E stated staff member R had an incident sometime in April 2025 with medication errors. Staff member R was found in the lounge and was non-responsive, but seemed to improve after. Staff member E stated the situation with the more than 50 medication errors was investigated by staff member B. Staff member E stated she was directed to review resident charts, medications, treatments, and blood glucose machines, and identified concerns with 11 (#s 1, 2, 3, 4, 5, 7, 8, 9, 10, 11, and 12) residents. Staff member E stated she did receive concerns regarding staff member R, and stated she did not report the concerns to a supervisor, investigate the concerns, or document the concerns presented by the nursing staff, to ensure resident safety.During an interview on 11/17/25 at 2:13 p.m., staff member L stated she had reported concerns to administrative staff about staff member R, when she identified concerns related to staff member R's work duties and actions, after she worked the shifts following after staff member R. The concerns included medications being found in different drawers, medications not being given, and the staff member's cognition changes. Staff member L stated that staff member R had been having cognitive issues for three or four months, and then she went on a leave of absence. Staff member L stated she reported the missed medication administrations to staff member I. During an interview on 11/17/25 at 2:30 p.m., staff member A stated the care staff member R provided was good, and the medication error rate had improved. She stated she could not investigate someone (a staff member) for cognitive issues because they were personal issues. Staff member A stated the concerns of staff member R's changes, such as the slurred speech, cognitive changes, and dementia, had not been reported to her by the supervisors. 2. During an observation and interview on 11/18/25 at 9:48 a.m., staff member I stated she reviewed the medications listed on the resident medication records to ensure accuracy. Staff member I stated she was not sure who reviewed the medication records for missed doses or holes in the chart. Staff member I stated she submitted a medication error report to the QAPI team monthly, but the missed doses were only considered when the medication was returned to the pharmacy without an explanation.Review of medication administration records for resident #1, 2, 3, 4, 5, 7, 8, 9, 11, 14, 16, 17, dated 9/1/25 - 11/18/25, reflected 138 medications were missed, 59 fentanyl patch checks were missed, and 17 lidocaine removals were missed. The medication administration concerns were not addressed by the facility administrative staff or per the facility policies. Review of a facility policy, Medication Error Reporting and Prevention, dated 8/14/25, reflected:- . 4. Examples of Medication Errors . Medication omission .Review of a facility policy, Medication Administration & Safe Handling, Principles of, revised 3/20/25, reflected:- . 3. DOCUMENTATIONa. Document on the MAR immediately after the administration of each patient's medication.b. Document on the MAR refusals, PRN's reason and response, STAT medications, medications administered at times other than prescribed.

Based on interview and record review, a staff member failed to provide necessary ADL care for a dependent resident when the staff member was directed to provide the necessary care, but the staff member left the shift and did not help the resident, and the resident was found with a soiled brief/chair, for 1 (#6) of 17 sampled residents. Findings include: Review of a facility reported incident, dated 11/4/25, reflected staff member G was instructed to change the brief of resident #6. During the staff's change of shift, resident #6 was found with dried feces up his back and in and under his wheelchair cushion. The facility reported the performance concerns as neglect of care. It was identified this was not a resident care system issue but isolated to the resident. Review of a staff member's witness statement, dated 11/4/25, reflected that the nurse had instructed staff member G to change resident #6's brief because the resident was soiled. When the second shift arrived, resident #6 had dried feces up his back, on his clothing, in his wheelchair, and under his wheelchair cushion. During an interview on 11/17/25 at 2:15 p.m., staff member U stated on the day resident #6 was found covered in feces, staff member U was working. Staff member U stated that staff member G did not change resident #6 when the nurse told her to. Staff member U stated that staff in the area could smell that resident #6 had soiled himself, and stated that staff member G had supposedly gone to change #6's soiled brief, but had returned in under five minutes. Staff member U stated resident #6 required full assistance to be ambulated and for his brief to be changed, and this could not have been done in five minutes or less.This surveyor attempted to contact staff member G, who was on administrative leave, on 11/17/25 at 7:35 a.m. and again at 10:40 a.m. There was no option to leave a message with staff member G, as the phone's voicemail option had not been set up to accept messages. During an interview on 11/17/25 at 1:15 p.m., staff member A stated the Human Resources department, and herself had also reached out to staff member G and received no response. Staff member A stated staff member G was supposed to be available between the hours of 8:00 a.m. and 5:00 p.m. Staff member A stated staff member G had been placed on administrative leave for the third time related to performance issues since September (2025). Staff member A stated some staff complained staff member G was lazy and did not complete her duties. Review of a facility policy, Activities of Daily Living, revised 3/20/25, reflected: .Care and services will be provided for the following activities of daily living per the CNA training Manual to include: . 3. Toileting .Review of a facility policy, Abuse, Misappropriations, and/or Neglect of Residents, revised 11/18/24, reflected: .12. Neglect is the failure of the facility, its employees, or service provider to provide goods and services to a resident necessary to avoid physical harm, pain mental anguish or emotional distress.

Based on observation, interview, and record review, the facility failed to identify two areas of concern, which were contributing factors for a resident's severe weight loss of 11.86% over 3 months, which included the resident's increased sedation [sleeping through meals], and the resident had an ADL decline. The facility did not address the two contributing factors timely manner, in an attempt to intervene and prevent the severe loss, for 1 (#1) of 14 sampled residents. Findings include:During an interview on 7/29/25 at 2:35 p.m., staff member O stated that when resident #1 was first admitted , he was very agitated. Now the resident had stabilized on his medications and was more mellow, and maybe he had a little bit of a decline. Staff member O stated the resident had gotten a lot easier to redirect and was he was not having behavioral issues.Review of resident #1's MDS admission assessment, with an ARD of 4/30/25, showed the resident was coded as needing set up and clean up only for eating. The resident was independent for toileting and ambulation.Review of resident #1's nursing progress notes, dated 7/2/25 - current, showed the following:-7/2/25 . Seems more ‘out of it' than what this RN previously knew .-7/16/25 . 1:1 who had to encourage every bite of dinner. Res appeared sedated . [sic]-7/17/25 Resident slept all day this far. Was able to wake him up to take am and noon meds. He have very few bites of lunch . [sic]-7/17/25 . he was laid back down and immediately asleep. Res very sedated today. Very little intake. [sic]-7/19/25 [Resident #1] is sleepy this shift. Hard to rouse for check and changes .-7/21/25 [Resident #1] has been sleeping in recliner since before 1800 [6:00 p.m.]. He wouldn't wake to eat dinner or take meds. Is still in chair sleeping. Very somnolent and hard to rouse. [sic]-7/21/25 . did not wake up for lunch.-7/22/25 [Resident #1] is needing more assist with dressing, personal hygiene, toileting, and eating .-7/23/35 Res profoundly sedated this shift and is minimally responsive to staff. Res sits with eyes closed and is difficult to rouse . resident's sedation load is very high with the current medication profile of Seroquel, olanzapine, Haldol, Ativan, trazadone, Melatonin, and occasionally oxycodone. No behaviors noted this shift. [sic]-7/25/25 Res sedated but awake in dayroom after dinner. Minimal intake at dinner . [sic]-7/29/25 . Res requires almost 100% assistance from staff with ADLs. [sic]During an observation on 7/30/25 at 8:22 a.m., resident #1 was sitting in a wheelchair, and he was receiving full feeding assistance from staff with breakfast.Review of resident #1's documented weights showed:-4/24/25 236 lbs.-5/5/25 233 lbs.-6/4/25 229 lbs.-7/7/25 refused.-7/22/25 209 lbs. This represented an 11.86% severe weight loss over three months.A request was made on 7/29/25 for resident #1's nutrition notes to determine the implemented interventions for the severe weight loss. Review of resident #1's nutrition note, dated 7/29/25, showed the resident had lost 27 lbs. since admission. A reweigh was requested, and new orders for double portions at breakfast, weekly weights, and nutritional supplements were added for weight loss prevention. Review of resident #1's nursing progress note, dated 7/30/25, showed, Late entry from 7/28/25. Called rsdt [resident] guardian at 1000 [10:00 a.m.] and informed her of weight loss . The notification was not timely.During an interview on 7/30/25 at 10:38 a.m. staff member N stated resident #1 was on a medication called rivastigmine, a dementia medication, that had side effects of weight loss and loss of appetite. Staff member N stated resident #1 had some appetite loss, as he used to eat all his food, and loved sweets, like Reese's peanut butter cups. Staff member N stated the psych provider had been updated, and a medication taper had been initiated. Staff member N stated that the July weight for #1 was not done by the staff member who normally did the weights, and the facility was attempting to locate more information. Staff member N stated that any resident having more than a five-pound discrepancy would need to have a reweigh completed, and if a resident refused, they should be reapproached at another time.During an interview on 7/30/25 at 11:52 a.m., staff member J stated the pharmacy reviews were completed monthly, and the pharmacist looked at nursing notes, physician orders, labs, physician notes, and the medication administration report for the as-needed medication usage. Staff member J stated if there was a lot of documentation related to a resident being excessively sedated, the pharmacy would look at psychiatric medications and pain pills, and if the resident was getting a whole bunch of PRNs (as needed medications) they would look to see if a certain time of day was where the sedation was occurring to correlate to medication timing. Staff member J was unsure when resident #1's most recent pharmacy review occurred. During an observation on 7/30/25 at 12:26 p.m., resident #1 was getting full feeding assistance at lunch. His eyes were closed, and he was restless and fidgeting in the recliner.During an interview on 7/30/25 at 1:54 p.m., staff member M stated they were notified of resident #1's weight loss, . just in the last few days, and was over to see the resident yesterday (7/29/25). Staff member M requested a re-weight, noting that anytime there was a five-pound difference, a re-weight should occur. Staff member M stated that without a re-weigh, it was difficult to function in their role for resident care [referring to the refusal in early July].During an interview on 7/30/25 at 2:17 p.m., staff member N stated resident #1 had been reweighed that morning with a result of 207.5 lbs.During an interview on 7/30/25 at 3:16 p.m., staff member B stated the physicians had been notified [medical on 7/25/25 and psychiatric 7/23/25 per progress notes], medication changes had occurred, and the resident had been discussed in IDT meetings. Staff member B stated there was consideration that the weight loss and sedation were a natural progression of the resident's dementia.

Based on interview and record review, staff assigned to deliver mail to residents failed to do so for an extended period, and the mail was found piled in an employee's office, undelivered; and some mail was time-sensitive or confidential. This failure involved 9 (#s 6, 7, 8, 9, 10, 11, 12, 13, and 14) residents out of 14 sampled residents. It was also identified that staff did not assist residents with cognitive impairments with opening or understanding the mail. Findings Include:Review of the facility investigation notes for a Facility Reported Event, dated 1/10/25, which was related to undelivered mail, showed:-Residents 6, 7, 8, 9, 10, 11, 12, 13, and 14 had either personal mail, legal mail, or holiday packages sent to the faculty, which were undelivered between October 2024 and the beginning of January 2025. -Resident #6 was interviewed on 2/6/25 but unable to answer. Review of facility staff email communication, dated 7/7/25, showed resident #6's guardian was contacted on 1/9/25 regarding the late mail delivery, and was not concerned. Review of the mail inventory, which was delivered late and found in NF2's office, showed resident #6 had a personal letter with a postal stamp date of October 25, 2024.-Resident #7 was interviewed on 2/6/25 but unable to answer. Review of facility staff email communication, dated 7/7/25, showed resident #7's guardian was contacted on 1/9/25 regarding the late mail delivery, and was not concerned.-Resident #8 was interviewed on 2/5/25 and stated, I'm not getting it. I want to get it (mail) faster.-Resident #s 9, 10, and 11 were interviewed on 2/6/25 and had no ongoing concerns related to the mail delivery.-Resident #12 was interviewed on 2/5/25 and had no concerns. Review of the late delivered mail inventory, found in NF2's office, showed resident #12 had a Social Security Administration letter with a postal stamp date of December 10, 2024. -Resident #13 was interviewed on 2/5/25 and had no concerns. Review of the late delivered mail inventory, found in NF2's office, showed resident #13 had a personal letter with a postal stamp date of November 4, 2024.-Resident #14 was interviewed on 2/5/25 and stated, I am not getting any mail. When they deliver the mail, make sure the mail is mine. Review of the late delivered mail inventory, found in NF2's office, showed resident #14 had a personal letter with a postal stamp date of August 17, 2024, and a Social Security Administration letter with a postal stamp date of December 10, 2024.-NF3 did not report the issue or deliver the mail and packages as directed. NF3 was put on administrative leave and ended employment on 2/28/25. -NF2 was on medical leave when notified of administrative leave, and then the employee resigned on 1/13/25, during the investigation. All residents' mail and packages were delivered, and the responsible parties were notified. No lasting effects of the late mail were found.During an interview on 7/29/25 at 1:32 p.m., NF1 stated there had been no issues with legal mail delayed to residents. There had been some late packages, but nothing that had caused a negative impact to a resident. NF1 stated there had been no further resident concerns related to resident mail delivery. NF1 spoke with all of the resident family members involved in the incident.During an interview on 7/29/25 at 4:11 p.m., staff member C stated another staff member had noticed packages piled in NF2's office and brought it to her supervisor, NF3. NF3 was told to deliver the packages, and when it was noted she did not complete the directive, she was placed on administrative leave. An investigation was completed, and the entire office was checked for any outstanding mail and packages. The packages were delivered by a case manager. The facility had notified all the responsible parties of those residents involved, to inform them of the investigation, with only two being upset. Staff member C stated all other residents were interviewed, who were assigned to NF2, and there were a few issues with her timeliness for the mail delivery. One resident was found to have given her two gifts, one was edible and was eaten, and in the trash at the time of her leave, but it was noted that she told the resident she could not accept gifts. The unused gift was returned to the resident. Staff member C stated that the process was that all mail was stamped with the date of delivery to the facility, packages were logged when delivered, and given to residents.During an interview on 7/30/25 at 11:17 a.m., staff member A stated the failure to deliver a resident's mail was more of a personal failure than a process one. Staff member A stated that the people involved no longer worked at the facility. Staff member A started daily spot checks on the mail sign-out and hired a new case manager, who was trained on the correct process. Staff member A stated the facility had followed up with Social Security on behalf of residents who received late letters to ensure there were no repercussions. Staff member A stated they had met with their QAPI team to investigate the occurrence, interviewed residents, and interviewed resident representatives who had been impacted by the late delivery. All staff completed abuse training by April 2025.QAPI met to review the event on 1/22/25.All staff training occurred on 3/19/25 and 3/20/25. The facility identified the concern with the mail delivery system and staff responsible and corrected the deficient practice prior to the complaint survey. The surveyors identified there were no ongoing concerns.

Based on interview and record review, the facility failed to notify the resident's physician, dietician, and representative in a timely manner of the resident's severe weight loss, for 1 (#1) of 14 sampled residents. Findings include:Review of resident #1's electronic health record reflected the resident lost 27 pounds in a three-month time period. This weight loss represented an 11.86% severe weight loss. The weight 229 lbs. was recorded on 6/2/25, and the weight of 209 lbs. was recorded on 7/22/25, which showed a 20# loss occurred in under 2 months. The documentation showed the resident had a severe weight loss. The medical record did not show that the physician, dietitian, or representative was immediately notified of the severe loss.Review of resident #1's nursing progress notes, dated July 2025, showed the following physician notifications:-The psych provider was updated on 7/23/25 of the resident's change in status and behaviors.-The medical physician was notified of the weight loss on 7/25/25 while rounding for the 90-day visit. A UA was ordered to investigate the resident's fatigue. A request was made on 7/29/25 for resident #1's nutrition notes.Review of resident #1's nutrition note, dated 7/29/25, showed the resident had lost 27 lbs. since admission. New orders of double portions at breakfast, weekly weights, and nutritional supplements for weight loss were initiated. Review of resident #1's nursing progress note, dated 7/30/25, showed, Late entry from 7/28/25. Called rsdt [resident] guardian at 1000 [10:00 a.m.] and informed her of (#1's) weight loss .A phone interview with resident #1's family was attempted on 7/29/25 at 2:15 p.m., with no return call received.During an interview on 7/30/25 at 1:54 p.m., staff member M relayed details of being notified of resident #1's weight loss in the last few days, and staff member M went over to see the resident yesterday (7/29/25). Staff member M had requested a weight reweigh, noting that anytime there was a five-pound difference in weight, that should occur. Staff member M stated that without a weight, it was difficult to function in the role for resident care [referring to the refusal in early July].

Based on interview and record review, the facility failed to address the timely completion or implementation of treatment wishes, specifically related to the Provider Orders for Life-Sustaining Treatment (POLST) forms, for 2 (#s 43, and 60); and failed to ensure advanced directives were in place for 1 (#37) of 29 sampled residents. Findings include: 1. Resident #43 said she remembered being asked about her code status by the staff at the facility. A review of resident #43's admission records, showed the POLST was not completed for over thirty days after #43's admission, to address her treatment wishes. 2. Review of the admission form showed resident #60 was admitted on [DATE], and the POLST form for treatment wishes was not completed until 10/16/23. This was almost two months after the resident's admission, and the timeline did not correlate with the facility policy. During an interview on 10/24/24 at 9:11 a.m., staff member I stated in the absence of a POLST the staff would consider the resident a full code. Due to this, if a resident wished to be a DNR, but did not have treatment wishes determined and documented in the medical record on admission, the resident may receive treatment they did not wish to have. During an interview on 10/23/24 at 8:45 a.m., staff member A stated the physicians were the only staff allowed to complete the POLST forms at the facility. Staff member A said the POLST may not be completed until the physician or nurse practitioner makes their initial visit which may not be very often. Staff member A stated the facility had been completing audits of the POLST's as part of QAPI. During an interview on 10/24/24 at 9:11 a.m., staff member I stated the physicians were the only ones to complete the POLST forms at the facility. Staff member I said she would not trust other staff to be able to know how to complete the forms. It would be typical for the physician to not see the resident for two to three weeks after their admission to the facility, and per staff member I's interview, the resident would be considered a full-code, unless treatment wishes were already established. 49554 3. Review of resident #37's medical record showed there was no advanced directive filled out, and her progress notes failed to show a discussion was had regarding her wishes. Resident #37 was admitted to the facility on [DATE]. Review of resident #37's initial visit provider notes failed to show the resident's provider discussed the right to advanced directives and the resident's wishes. A request was submitted to the facility for information regarding an advanced directive or a refusal for resident #37. The facility did not provide this information prior to the end of the survey. During an interview on 10/24/24 at 9:50 a.m., staff member B stated the resident's provider will discuss advanced directives and assist the resident with filling out the POLST, upon the initial provider visit, which is within the first thirty days after admission. Staff member B stated, We conduct monthly audits of the resident charts to ensure the POLST is present and properly filled out for all residents. Review of a facility document titled Advanced Medical Directive (POLST) with a revision date of 2/6/23 showed: . Procedure: . B. If resident does not have a completed POLST at admit, their Provider will be notified to complete this for discussion with them and/or guardian at their first medical visit . 1. Resident and/or their guardians who do not wish to make any advance directives can note that on the Provider Orders for Life Sustaining Treatment . Review: 1. Advanced Medical Directive/POLST form will be reviewed annually by Social Services staff for proper completion and location within the chart. 2. Social Service staff will offer educational material to all interested families or guardians as requested . [sic]

Based on interview and record review, facility staff failed to ensure an allegation of resident-to-resident abuse was reported to the State Survey Agency, within 24 hours after the allegation occurred, for 6 (#s 26, 37, 47, 53, 64, and 70) of 29 sampled residents. Findings include: 1. Review of a facility reported incident, dated 7/8/24 at 6:05 a.m., showed an allegation of resident-to-resident abuse for residents #64 and #47. This allegation occurred on 7/6/24, and was not reported to the State Survey Agency, until 7/8/24. 2. Review of a facility reported incident, dated 7/8/24 at 9:05 a.m., showed an allegation of resident-to-resident abuse for residents #64 and #47. This allegation occurred on 7/6/24, and was not reported to the State Survey Agency, until 7/8/24. 3. Review of a facility reported incident, dated 7/24/24, showed an allegation of resident-to-resident abuse for residents #70 and #26. This allegation occurred on 7/22/24, and was not reported to the State Survey Agency, until 7/24/24. 4. Review of a facility reported incident, dated 9/16/24, showed an allegation of resident-to-resident abuse for residents #37 and #53. This allegation occurred on 9/12/24, and was not reported to the State Survey Agency, until 9/16/24. During an interview on 10/23/24 at 8:10 a.m., staff member J stated, Floor staff report any incidents (of abuse/neglect) to the nurse working. They (nurses) are supposed to fill out a report on a behavior sheet. During an interview on 10/24/24 at 10:10 a.m., staff member A stated, We have an abuse team who oversees investigating facility incidents. The nurse on duty would send an alert via Tiger Text, a confidential texting application, to the team. The team would designate an individual to investigate the concern and submit it through BOUNDS (facility on-line reporting system). I review all allegations and ensure they are submitted timely . Review of a facility document titled, Abuse, Misappropriations, and/or Neglect of Residents with a revision date of 6/6/24, showed: . INVESTIGATION OF ABUSE, NEGLECT, OR MISAPPROPRIATION: The facility conducts an internal investigation. The process is as follows: 1. Administrator and Quality Coordinator initially inputs the alleged abuse report into the Bounds system within 24 hours .

Based on observation, interviews, and record review, the facility failed to ensure expired immunizations which were stored in 1 of 2 medication refrigerators in the treatment room were properly disposed of. The facility failed to monitor the treatment room and unit medication refrigerator and freezer temperatures. This failure created the potential for residents to experience negative effects related to the administration of expired Shingrix immunizations and negative effects related to inadequately monitored medication and immunization refrigerator and freezer temperatures. Findings include: During a record review on [DATE] at 9:55 a.m., the treatment room immunization freezer temperature logs were not completed for the following dates: [DATE], 7, 15, 16, [DATE], and [DATE]. The treatment room immunization (Med-Lab Performance) refrigerator logs were not completed for the following dates: [DATE], 7, 15, 16, [DATE], and [DATE]. During an observation and interview on [DATE] at 9:58 a.m., in the treatment room refrigerator/freezer, a box of expired Shingrix vaccines labeled 'Zoster Vaccine Recombinant, Adjuvanted' with a lot number of FH79Y, manufacturer GlaxoSmithKline Biologicals, with an expiration date of [DATE], was on a shelf. Staff member L stated expired immunizations were brought to the pharmacy to be returned and replaced. Staff member L stated staff member K usually brings them to the pharmacy when they are expired, and Staff member K is in and out of here (the treatment room) a lot during the day, and I'm surprised this is in here. I check the temps too, but I am busy with the doctors during the day. During an interview on [DATE] at 10:04 a.m., staff member K stated she would check the treatment room fridge often, Daily, when I am here. The immune fridge temps are checked by the night shift nurses when [staff member L] or myself are not there to check, such as on weekends or holidays. Review of a facility document labeled, 'Glacier Med Fridge Nurses Station 2024' showed: Fridge Temp Range: Medications= 36 F - 45F . P.M. and Night nurses check refrigerators when doing narcotic counts. There was no documentation on the log for temperatures on [DATE], 6, 10, or 30th. The log showed no documentation for temperatures on [DATE]. Review of a facility document, '[Facility] Shift to Shift Charge Report', showed, Charge concerns . All refrigerador temps documented including vaccine fridge in treatment room? [sic] Review of a facility document of an unlabeled nurse task list showed, On the weekends it is the charge duty to check all fridge temps. Use the temp book provided by the infection control nurse. Review of a facility policy, 'Temperature log' with an original date of [DATE], showed: . Department: Infection Prevention and Control. [Facility Name] will maintain temperatures of coolers and freezers at the appropriate temperature to promote food safety. This protocol also addresses refrigerated storage . Logs for recording temperatures for each refrigerator or freezer will be posted in a visible location outside the freezer or refrigerator unit. a. Temperatures will be checked and logged at least daily by designated personnel .

Based on observation, interviews, and record review, the facility failed to ensure the consistent practice of properly dating and labeling open foods, storing food, and monitoring food temperatures in unit refrigerators and freezers. This failure had the potential to lead to food borne illnesses and improper infection control practices for residents consuming food from the refrigerators and freezers on the Glacier and Firefly units. Findings include: During an observation on 10/21/24 at 3:05 p.m., the Firefly unit kitchen refrigerator and freezer had a log with no documentation of temperature recordings on 19 of 24 opportunities, and there was no documentation on October 5, 8, 12, 14, and 19, 2024. During an observation on 10/21/24 at 3:07 p.m., the Firefly unit kitchen freezer had a Styrofoam bowl with food that had a white topping, unlabeled with no name or date, covered with a paper towel, with a plastic spoon sticking out of the paper towel covering. During an observation on 10/22/24 at 8:56 a.m., the Firefly unit kitchen refrigerator and freezer had a log with no documentation of temperature recording for 19 of the 24 days to complete the temperature recordings. Documentation was missing for October 5, 8, 12, 14, and 19. During an interview on 10/23/24 at 4:52 p.m., staff member Q, who was working on the Glacier wing, stated it was the night shift nurses responsibility for following the nursing task list which included the completion of refrigerator and freezer documentation on all units. During an interview on 10/24/24 at 9:52 a.m., staff member I stated the night shift charge nurses were responsible for checking refrigerator and freezer temperatures on all units and logging the temperatures. Review of a facility provided log, labeled, 'Firefly 2024 Food Fridge @ Nurses Station,' showed: Fridge Temp Range: Food = 36 F - 40 F . P.M. and Night nurses check refrigerators when doing narcotic counts. There was no documentation on the log for temperatures on July 9, 25, 26, 30 of 2024. The log showed no documentation for temperatures on August 14 of 2024. The log showed no documentation for temperatures on September 3, 9, 10, 24 of 2024. The log showed no documentation for temperatures on October 4, 5, 6 of 2024. Review of a facility provided log labeled, 'Glacier 2024 Food Fridge Nurses Station', showed: Fridge Temp Range: Food = 36 F - 40 F . Freezer: 0 Fahrenheit or below . P.M. and Night nurses check refrigerators when doing narcotic counts. There was no documentation on the log for temperatures during the month of July crossed out and written in as January for 8, 13, 28, 29. The log showed no documentation for temperatures on October 17. Review of a facility document, '[Facility Name] Shift to Shift Charge Report,' showed, Charge concerns . All refrigerador temps documented including vaccine fridge in treatment room? [sic] Review of a facility document of an unlabeled nurse task list showed, On the weekends it is the charge duty to check all fridge temps. Use the temp book provided by the infection control nurse. Review of a facility policy 'Temperature log' with an original date of 8/29/24, showed: . Department: Infection Prevention and Control. [Facility Name] will maintain temperatures of coolers and freezers at the appropriate temperature to promote food safety. This protocol also addresses refrigerated storage . Logs for recording temperatures for each refrigerator or freezer will be posted in a visible location outside the freezer or refrigerator unit. a. Temperatures will be checked and logged at least daily by designated personnel . 3. All refrigerated storage must be maintained at or below 41 degrees Fahrenheit, unless otherwise specified. 4. All frozen storage must be maintained at or below 0 degrees Fahrenheit, unless otherwise specified . 7. Refrigerated food shall be labeled, dated, and monitored so that it is used by the use by date, frozen, or discarded, whichever is applicable.

Based on interview and record review, the facility failed to ensure resident medical record documentation was dated appropriately, labeled with the resident's information, and completed in entirety, for 4 (#s 11, 43, 60, and 66) of 29 sampled residents. Findings include: Incomplete Medical Record Documenation: 1. Review of resident #11's hard-copy POLST form, showed: - In the section for the person preparing the form and date section, the form was incomplete for the person preparing the form and the form was not dated when signed by the resident's legal decision maker. - The section for the provider phone number was incomplete. 2. Review of resident #43's hard-copy POLST form, showed: - In the mandatory section, where the signature was for the person completing the form, was blank. - The phone numbers for the person completing the form, and the physicians phone number, were incomplete. Resident #43 said she remembered being asked about code status by the staff at the facility. 3. Review of resident #60's hard-copy POLST form, showed: - In the mandatory phone number section, the form did not have the telephone number of the medical provider. During an interview on 10/23/24 at 8:45 a.m., staff member A stated the physicians were the only staff allowed to complete the POLST's at the facility. Staff member A said the POLST may not be completed until the physician or nurse practitioner makes their initial visit, which may not be very often. Staff member A stated the facility had been completing audits of the POLST's as part of QAPI. During an interview on 10/24/24 at 9:11 a.m., staff member I stated the physicians were the only ones to complete the POLST's at the facility. Staff member I said she would not trust other staff to be able to know how to complete the forms. 4. Review of resident #66's note with page titled, interdisciplinary progress note, showed no identifying information listed in the boxes marked resident last, and first name, physician, medical record number and room/bed. The nursing notes on this page were dated 9/30/24 and 10/2/24. A reader would not know which resident the form was for, due to the lack of information. 5. Review of resident #43's monthly medication administration record showed two sets of medication administration records were provided. Both sets were numbered one through three at the bottom of the page. The pages were not labeled as to month or year. The only dates on the monthly medication administration records were residents #43's date of birth and the date of her admission. It was unclear what the dates were for the MARs. During an interview on 10/24/24 at 10:36 a.m., staff member B was unable to identify the month resident #43's medication administration records were labeled.

Based on interview and record review, the facility failed to notify the guardian of a transfer to the emergency department, for 1 (#9) of 29 sampled residents. Findings include: Review of Emergency Department Reports from [Hospital] for resident #9, dated 10/20/24 at 11:34 p.m., showed the resident was admitted to the emergency department on 10/20/24 at 9:49 p.m. Review of resident #9's medical record lacked documentation that showed the resident's guardian was notified of the transfer to the emergency department on 10/20/24. During an interview on 10/23/24 at 1:47 p.m., NF1 stated she was not notified of the transfer to the emergency department on 10/20/24. During an interview on 10/23/24 at 3:40 p.m., staff member I stated the resident's guardian should have been notified when the resident was transferred to the emergency department. Staff member I stated the guardian for resident #9 was not notified of the 10/20/24 transfer to the emergency department. Review of the facility's policy, Scope of Social Services, revised 2/6/2023, showed, .Procedure: . D. Family Contact: . Contacts in coordination with nursing services will also be made with family and/or guardian when the resident's condition changes, or significant events occur.

Based on record review and interview, the facility failed to implement an effective discharge planning process for 1 (#67) of 1 sampled resident, who left the facility Against Medical Advice. Findings include: A review of court documents, dated [DATE] showed resident #67 was required to stay at the facility due to a court commitment which showed he was to be there for a minimum of 90 days. A review of resident #67's medical record showed an admitted [DATE]. A review of nurse's notes, dated [DATE], showed resident #67 did not want to remain at the facility and was exit seeking. A review of nurse's notes, dated [DATE], showed resident #67 wanted to go home. A review of case management notes, dated [DATE], showed resident #67 wanted to return home. A review of the interdisciplinary team admission assessment, dated [DATE], showed the resident#67's primary mode of locomotion was a wheelchair. A review of a note written by the nurse summarizing the nurse practitioner's visit, dated [DATE], showed resident #67 voiced his desire to return home. A review of nurse's note written by a nurse summarizing the nurse practitioners visit dated [DATE], showed resident #67 was not happy and did not want to remain in the facility. The note showed resident #67 wanted to be somewhere he could smoke. A review of a nurse's note dated [DATE], showed resident #67 was discharged against medical advice. The note showed the resident was given three days' supply of his medications. The note showed the resident should make an appointment to see his physician. A review of an email, which was written on [DATE], showed a miscommunication was made, and the re-commitment had been missed. The failure to obtain a re-commitment allowed resident #67 to be in the facility on a voluntary basis. During an interview on [DATE] at 8:45 a.m., staff members A and E were both interviewed. Staff member A said resident #67's court commitment expired, and a re-commitment had not been filed in time. Staff member E said there was no discharge planning being done as resident #67 was happy being in the nursing home. Staff member A said the discharge planning also had not been started as there were some financial issues needing worked through, as resident #67 was co-owner of a house. Staff member E said no discharge planning was completed as the resident did not show he was unhappy and wanted to leave the facility. Staff member E said there were no post discharge accommodations being made for the resident to include a follow up appointment, ensuring resident #67 had a wheelchair for use and would have enough medication until he could get a prescription, as the staff assumed resident #67 would stay in the facility. Physician orders for discharging against medical advice were not found in resident #67's chart. No orders for directing the staff to send a three-day supply of medications was found in the medical record.

Based on observation, interview, and record review, the facility failed to ensure 1 (#43) of 29 sampled residents was administered oxygen at the rate the physician had prescribed, and ensure respiratory equipment was maintained in a manner of acceptable parameters. Findings include: During an observation on 10/22/24 at 8:59 a.m., resident #43 was observed using oxygen per a nasal cannula connected to an oxygen concentrator. The oxygen cannula was lying on the floor, and the nose pieces were directly in contact with the floor. The oxygen concentrator was turned on at a rate of two and one-half liters per minute. The oxygen air inlet filter, on the right side of the machine, had a fine layer of gray particles present. The air inlet filter, on the left side of the machine, had a heavy layer of particles and hair-like substance present. Resident #43 said she did not know there was even a filter on the other side, and she had not cleaned it. Resident #43 took the filter and was observed to peel the layer of debris off the filter. Review of a physician's order written on 5/24/23, showed resident #43 was ordered to have oxygen up to 5 liters per minute. The order did not include parameters for how the oxygen would be delivered. During an observation on 10/23/24 at 2:15 p.m., the oxygen concentrator setting was observed to be at two and one-half liters of oxygen per minute. During an interview on 10/24/24 at 9:11 a.m., staff member I said the night shift cleans the oxygen concentrator filters once a month. The company the oxygen concentrators are rented from come quarterly and do preventative maintenance. Review of the certified nurse assistant documentation flow sheets, for October 2024, showed the oxygen filter for #43 was scheduled for cleaning on 10/18/24, but had not been signed as completed. Review of resident #43's current and active physician orders, dated 10/1/24 through 12/31/24, showed supplemental oxygen: up to 5 liters via nasal canula prn for hypoxia. Review of resident #43's monthly medication administration records and treatment records for two unlabeled months showed no oxygen monitoring results, or that the oxygen liter flow had been documented for the two months reviewed. A review of the facility's policy, titled Oxygen Therapy, dated 4/16/21, showed the following: .- Administer 2L (liters) of O2 via nasal cannula (n/c) with titration to maintain SpO2 level at 90% or greater . Assess SpO2 as needed after applying O2 to adequately titrate O2 further . Air inlet filter on the concentrator is washed and rinsed in warm soapy water at least monthly and as needed .

Based on observation, interview, and record review, the facility failed to protect a resident's right to privacy for 1 (#2) of 2 residents sampled for hoarding tendencies. This deficient practice caused the resident mental anguish and distrust of her caregivers. Findings include: During an interview on 4/8/24 at 2:33 p.m., NF1 stated there had been an incident where staff went into resident #2's room while she was out of the building and did a room clean. She stated the facility didn't have a policy or procedure to dictate how the room clean should happen for consistency. She stated this surprise room cleaning had caused mental anguish for resident #2 when she returned to find all her stuff moved. NF1 stated the facility said they only went into throw away garbage, and she had to argue that everyone's definition of garbage is different. During an observation and interview, on 4/9/24 at 9:20 a.m., resident #2 was seated on her bed. She had stuffed animals lining the side of her bed that touched the wall. Her shelves were cluttered, but they appeared clean. There was no odor in the room. The floor was clear of any tripping hazards. Resident #2 stated she was upset the [March 1, 2024] room clean had been done without her knowledge, and she had, expected reason and conversation because I'm an adult. She stated before the room clean, she trusted staff, but now she did not, and she had not been informed room cleaning was added to her care plan. Resident #2 stated she had been told her room was cleaned up for safety. She stated staff did not like how her bed was cluttered with stuffed animals and told her that was why she had previously fallen out of bed. Resident #2 stated she sleeps with stuffed animals, which take up half of the bed, because her husband always took up most of the bed, so she finds comfort in a non-empty bed. She stated her fall had been when her legs got tangled in a sheet, and the falls was not related to the animals. Resident #2 stated she was not going to report any more falls to staff. She was embarrassed and stated she wanted advance notice before people went through her drawers because, No one needs to see my underwear but me. Resident #2 stated after the room clean, she reported she had been unable to find some of her smaller items. She stated a staff member had come in to her room and taken several photos of her space [without her permission] to document nothing was missing. She stated they brought another staff member for a witness and resident #2 asked, Where's my witness in all of this? During an interview on 4/9/24 at 10:15 a.m., staff member B stated resident #2 had been looking forward to the bookstore outing that had been organized to get her out of the building. The room clean had been organized and conducted by members of the QAPI team. Staff member B was unsure if resident #2 would trust her possessions to be safe for her to go on another outing again. Staff member B stated resident #2 had been receptive to cleaning her room and was given totes to organize her things. There had been a concern for a power strip teetering on the drawer of the resident's nightstand, but she had also been receptive to the plan to move it for safety. Staff member B stated there was another resident [#3] with a hoarding diagnosis. This resident had a very detailed care plan dictating how the room clean should go. This process did not occur for resident #2. Review of resident #3's Room Cleaning Protocol, dated 2/24/23, showed: Process: . [Resident name] will be notified the day prior to a room cleaning and can be offered the option to put items into totes for storage at that time . [Resident name] may choose to stay in the room or step out and may see what items are being removed . During an interview on 4/9/24 at 12:51 p.m., staff member E stated the room clean had been proposed for a while. The IDT had sought out her advice on the best approach. Staff member E stated this was a unique situation, she did not know resident #2, and typically did not have direct contact with the residents in the facility due to her role. Review of resident #2's care plan, dated 2/14/24, showed an update for room cleaning due to hoarding tendencies. Review of resident #2's physician's note, dated 3/14/24, showed, . Pt started crying when she came to know about her room being cleaned . was crying, shaking, and stating she wouldn't leave her room again stated she had special things missing . pt is now not leaving the room until the office staff have left. Pt is skipping breakfast and lunch due to this . Pt states 'They were in my room without permission. I'm not going anywhere, I'm not leaving my room. I'm not going to go to my doctor's appointments' . [sic] Review of resident #2's medical record showed her scheduled 3/29/24 cardiology appointment was moved to be a virtual appointment, after conversations she would not be leaving her room, to attend. Review of an article in Psychology Today, titled, The Pros and Cons of Intensive Hoarding Cleanups, dated 9/8/20, showed, The destabilizing effects of intensive short-term cleanup blitzes intensify the existing anxiety the person is already living with, and causes feelings of disconnection from the only place they can call home . One of the most frustrating things about extreme cleanups to someone who hoards is they feel they can't find anything after, combined with the fear that things have been mistakenly discarded. Whether or not anything they needed or wanted kept is actually missing, there is always an intense feeling and belief that there are items missing, even when they are unable to name the missing thing . working with clients in a spirit of voluntary partnership using evidence-based strategies is best.

Based on interview and record review, the facility failed to investigate and protect other vulnerable residents from potential financial exploitation after 1 (#1), of 3 sampled residents, was approached by a staff member to become a financial payee. Findings include: Review of a facility reported incident, dated 3/7/24, showed NF2 was terminated. This was after resident #1 told her caseworker NF2 offered to become her financial payee. Review of the investigation showed there had been some concerns brought forth by a former coworker of NF2 about NF2's relationship with resident #1. These concerns were voiced when NF2 started working at the facility in September 2023. As a result of these concerns, NF2 was never scheduled to work on the wing where resident #1 resided. During an interview on 4/9/24 at 11:40 a.m., staff member A stated NF2 was never scheduled with resident #1. She stated they were monitoring NF2 to make sure she was not having payee conversations with other residents. Staff member A stated they had considered the September information from the former coworker about NF2 to be heresay and not something they could act on for termination. During an interview on 4/9/24 at 11:45 a.m., staff member D stated she couldn't speak to if other residents were interviewed about NF2 during the abuse investigation. During an interview on 4/9/24 at 12:07 a.m., staff member C stated she was unaware of the concerns around NF2 or to be on the lookout for potential exploitation for her resident caseload. During an interview on 4/9/24 at 1:30 p.m., staff member F stated she did not know about NF2's previous history. She did not know if other residents NF2 had taken care of had been interviewed. Review of the facility policy, Abuse, Misappropriations, and/or Neglect of Residents, revised 2/22/23, showed: Abuse Investigation Template . Assessement: . Interview the resident . Interview other residents. Have other residents had any issues with any particular staff? . NF2 was removed from her position on March 6, 2024, and reported to the state board and law enforcement. Further investigation by the facility determined she had been released from a previous employment contract for financial exploitation.

Based on interview and record review, the facility failed to follow professional standards related to a resident's hoarding behavior and interventions, for 1 (#2) of 2 residents sampled for hoarding tendencies. This deficient practice resulted in a resident's mental anguish including crying, distrust of staff, and fear of leaving her room. During an interview on 4/9/24 at 9:20 a.m., resident #2 stated staff had gone into her room when she was out of the facility and cleaned it out. She stated she was missing items like a Starbucks cup, a card from her sister, and a small pencil she liked to write with. Resident #2 stated these things were not on the ground or creating any type of tripping hazard. Resident #2 stated she was bothered because she had trusted staff and had been taken by surprise. During an interview on 4/9/24 at 10:15 a.m., staff member B stated they had been told by staff member E the best practice for a hoarder was to just go in the space and clear out the trash. It had been decided to do the cleanup while the resident was out of the facility to reduce her anxiety. During an interview on 4/9/24 at 11:30 a.m., staff member C stated another resident had a hoarding diagnosis and formal room cleaning plan. Staff member C stated resident #2's room clean had not been that formally organized. Review of the other resident's Room Cleaning Protocol dated 2/24/23, showed: Process: . [Resident name] will be notified the day prior to a room cleaning and can be offered the option to put items into totes for storage at that time . [Resident name] may choose to stay in the room or step out and may see what items are being removed . This resident was given advance notice and allowed to participate. Review of resident #2's psychiatry note, dated 3/14/24, showed the physician was talking with the resident after the room clean that occurred on March 1, 2024. The note showed resident #2 continued to be upset discussing the matter. The note also showed, . Writer spoke at length with pt about the situation and discussed the possibility to having a meeting with staff to come to a decision regarding cleaning schedules and the way of getting the room clean . Review of a National Library of Medicine article, titled, Hoarding Disorder: Development in Conceptualization, Intervention, and Evaluation dated November 5, 2021, showed, On the surface, hoarding may appear to be a relatively straightforward problem to address. One could simply hire a service to completely clean out the home or forcefully relocate the person who hoards to another residence. However, existing literature describes involuntary cleanouts as both traumatic to the person who hoards and ineffective in the long run, because they often lead to increased rates of recidivism. Review of an article in Psychology Today, titled, The Pros and Cons of Intensive Hoarding Cleanups dated 9/8/2020, showed, The destabilizing effects of intensive short-term cleanup blitzes intensify the existing anxiety the person is already living with, and causes feelings of disconnection from the only place they can call home . One of the most frustrating things about extreme cleanups to someone who hoards is that they feel they can't find anything after, combined with the fear that things have been mistakenly discarded. Whether or not anything they needed or wanted kept is actually missing, there is always an intense feeling and belief that there are items missing, even when they are unable to name the missing thing . working with clients in a spirit of voluntary partnership using evidence-based strategies is best.

Based on interview and record review the facility failed to update and revise care plans for 2 (#'s 13 and 43) of 21 sampled residents. This deficient practice did not show updated problems or interventions that would give staff the correct information to properly care for the residents. Findings include: 1. A review of resident #13's care plan, with a date of 8/23, showed, resident #13 had had a scratch to his chest, with an intervention for weekly skin checks by LN (Licensed Nurse). During an interview on 11/7/23 at 9:10 a.m., staff member E stated resident #13 did not have any skin concerns or scratches even though his care plan stated he did. A review of resident #13's weekly skin checks, dated 7/1/23-9/30/23, showed no mention of any scratches or skin concerns. 2. During an observation on 11/7/23 at 12:10 p.m., resident #43 was sitting in his wheelchair, leaning far to the right, at the dining room table. Staff member F sat down and fed resident #43. Resident #43 was not repositioned in his wheelchair prior to being fed. Resident #43 coughed throughout lunch. A review of resident #43's paper medical record, from Feburary 1, 2023, to November 7, 2023, showed resident #43 had been hospitalized on [DATE]-[DATE], 3/19/23-3/22/23, and 4/30/23-5/2/23, with a diagnosis of aspiration pneumonia. During an interview on 11/7/23 at 2:14 p.m., staff member F stated she fed resident when she was scheduled to work. Staff member F stated resident #43 had a hard time feeding himself and would not eat well. During an interview on 11/7/23 at 3:36 p.m., staff member I stated she was not sure if any interventions were in place for resident #43's aspiration issues. A review of resident #43's care plan showed no interventions or precautions in place for aspiration pneumonia. During an interview on 11/7/23 at 4:40 p.m., staff member G stated care plans should be revised if something new happens or changes. Staff member G stated, We all revise care plans as we go along. Nursing, Dietary, and Social Services update their sections of the care plans as needed. Staff member G stated floor nurses had been educated on how to update and revise resident cares plans. Staff member G stated, This is a constant work in progress to get the floor nurses to update and revise care plans as resident needs change. Staff member G stated resident #43's care plan should have been updated by nursing and the dietician regarding the aspiration. A review of a facility document titled, Care Planning, with a revision date of 2/15/23, showed: Policy: Nursing - .Care plans will be reflective of the assistance or support the resident needs and updated as necessary. - .A. The Care Plan will be updated based on the needs and goals of the residents.

Based on observation, interview, and record review, the facility failed to safeguard a resident from recurring aspiration pneumonia for 1 (#43) of 21 sampled residents. The resident was admitted to the hospital on three occasions for aspiration pneumonia. Findings include: During an observation on 11/7/23 at 12:10 p.m., resident #43 was sitting in his wheelchair, leaning far to the right, at the dining room table. Resident #43 was not repositioned in his wheelchair prior to being fed by staff member F. Resident #43 coughed throughout lunch. No interventions were observed from staff in the dining room. During an interview on 11/7/23 at 2:16 p.m., Staff member F stated, I know what the signs of aspiration are because I have been a CNA for so long. If I noticed anything I let my nurse know. During an interview on 11/7/23 at 2:18 p.m., staff member E stated she had not been notified that resident #43 was coughing in the dining room and she was not aware that resident #43 should be monitored for signs or symptoms of aspiration. During interviews on 11/7/23 at 3:30 p.m., staff members E and F stated they had not received any education on aspiration precautions. During an interview on 11/7/23 at 3:36 p.m. staff member I stated she was not sure if any interventions were in place for resident #43's aspiration issues. During an interview on 11/7/23 at 4:05 p.m., staff member C stated they did not have any education, policies, or skills competencies for feeding or aspiration precautions. A review of resident #43's hospital admission records showed: -Resident #43 was hospitalized on [DATE]-[DATE], with a diagnosis of pneumonia, aspiration/impaired swallowing, and respiratory failure. On 2/21/23, an x-ray video swallow evaluation was completed and showed resident #43 had moderate to severe pharyngeal gross aspiration and recommended diet change and aspiration precautions (fully upright, alert, meds whole in puree, no straws, small bites and sips). -Resident #43 was hospitalized on [DATE]-[DATE], with a diagnosis of aspiration pneumonia. When resident #43 was discharged from the hospital the instructions showed, .aspiration precautions ., and, -Resident #43 was hospitalized on [DATE]-[DATE], with a diagnosis of aspiration pneumonia and sepsis with acute hypoxic respiratory failure. The resident has not been admitted for aspiration pneumonia since May, but the facility continues to fail to address the risk of aspiration sufficiently. A review of resident #43's care plan, not dated, showed no interventions or precautions in place for signs or symptoms of aspiration.

Based on interview and record review, a facility licensed nurse failed to provide necessary medications as ordered for one (#18) of 22 sampled residents. This error caused the resident to receive a higher dose of medication than ordered, which led to the resident having decreased respirations for 30 minutes, and a decrease in oxygen saturations during that time. The nurse failed to administer oxygen to resident #18 during the time of decreased oxygen saturation and failed to properly document all doses of medication given to the resident. Findings include: Review of a facility document titled, Reportable Incident, dated 12/11/22, showed, resident #18 received 6.4 mg of Morphine instead of 4 mg of Morphine per the doctor's order, by the nurse flushing a subcutaneous line with saline causing additional medication to be administered to the resident. Nursing assessment revealed a decrease in respirations to 5 per minute from 12 per minute prior to administration of the medication. Respirations rebounded to 10 over a 30-minute period. Review of resident #18's medical record showed, staff member M wrote a verbal order on 12/11/22 showing, If no more Roxanol 5 mg SL available may change to Morphine inj 4 mg subq q 1 hour. Resident #18's Medication Administration Record did not show the order on the record or any documentation regarding the administration of the medication by staff member N. The medical records show the subcutaneous line was primed with 0.24 ml of 4 mg/ml Morphine per the facility's policy. Review of a facility document titled Medication Error Report Form, dated 12/11/22, showed staff member N gave resident #18 6.4 mg of Morphine instead of the ordered 4 mg of Morphine when he flushed the subcutaneous injection line with saline. Causing the resident to have decreased respirations. Review of the facilities root cause analysis form showed, two RN's advised staff member N not to flush the subcutaneous line per facility policy but staff member N argued with them and did it anyway, causing the additional 0.24 ml of 4 mg/ml morphine solution to be given to the patient. The document showed staff member N did not chart all the doses of medication he gave to resident #18 when the facility compared the narcotics sign out sheet to the administration records, and staff member N failed to place oxygen on resident #18 when he determined resident #18's respirations had decreased, and oxygen levels dropped below 90% after the medication error. The root cause analysis form showed the facility terminated staff member N's contract and reported staff member N to the Montana State Board of Nursing and law enforcement for a pattern of drug diversion. The root cause analysis form showed the facility wrote their own plan of correction to include audits conducted on education and charting. During an interview on 8/16/23 at 11:27 a.m., staff member B stated the facility immediately terminated staff member N's contract. Staff member B stated the facility learned of several opportunities for improvement during the investigation into the medication error and wrote their own plan to follow including audits to correct the opportunities for improvement discovered during the investigation. Staff member B stated, through QAPI meetings, she and the facility feel they have corrected the problems uncovered during their investigation. Staff member B said the facility has included training for subcutaneous injection of medication to all travel nurse and new hire nurse orientation packets. The facility has added additional observed orientation for all travel staff. Staff member B said the facility is no longer using the travel nurse agency staff member N was hired from. Review of a facility policy titled Subcutaneous Injection Butterfly Insertion and Intermittent Rx Administration, dated 2/11/2020, showed, Prime the set with medication (additional 0.2 or 0.4 ml for priming the set including the leurlock) . Do NOT flush tubing (medication remaining in tubing will be given during the next administration.)

Based on observation, interview, and record review, the facility failed to implement effective fall interventions and provide adequate supervision or devices for a resident who had significant fall history and risk factors for more falls. This failure resulted in head lacerations and a hospitalization for 1(#14); failed to implement interventions to reduce risk for falls for 1(#5) of 7 sampled residents, and this increased the risk of injury for both of the residents identified. Findings include: 1. During an observation and interview on 8/15/22 at 3:59 p.m., resident #14 was seen lying in her bed with a blanket on. Her room was approximately 50 feet from the nursing station. The door was closed prior to entry. A 'call don't fall' sign was noted on the wall by her bed. The resident had a healed wound in the middle of her forehead, near the scalp line. The resident stated she got the wound on her forehead when she fell . During an interview on 8/16/22 at 12:27 p.m., staff member I stated resident #14 had fallen again that morning, and sustained a 2 cm laceration above her left eye. She said the resident fell out of her bed and was found on the floor of her room by a nurse. During an interview on 8/16/22 at 2:43 p.m., resident #14 stated, I fell out of bed, I was trying to get up (this morning). During an interview on 8/17/22 at 8:55 a.m., staff member L stated resident #14 was using a walker, and was independent with occasional falls over the last several months. During an observation on 8/17/22 at 11:07 a.m., resident #14 was found to be asleep in bed in her room. The door was closed prior to surveyor entry, with a walker placed in the hallway. During an interview on 8/17/22 at 11:18 a.m., staff member T stated when resident #14 was placed in bed, they put the call light in her hand and reminded her to call. Staff member T stated the resident was expected to hit the call light before she got up to go to bathroom. During an interview on 8/17/22 at 12:49 p.m., staff member B stated resident fall incidents went to the fall committee. They had an internal review, and then care plans were updated. For residents with frequent falls, they were checked on in their rooms. Depending on the resident, it could have been every 30 minutes or hourly, and sometimes the door was left open. During an interview on 8/17/22 at 3:32 p.m., staff member S stated resident #14 walked on her own prior to the resident's room change. Now the resident was walking unsteadily, and leaning forward with her eyes closed while she ambulated, without a walker. During an interview and observation on 8/17/22 at 3:38 p.m., resident #14 was seen resting in bed. A walker device was outside the door in the hallway. The resident satated she had not used a walker recently. Record review of resident #14's physical therapy evaluation, by an outside facility, printed on 3/7/22, showed, With verbal cueing to help correct gait deviations that do increase patient's fall risk, patient was unable to follow them. Patient did demonstrate better stability and balance when utilizing a walker .however does require significant cueing for keeping walker close Patient does demonstrate gait deviations. Record review of resident #14's care plan face sheet, undated, showed: She walks in room @ x's [at times]. The Line next to wheels was checked. The line next to uses walker/cane/hemi-walker was marked with an x, and walker was circled. The line next to independent had [@ x's] written in space. The line next to assist was checked. The line next to cue/supervise was blank. Record review of resident #14's care plan, reviewed on 5/25/22, showed, under the interventions column: 1.Wheelchair PRN 2. ambulate with walker and 1 assist 3. Wear padded pants when up for the day .'as she allows' 5/17/22. 4. Lipped mattress 5. Wears handled gait belt when up as she allows 5/17/22 6. Reminder sign call don't fall. 7. Night light in room. Turn on at hs. 8. In line of sight when up. 9. Limit number of blankets on bed 10. ambulate her from bed/wc to bathroom and back bed/wc 3/24/22 11. Ambulate her from her room to lounge for all meals 4/7/22 12. Provide her with engagement 4/11/22 13. Encourage her to come out to lounge 4/11/22 14. Sit in front of her, in low/calm tone ask her to talk so you can understand (cut off by copier) Acknowledge and assist if necessary 8/11/22 Review of facility fall investigation documents, dated 1/25/22-8/16/22, under Interventions Implemented section, showed: -1/25 wear gripper socks at HS. -1/31 shoes on with walking . Gripper socks when not in shoes . -2/9 Provide a reminder sign- call don't fall . -3/8 Wear gripper socks when not wearing shoes -3/14 Gripper socks/proper shoes -8/6 Shoes . -8/16 .Look at shoes. Review of facility incident reports for resident #14, dated 2/12/22-8/16/22, showed, call light within reach box checked on seven subsequent falls. Review of the facility's policy, Fall Risk Policy, reviewed 3/01/21, showed: .5. Document the resident's response to interventions and alter interventions if they are not successful .9. Falls review will include the following .f) review common fall risk factors and interventions .k) Interventions: what changes were made to help the resident or to keep the event from reoccurring. 45447 2. During an observation on 8/16/22 at 8:57 a.m., resident #5 was in a group area, sitting at a table, and sleeping in a chair. The resident had a walker in front of her, with loose fitting socks on, and a gait belt fastened around her waist. During an interview on 8/16/22 at 3:41 p.m., staff member I stated the staff always assumed resident #5 would fall, and she had a history of falls so was a high fall risk. Staff member I stated the staff were careful with her when transferring her. During an observation on 8/17/22 at 8:00 a.m., resident #5 was sitting in a chair at a table in a group area on hall G. The resident was leaning to the left, with her eyes closed, and appeared to be sleeping. The resident had non-slip socks on, with a gait belt around her waist, and a walker by her right side. Staff member H came to the resident, touched her arm to wake her up, and had her stand immediately. The resident appeared shaky when she stood up from the chair and grabbed the walker's handles. Staff member H asked resident #5 to use her walker to walk, but the resident started to turn around to sit on the walker. The resident did not have shoes on. Staff member H told resident #5 not to sit, but the resident continued to sit, and appeared unsteady when she sat. The resident landed partially on the walker seat, and staff member H left her side to look for a wheelchair. Staff member A walked towards the resident quickly and asked the resident to scoot onto the walker's seat completely. When asked, the resident told staff member A she was not alright. Staff member H came to resident #5 and staff member A with a wheelchair, and the staff members assisted the resident into the wheelchair. During an interview on 8/17/22 at 8:06 a.m., staff member A stated she felt staff member I handled the transfer wrong. Staff member A stated the resident should not have been allowed to sit on the walker because the seat was slanted and resident #5 could have slipped off the seat. Staff member A stated the facility needed to educate staff member H, as she felt staff member H could have transferred the resident better. During an interview on 8/17/22 at 8:30 a.m., staff member L stated resident #5 did not ambulate well, and fall interventions were in her care plan. Staff member L stated all nursing and associated staff were responsible for looking in the resident's care plan to know what her fall interventions were. During an interview on 8/17/22 at 10:45 a.m., staff member H stated resident #5 could walk with her walker by herself with some guidance. Staff member H stated he would not have resident #5 walk if she was sleepy and would have the resident use a wheelchair instead of her walker. Staff member H stated he checked the CNA sheet and got report from a nurse to know how to transfer and ambulate the resident. Staff member H stated resident #5 was not supposed to sit on her walker because it was not stable, and he thought the resident only needed to wear the non-slip socks when she ambulated. During an interview on 8/17/22 at 2:13 p.m., staff member B stated she expected the CNAs to review the residents' care plans, as it was their duty to know what interventions were in place. Staff member B stated if there were changes made to the care plans, the CNAs were to look in the chart for a colored flag that indicated a change. Staff member B stated the staff have mandatory training on fall prevention, but staff member H missed the most recent fall training and had not had any fall prevention training by the facility since he had been there. Staff member B stated she assumed staff member H had fall training to get his CNA licensure before coming to the facility. Staff member B stated resident #5 was unable to lock her walker, so it was not safe for her to sit on the walker seat, and there should not have been a seat on the walker because there had not been a recent assessment done to see if the resident could lock the walker. During an observation on 8/18/22 at 8:13 a.m., resident #5 was ambulating to the dining hall with her walker with a staff member nearby, with non-slip socks, and without shoes on. Review of resident #5's Quarterly MDS, with an ARD of 5/10/2022, showed the resident had two or more falls without injury, and one fall with an injury (except major). The MDS also showed the resident was not steady when walking without an assistive device and making surface-to-surface transfers (such as between a chair and a wheelchair). Review of resident #5's care plan, dated 5/2022, showed: -Under the 'Mobility' section: Fall risk. Ensure she has good shoes on when gets up to walk. -Problems/Needs: At risk for falls. She ambulates with the use of an FWW. Her gait is unsteady at times. -Intervention: .3. Encourage [resident name] to wake full up and get her bearings before getting up to ambulate. A review of the facility's policy, Fall Risk Policy, reviewed 3/1/2021, reflected: .A fall reduction program will be established and maintained, to assess all residents to determine their risk factor for falls. A plan of care will be implemented based on the resident's assessed needs. .3. Individualized care plan interventions will be implemented for those residents found to be at high risk for falls. .c. Assess the environment and make appropriate changes, e.g.call bell cord .walkers, wheelchairs within reach of the resident. .5. Document the resident's response to interventions and alter interventions if they are not successful.

Based on interview and record review, the facility initiated Cardio [MEDICAL CONDITION] Resuscitation on one of four sampled residents, (resident #1) who had elected a DNR (do not resuscitate) status on a POLST (physician's orders [REDACTED]. This deficient practice did not follow resident #1's end-of-life directives when an emergent situation arose, and placed all 76 residents on census at the facility in a position to not have their end-of-life directives followed when emergent situations arise. IMMEDIATE JEOPARDY On [DATE] at 5:15 p.m., the facility Administrator of Addictive and Mental Disorders Division, the Superintendent/Administrator, and the Director of Nursing, were notified that an Immediate Jeopardy existed in the area of F578 (§483.10.) Severity and Scope identified for the Immediate Jeopardy was identified to be at the level of L, and upon removal of immediacy lowered to a G. The surveyor verified the removal of the immediacy on [DATE] at 2:00 p.m. Findings include: Resident #1 was re-admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #1 expired on [DATE] in the facility. Review of resident #1's Montana Provider Orders for Life-Sustaining Treatment (POLST), provided by the facility and signed by resident #1 and the physician on [DATE], showed resident #1 had chosen a DNR (do not resuscitate) status, along with comfort care. In an interview with staff member C, on [DATE] at 4:17 p.m, she said she had started CPR on resident #1 after he had choked on a sandwich and [MEDICATION NAME] maneuvers had been unsuccessful. Staff member C said, He went limp in my arms and we laid him on the floor. I did a few abdominal thrusts from the floor. He was unresponsive, he was blue and not breathing. I checked for a pulse and could not find one and so that's when I said I need to start CPR and asked (staff member G) to go down and get his DNR status. At the same time, I had her call for our other nurse (staff member E). So when (staff member G) and (staff member E) got back to the room they got there at the same times. I was doing CPR. (Staff member G) said, 'He is DNR,' and (staff member E) asked (staff member G) to, 'Please just go get the chart.' Staff member C said she had continued CPR on resident #1 until the chart was brought back to the room and it was confirmed resident #1 was in a DNR status, at which time she discontinued CPR and resident #1 expired. In an interview on [DATE] at 4:45 p.m., staff member E said, . When I got there (resident #1's room), (staff member F) was coming back from the nurse station and said (resident #1) was a DNR, and I said, 'Go get the chart,' so she ran and got the chart. I looked at his POLST after she got back, and he was a DNR .We would normally know what the DNR status is by the sticker on the chart. I have been there a while and (resident #1) had been a full code for years. He had been sick and I knew he had been changed to a DNR. He had been so sick and it was a concern that he was a full code. I had a pretty strong suspicion that he was a DNR, but things change so I had her go and get the chart to make sure. Then they stopped the CPR. The practice here would normally be that you check the chart before you start CPR . In an interview staff member B, on [DATE] at 1:30 p.m., said, . He became weak and started to go down, and they assisted him to the floor. Abdominal thrusts were attempted . attempted until no pulse and then (staff member C) started chest compressions . they were doing CPR before they knew his (#1) code status. His status was DNR. She said, (CPR) should not have been done. Review of the facility Cardiac Emergency Response Plan (CERP), dated [DATE], showed, . The resident code status will be identified PRIOR to starting CPR. The code status can be found on the front of the resident chart, on the residents POLST in the front of their chart, or on the Code status sheet located on the front of the RN binders on each wing.

Based on interview and record review, the facility failed to have glucose immediately available for use in medication carts, when one of four sampled residents (#1) experienced an episode of a critically low blood glucose level. This deficient practice contributed to the decline of resident #1, placed all 26 current diabetic residents at risk for adverse outcomes, and resident #1 expired after choking from food given after a low blood glucose change of status. IMMEDIATE JEOPARDY On [DATE] at 5:15 p.m., the facility Administrator of Addictive and Mental Disorders Division, the Superintendent/Administrator, and the Director of Nursing, were notified that an Immediate Jeopardy existed in the area of F755 (§483.45.) Severity and Scope identified for the Immediate Jeopardy was identified to be at the level of K, and upon removal of immediacy lowered to G. The surveyor verified the removal of the immediacy on [DATE] at 2:00 p.m. Findings include: Review of resident #1's Interdisciplinary Progress Notes, dated [DATE] at 11:30 p.m., showed staff member D, At 21:45 (11:30 p.m.) went into resident's room to obtain BG (blood glucose). (Resident #1) was lying in bed. Handed him BG supplies. He was unable to do it and stated, 'blood sugar is low.' The RN (registered nurse) performed BG. Hands/fingers cold & clammy with down blood flow. BG machine read low (Lo.) Review of the facility investigative interview, dated [DATE], showed staff member D had to contact staff member C to get some glucose out of the pharmacy supply closet. In an interview on [DATE] at 4:17 p.m., staff member C said, (Staff member D) called the charge phone to let me know that (resident #1) was having low BS. I asked her if he could take some oral glucose and she said she didn't have any on her cart. So, I went to the pharmacy and got the glucose . We met in the hallway and went into (resident #1's) room. Staff member C said after the incident with resident #1, she checked her medication cart and there was glucose in her cart. In an interview with staff member E, on [DATE] at 4:45 p.m., staff member E said, . She (staff member D) came over to get some glucose gel. She (staff member D) said (resident #1's) blood glucose was low. I didn't have any (glucose) on my cart, so I gave her the charge nurse's phone number. She called from the e-unit and I understood that they were going to meet on the A-unit. In an interview with staff member D, on [DATE] at 8:32 a.m., she said . At a quarter to ten I went into his room (resident #1), gave him his supplies and set him up on his bed and stood back. It took him about less than a minute and he could not perform the blood glucose test. He said 'It's low' . He allowed me to take the blood test. His hands were cold, he had poor circulation anyway. I took it and the BS (blood sugar/glucose) machine read low . Then I went back down to the nurse station to check for glucose and there was none in the cart. The night shift CNA (certified nurse assistant) arrived and said I better call the charge nurse and she didn't answer the call . I went to look for her . Then I went to F-wing . and then went to E-wing and they didn't have any glucose in their cart . The G-wing cart did not have any glucose. The nurse on E-wing told me to call the charge nurse. There was no glucose on all four medication carts. Staff member D said she then met with the charge nurse and walked to A-wing where the charge nurse grabbed two tubes of glucose from the pharmacy. Staff member D said, Just the charge nurse has access to the pharmacy . In an interview on [DATE] at 11:20 a.m., staff member B said, There is no policy that covers ensuring there is glucose on the cart. When a nurse uses an OTC (over the counter) medication, she needs to replenish it, and she must fill out a form that lets the pharmacist know the OTC needs to be replenished. During the facility exit interview, on [DATE] at 2:00 p.m., staff member B said the nurses took five tubes of glucose out of the pharmacy that day, [DATE]. Review of the policy, Access to Pharmacy, last revised on [DATE], provided by the facility, showed. When Pharmacy staff is out of the building, it may become necessary for the nursing supervisor or charge nurse to obtain medication from the Pharmacy that is not available from floor stocks . keys carried by the Nursing Supervisor or Charge Nurse and will remain in the supervisor's possessions. Entry to the Pharmacy will not be delegated to any other persons at any time.

Based on interview and record review, the facility failed to comprehensively assess and evaluate one resident's clinical condition and risk factors, and failed to implement interventions that were consistent with the resident's needs during an episode of Lo blood glucose levels, for one of four sampled residents (#1). Resident #1 did not receive services to the level of professional standards. This deficient practice may have contributed to resident #1's demise and could potentially place all 26 current diabetic residents at risk for adverse events. IMMEDIATE JEOPARDY On [DATE] at 5:15 p.m., the facility Administrator of Addictive and Mental Disorders Division, the Superintendent/Administrator, and the Director of Nursing, were notified that an Immediate Jeopardy existed in the area of F684 (§483.25). Severity and Scope identified for the Immediate Jeopardy was identified to be at the level of K, and upon removal of immediacy lowered to a G. The surveyor verified the removal of the immediacy on [DATE] at 2:00 p.m. Findings include: Resident #1 was re-admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #1 expired on [DATE] in the facility. Review of resident #1's care plan, last updated ,[DATE], showed under the Problems/Needs area: Alteration in Blood Glucose Metabolism: Hard to manage blood sugars. HX of falls r/t low BS. Under Interventions: . 6. When BS < 50 repeat diabetic standing orders. Measure BS every 15 minutes. If not > 50 notify MD for further orders. And, (Resident #1) is diagnosed with [REDACTED]. (Resident #1) has poor insight into his diabetes and has fixed beliefs regarding how to treat it. The interventions listed did not directly address resident #1's diabetes, but addressed a global approach to his Neurocognitive disorder. Under Problems/Needs: (Resident #1) receives an RCS (reduced concentrated sweets) diet but is very rigid with what he will eat. He refuses to eat anything that he believes has fat in it. He is also resistant to how often he will accept a supplement . Late afternoon [DIAGNOSES REDACTED] and uncontrolled glucose levels. Interventions included, multiple routes to increase resident #1's intake of all nutrients including proteins, carbohydrates, fats; the appetite stimulant [MEDICATION NAME], and multivitamins and iron. Review of resident #1's physician orders [REDACTED].#1 should receive sliding scale insulin before meals and TID (three times a day). On [DATE] resident #1 received an ordered to have finger stick blood glucose checks three times a day before meals, before bedtime, with baths, and at 3:00 a.m. Review of resident #1's Diabetic Chart, showed on [DATE], the bedtime blood glucose reading was not documented. At 16:40 (4:40 p.m.), the blood glucose level was documented as being 110, and 4 units of [MEDICATION NAME] were administered. Review of resident #1's MAR (medication administration record) for the month of ,[DATE], failed to show on [DATE] at 4:40 p.m., the 4 units of insulin were given as the insulin was not signed off on the MAR by the nurse, staff member D. Review of resident #1's Interdisciplinary Progress Notes (nursing notes), dated [DATE] at 11:30 p.m., showed staff member D wrote, At 21:45 (9:45 p.m.) went into resident's room to obtain BG (blood glucose). (Resident #1) was lying in bed. Handed him BG supplies. He was unable to do it (administer the blood glucose test) and stated, 'Blood sugar is low.' The RN performed BG hands/fingers cold and clammy with down blood flow (sic). BG machine read low (Lo). Instructed CNA to bring OJ (orange juice) with sugar/cheese. Still in lying position. (Resident #1) was able, with straw, to drink OJ. Nite (sic) CNA was able to get (resident #1) to drink 8 oz skim milk and fed him ,[DATE] of PBJ (peanut butter and jelly) sandwich. Charge RN/myself entered room and (resident #1) more alert and able to sit on side of bed. (Resident #1) was then able to shovel the rest of the sandwich in but then choked. Sandwich had become lodged in throat and (resident #1) started trying to gag. See Charge Nurse note. The nursing note did not contain documentation showing a second blood glucose test was conducted to confirm the Lo test reading, and did not show evidence an evaluation or assessment of resident #1's blood glucose level after consumption of the orange juice before consumption of the peanut butter and jelly sandwich, or assessment of resident #1's physical ability to safely consume food items. The nursing note did not show administration of glucose to resident #1 for the episode of Lo blood glucose. Review of all documentation for resident #1 on [DATE] including Interdisciplinary Progress Notes, medication administration records, diabetic chart, and facility incident investigation notes, did not hold evidence that staff member D documented the original blood glucose test administered at 9:45 p.m., and did not hold evidence staff member D conducted a follow-up blood glucose test. Staff member D did not conduct further subjective or objective assessments such as measuring vitals or interview of resident #1 and did not implement resident #1's care plan which outlined actions to be taken to care for resident #1's known history of hypoglygemic events. Review of the facility investigation interview with staff member D, conducted on [DATE], showed at 21:45 (9:45 p.m.) resident #1's blood glucose level read Lo, and there was no glucose in the medication cart. The interview held no evidence staff member D had returned to resident #1 and conducted further assessment of resident #1's status after the initial Lo blood glucose reading. Staff member D did not ensure glucose was immediately available for use in the medication cart to address hypoglycemic events. Review of the True Metrix Self-Monitoring Blood Glucose System, manufacturers directions for use, circa 2018, showed, . If test result is less than 20 mg/dL, Lo appears in Display . ALWAYS repeat blood tests to confirm Low Lo and High Hi results. If blood results still display Lo or Hi, call your Doctor or Health care Professional immediately . Note: Lo results are included in the Average as 20 mg/dL. Review of resident #1's clinical record, including the Diabetic Chart, MARs, and Interdisciplinary nurses notes, for the day of [DATE], and did not show evidence staff member D had conducted a second blood glucose test when the reading was found to be Lo, or at any time after the initial reading of Lo. Review of the facility investigation documentation, written by staff member F, . At 21:45 the nurse went to Firefly to relieve the medication aide. (Resident #1) was unable to sit up or move his limbs, so I called nurse on the phone and got a straw. At 21:50 (resident #1) drank the orange juice. Nurse returned to wing. Staff member D did not closely monitor resident #1's recovery from the hypoglycemic event which presented as Lo on the blood glucose monitor and in which resident #1 exhibited signs of physical and mental distress. In an interview on [DATE] at 8:32 a.m., staff member D said, Usually there was no glucose available on the medication cart. I don't remember seeing it on a regular basis. (Resident #1) would usually show up about 9:30 and we set everything up and he would do it on his own (blood glucose check). (Resident #1) got a bedtime snack, milk, PBJ (sandwich), maybe a boost or glucose drink. He basically would take that back to his room and eat it. At quarter to ten, I went into his room, gave him his supplies and set him up on his bed and stood back. It took him about less than a minute and he could not perform the blood glucose test. He said, 'It's low.' He is a creature of habit he will not let you check his blood sugar, but that night he couldn't perform the blood test. He allowed me to take the blood test. His hands were cold. He had poor circulation anyway. I took it (blood glucose test) and the BS (blood sugar) machine read low. At the nurse's station, I got orange juice and put two to three packs sugar in there. I wanted him to get protein, so I got a mozzarella cheese stick for him, and the aide gave him the orange juice, (staff member F). We had to go back and get a straw because he (resident #1) was laying down. Then I went back down to the nurse station to check for glucose and there was none in the cart. The night shift CNA arrived and said I better call the charge nurse and she (charge nurse) didn't answer the call. I called, and the charge nurses didn't answer, I went to look for her. Then I went to F-wing. I did a narcotic count with the med tech that was going off shift, and then went to E-wing, and they didn't have any glucose in their cart. The G-wing cart did not have any glucose. The nurse on E-wing told me to call the charge nurse. I met with the charge nurse and walked to A-wing and she crabbed two tubes of glucose from the pharmacy. Just the charge nurse has access to the pharmacy. We walked into (resident #1's) room and he was sitting on the side of the bed. I was unable to give the glucose because he had shoved ½ a sandwich into his mouth, and it was obvious that he couldn't swallow, and then he began choking. The aide (staff member G) had been able to get him to drink the orange juice and 8 oz of milk and eat the first half of the sandwich. His mouth was full with the second half of the sandwich. He had shoved the whole thing in his mouth. He was unable to talk the whole time I was in the room, but it became obvious that he was choking . As a nurse I know what to do, I've been a nurse for [AGE] years. At this facility I did not receive any of that training. His blood sugar would usually come up with his snacks, but he was resistant with consuming his protein part of the snacks. He would only drink the orange juice with the sugar, and you need protein to sustain the blood sugar being back up. He was not confused; his hand was shaking, and he knew his blood sugar was low. He said, 'It's low.' He was not able to coordinate getting the blood onto the strip because he was shaking. When (resident #1) started choking the charge nurse took over. They tried the [MEDICATION NAME] three times and staff member C took over . In an interview on [DATE] at 9:30 a.m., staff member G, said, I clocked in at 21:55 (9:55 p.m.) and came down to the wing. Then I saw (staff member F) heading into (resident #1's) room with the orange juice, with the sugar mixed in it. I think it was at that point that they told me he (resident #1) had low BS. I looked for the nurse and didn't see her. (Resident #1) looked terrible; he was dead white. I did not hear him talk or see him move. He could suck on the straw. His standard evening snack was at his bedside, milk, cheese stick, and a PBJ. He finished the milk. I had to feed him the milk. At this point he was finally able to lift his head. He pointed to his sandwich. He was still lying down. At that point I told the floor nurse (staff member D) to call the charge nurse, because I realized he was in bad shape and I wanted to have somebody to take charge. The floor nurse wasn't taking charge, and I knew the charge nurse and I had a lot of faith in her. The sandwich was cut in half and I took the first ½ and fed it do him in little tiny bites that I tore off. He seemed to do fine. He was on his side with his head on the pillow. At this point I left the room to talk to the charge nurse, by the time I got back into the room he had taken the 2nd half of the sandwich and jammed it into his mouth. At this point he sat himself up in the bed, not the bed side, and started kind of retching, but noting was coming out of his mouth. It took me about ten seconds to realize that nothing was coming out of his mouth, that he was choking. At that moment both nurses came in the door. I said he's choking. Someone said we have to do the [MEDICATION NAME] . I didn't think the floor nurse was adequately alarmed about the situation. Nobody was in the room when he grabbed the second half of the sandwich and shoved it in his mouth. Review of resident #1's Interdisciplinary Progress notes, dated [DATE], showed staff member C wrote, This nurse was notified by A-wing nurse, (staff member D), that pt was hypoglycemic and needed glucose gel . upon entering resident #1's room, with staff member D, . He began to choke. This nurse helped stand pt up and (staff member G) performed the [MEDICATION NAME] maneuver 3 times . Pt was unconscious and unable to support or bear weight . Felt for a pulse and was unable to detect a pulse or breathing . Began CPR . confirmed he was a DNR. CPR preformed for +/- 1.5 minutes. Time of death was 22:35 (10:35 p.m.). A period of 50-minutes time had elapse after the first blood glucose reading of Lo and staff member D returning to the resident #1's room with glucose. In an interview on [DATE] at 1:30 p.m., staff member B said she could not find evidence that resident #1's blood glucose level had been rechecked at any time after the initial blood glucose test that read 'Lo' . She said it was the nurses responsibility to ensure glucose was available for use on the medication carts. Review of Standing Orders for Physicians, last updated [DATE], showed: . 3. Diabetics: . 4. May check blood glucose levels for hypo or hyperglycemic symptoms. If blood glucose level <50 and resident is symptomatic, give food products (sandwich, orange juice, milk). *If blood glucose level does not respond to food products, give Glucose gel 15 gms PO if able to swallow. * Give [MEDICATION NAME] 1 mg subq or IM if altered level of consciousness makes it unsafe to swallow.

Based on interview and record review, staff member D failed to accurately assess, by not performing a second blood glucose test to confirm a Lo reading; Evaluate the circumstance that put the resident at risk; Plan and implement care in an expiditious manner, and respond to one of four sampled resident's needs (#1), when a change in condition occurred in the form of a critically low blood glucose level, for one (#1), and the resident passed away during the change of condition. This failure placed all 26 current diabetic residents at risk for adverse outcomes related to low blood glucose levels. IMMEDIATE JEOPARDY On [DATE] at 5:15 p.m., the facility Administrator of Addictive and Mental Disorders Division, the Superintendent/Administrator, and the Director of Nursing, were notified that an Immediate Jeopardy existed in the area of F726 (§483.35). Severity and Scope identified for the Immediate Jeopardy was identified to be at the level of K, and upon removal of immediacy lowered to a G. The surveyor verified the removal of the immediacy on [DATE] at 2:00 p.m. Findings include: Resident #1 was re-admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #1 expired on [DATE], in the facility. Review of resident #1's care plan, last updated ,[DATE], showed under the Problems/Needs area: Alteration in Blood Glucose Metabolism: Hard to manage blood sugars. HX of falls r/t low BS. Under Interventions: . 6. When BS < 50 repeat diabetic standing orders. Measure BS every 15 minutes. If not > 50 notify MD for further orders. And, (Resident #1) is diagnosed with [REDACTED]. (Resident #1) has poor insight into his diabetes and has fixed beliefs regarding how to treat it. The interventions listed did not directly address resident #1's diabetes, but addressed a global approach to his Neurocognitive disorder. Also, under Problems/Needs: (Resident #1) received an RCS (reduced concentrated sweets) diet but is very rigid with what he will eat. He refuses to eat anything that he believes has fat in it. He is also resistant to how often he will accept a supplement . Late afternoon [DIAGNOSES REDACTED] and uncontrolled glucose levels. Interventions included multiple routes to increase (resident #1's) intake of all nutrients including proteins, carbohydrates, fats; the appetite stimulant [MEDICATION NAME], and multivitamins and iron. Review of resident #1's physician orders [REDACTED].#1 should receive sliding scale insulin before meals and TID (three times a day) On [DATE] resident #1 received an ordered to have finger stick blood glucose checks three times a day before meals, before bedtime, with baths, and at 3:00 a.m. Review of resident #1's Diabetic Chart, showed on [DATE] the bedtime blood glucose reading was not documented. At 16:40 (4:40 p.m.), the blood glucose level was documented a.s being 110, and 4 units of [MEDICATION NAME] were administered. Review of resident #1's MAR (medication administration record) for the month of ,[DATE], failed to hold evidence on [DATE] at 4:40 p.m. the 4 units of insulin were given as the insulin was not signed off on the MAR by the nurse, staff member D. Review of resident #1's Interdisiplinary Progress Notes (nursing notes), dated [DATE] at 11:30 p.m., showed staff member D wrote, At 21:45 (9:45 p.m.) went into resident's room to obtain BG (blood glucose). (Resident #1) was lying in bed. Handed him BG supplies. He was unable to do it (administer the blood glucose test) and stated, 'Blood sugar is low.' The RN performed BG hands/fingers cold and clammy with down blood flow (sic). BG machine read low (lo.) Instructed CNA to bring OJ (orange juice) with sugar/cheese. Still in lying position. (Resident #1) was able, with straw, to drink OJ. Nite (sic) CNA was able to get (resident #1 to drink 8 oz skim milk and fed him ,[DATE] of PBJ (peanut butter and jelly) sandwich. Charge RN/myself, entered room and (resident #1) more alert and able to sit on side of bed. (Resident #1) was then able to shovel the rest of the sandwich in but then choked. Sandwich had become lodged in throat and (resident #1) started trying to gag. See Charge Nurse note. The nursing note did not contain an evaluation or assessment of resident #1's blood glucose level after consumption of the orange juice or before consumption of the peanut butter and jelly sandwich, or assessment of resident #1's physical ability to safely consume food items. The nursing note did not show administration of glucose to resident #1 for the episode of Lo blood glucose. In an interview on [DATE] at 1:30 p.m., staff member B said she could not find evidence that resident #1's blood glucose level had been rechecked at any time after the initial blood glucose test that read Lo. She said, . they were doing CPR (cardiopulmonary resuscitation) before they knew he was a DNR (do not resuscitate), which should not have been. Staff member D couldn't find the glucose gel on her cart and went looking on the other wings. Staff member B said, He has had several episodes of low blood sugars. We check his blood sugar five times a day. Staff member B said she did not know why glucose gel was not given to resident #1, and said, Each cart should have some in the cart. [MEDICATION NAME] is in the pharmacy, not on the cart. She said it was the responsibility of each nurse to replace glucose on the cart when they have used a tube up. The nurses fill out a form notifying the pharmacist it needs to be replaced. Review of the facility investigation interview with staff member D, conducted on [DATE], showed at 21:45 (9:45 p.m.) resident #1's blood glucose level read Lo, and there was no glucose in the medication cart. The interview held no evidence staff member D had returned to resident #1 and conducted further assessment of resident #1's status after the initial Lo blood glucose reading. Review of the True Metrix Self-Monitoring Blood Glucose System, manufacturers directions for use, circa 2018, showed, . If test result is less than 20 mg/dL, Lo appears in Display . ALWAYS repeat blood tests to confirm Low Lo and High Hi results. If blood results still display Lo or Hi, call your Doctor or Health care Professional immediately . Note: Lo results are included in the Average as 20 mg/dL. Review of resident #1's clinical record, including the Diabetic Chart, MARs, and Interdisciplinary nurses notes, for the day of [DATE], did not show evidence the staff member D had conducted a second blood glucose test when the reading was found to be Lo, or at any time after the initial reading of Lo. Review of resident #1's Interdisciplinary Progress notes, dated [DATE], showed staff member C wrote, This nurse was notified by A-wing nurse, (staff member D,) that pt was hypoglycemic and needed glucose gel to administer. Brought glucose gel to A-wing. Upon entering pt's room with (staff member D), (Staff member G) was giving pt juice and a sandwich. Pt was sitting upon the side of his bed. He began to choke. This nurse helped stand pt up and (staff member G) performed the [MEDICATION NAME] maneuver 3 times over +/- 30 seconds. Pt was unconscious and unable to support or bear weight. Moved pt to the floor, this nurse preformed [MEDICATION NAME] maneuver 3 additional times. Felt for a pulse and was unable to detect a pulse or breathing. Began CPR, sent CNA to get pt's chart and confirmed he was a DNR. CPR preformed for +/- 1.5 minutes. Nurses (staff member D), and (staff member E), listened for a pulse. 0 pulse, vital signs or signs of life detected for 5 minutes. Updated (physician) on patient status, order to follow policy/protocol. Time of death was 22:35 (10:35 p.m.) This was a 50-minute time lapse after the first blood glucose reading of Lo. In an interview on [DATE] at 3:06 p.m., staff member F said, it was 9:35 or 9:40 p.m., and the nurse asked me to have (resident #1) come to the dining room to get a blood sugar check. He did not want to come down and the nurse went to his room and checked his blood sugar and said it (the blood glucose level) was really low. I was giving (resident #1) his evening snack about that time. (Staff member D) told me to give him orange juice with two sugar packets. He got the orange juice down. I left the sandwich, and the milk, in the room. I had asked him to sit up and he didn't do it. I don't think he was able. I asked him if he could sit up and he said 'No.' I helped him by holding the glass and the straw. He drank the cup of orange juice. The only word I got out of him was no when I asked him if he could sit up. Went back to the nurse's station. It was end of shift for the medication aide who was getting off shift and (staff member D) went over there (F-wing) to do the narcotics count, (Staff member D) then would take over that wing. When I went to go get the straw for the orange juice I called (staff member D) and told her (resident #1) was not moving and not doing well. When I spoke to (staff member D,), he (resident #1) hadn't had the orange juice. I had gone to the nurse's station to get a straw because I thought it would be easier. (Staff member D) showed up about five minutes later. She came into the room and looked at him, she didn't do vitals or anything. She did not do a physical assessment while I was there. I don't remember if she talked to (resident #1). Then we went back down to the nurse's station. It was shift change, and a new CNA (certified nurse assistant) was coming on. As I left, I looked in on him with the oncoming CNA (staff member G.) At that time his eyes were open, but he didn't talk to us. Review of the facility investigation documentation, written by staff member F, showed, ( . At 21:45 the nurse went to Firefly to relieve the medication aide (Resident #1) was unable to sit up or move his limbs, so I called nurse on the phone and got a straw. At 21:50 (resident #1) drank the orange juice. nurse returned to wing. In an interview on [DATE] at 4:17 p.m., staff member C said, I was on-call, charge nurse. (Staff member D) called the charge phone to let me know that (resident #1) was having low blood sugar and the machine read low. I asked her if he could take some oral glucose and she said she didn't have any on her cart. So, I went to pharmacy and got the glucose by myself. She had called me from E-wing. After I got the glucose from the pharmacy on A-wing where (resident #1) lives, (Staff member D) was coming down the hallway, we went into (resident #1's) room together. (Staff member G.) was at the bedside and she was giving him a drink and a sandwich. She reported he had drank a full glass of juice and ate half a sandwich . (Resident #1) was sitting at bedside. He was alert. He had a huge mouth full of sandwich and was taking sips of the milk or juice at the same time. Within that short amount of time when (staff member G) had reported he had drank and ate, (resident #1) started kind of moving his shoulders up and down and taking sips of juice trying to swallow the food down. (Staff member G) asked if he was choking. I was looking and said yeah, he is choking. I said (Staff member G) you need to get behind him and do the [MEDICATION NAME] maneuver. He went limp in my arms and we laid him down on the floor. I did a few abdominal thrusts from the floor. He was unresponsive, he was blue and not breathing. I checked for a pulse and could not find one and so that's when I said I need to start CPR . I was doing CPR. (Staff member G) said he's a DNR and (staff member E) said '(staff member G) please just go get the chart.' I continued the CPR and then (staff member G) brought the chart back and (staff member E) looked and said that (resident #1) is DNR you can stop CPR, and so I stopped at that time . From the time I entered the room it was maybe 15 to 20 seconds before he started choking . (Staff member D) had called me after the CNA's shift changed (at 10:00 p.m.). In an interview on [DATE] at 4:45 p.m., staff member E said, . I had earlier talked to (staff member D). I was on E-unit. She came over to get some glucose gel. She said (resident #1) was low (sic). I didn't have any glucose gel on my cart, so I gave her the charge nurses phone number. She called from the E-unit, and I understood that they were going to meet on the A-unit. She then left. In an interview on [DATE] at 8:32 a.m., staff member D said, Usually there was no glucose available on the medication cart. I don't remember seeing it on a regular basis. (Resident #1) would usually show up about 9:30 and we set everything up and he would do it on his own (blood glucose check). (Resident #1) got a bedtime snack, milk, PBJ (sandwich), maybe a boost or glucose drink. He basically would take that back to his room and eat it. At quarter to ten, I went into his room, gave him his supplies, and set him up on his bed and stood back. It took him about less than a minute and he could not perform the blood glucose test. He said, 'It's low.' He is a creature of habit he will not let you check his blood sugar, but that night he couldn't perform the blood test. He allowed me to take the blood test. His hands were cold. He had poor circulation anyway. I took it (blood glucose test) and the BS (blood sugar) machine read low. At the nurse's station I got orange juice and put two to three packs sugar in there. I wanted him to get protein, so I got a mozzarella cheese stick for him, and the aide gave him the orange juice, (staff member F). We had to go back and get a straw because he (resident #1) was laying down. Then I went back down to the nurse station to check for glucose and there was none in the cart. The night shift CNA arrived and said I better call the charge nurse and she (charge nurse) didn't answer the call. I called and the charge nurses didn't answer, I went to look for her. Then I went to F-wing. I did a narcotic count count with the med tech that was going off shift, and then went to E-wing and they didn't have any glucose in their cart. The G-wing cart did not have any glucose. The nurse on E-wing told me to call the charge nurse. I met with the charge nurse and walked to A-wing and she grabbed two tubes of glucose from the pharmacy. Just the charge nurse has access to the pharmacy. We walked into (resident #1's) room, and he was sitting on the side of the bed. I was unable to give the glucose because he had shoved ½ a sandwich into his mouth and it was obvious that he couldn't swallow and then he began choking. The aide (staff member G) had been able to get him to drink the orange juice and 8 oz of milk and eat the first half of the sandwich. His mouth was full with the second half of the sandwich. He had shoved the whole thing in his mouth. He was unable to talk the whole time I was in the room, but it became obvious that he was choking . As a nurse I know what to do, I've been a nurse for [AGE] years. At this facility I did not receive any of that training. His blood sugar would usually come up with his snacks, but he was resistant with consuming his protein part of the snacks. He would only drink the orange juice with the sugar, and you need protein to sustain the blood sugar being back up. He was not confused; his hand was shaking, and he knew his blood sugar was low. He said, 'It's low.' He was not able to coordinate getting the blood onto the strip because he was shaking. When (resident #1) started choking the charge nurse took over. They tried the [MEDICATION NAME] three times and staff member C took over. In an interview on [DATE] at 9:30 a.m., staff member G, said, I clocked in at 21:55 (9:55 p.m.) and came down to the wing. Then I saw (staff member F) heading into (resident #1's) room with the orange juice, with the sugar mixed in it. I think it was at that point that they told me he (resident #1) had low BS. I looked for the nurse and didn't see her. (Resident #1) looked terrible; he was dead white. I did not hear him talk or see him move. He could suck on the straw. His standard evening snack was at his bedside, milk, cheese stick, and a PBJ. He finished the milk. I had to feed him the milk. At this point he was finally able to lift his head. He pointed to his sandwich. He was still lying down. At that point I told the floor nurse (staff member D) to call the charge nurse, because I realized he was in bad shape and I wanted to have somebody to take charge. The floor nurse wasn't taking charge and I knew the charge nurse and I had a lot of faith in her. The sandwich was cut in half and I took the first ½ and fed it do him in little tiny bites that I tore off. He seemed to do fine. He was on his side with his head on the pillow. At this point I left the room to talk to the charge nurse, by the time I got back into the room he had taken the 2nd half of the sandwich and jammed it into his mouth. At this point he sat himself up in the bed, not the bed side, and started kind of retching, but noting was coming out of his mouth. It took me about ten seconds to realize that nothing was coming out of his mouth, that he was choking. At that moment both nurses came in the door. I said he's choking. Someone said we have to do the [MEDICATION NAME] and both nurses went and stood him up. I did [MEDICATION NAME] from behind without success. He immediately passed out after he was stood up. He was never up at the bedside. So, we lowered him to the floor and (staff member C) did the [MEDICATION NAME] a few times. At this point he was gray. He was not breathing. (Staff member C) sent me to the nurse's station to see if he was DNR. After running and checking I went and told her that he was a DNR. She sent me back to call the other RN (registered nurse), which I did. When I got back to the room, they were trying to find his pulse. (Staff member E) showed up and sent me to get the chart to check for sure on the DNR. They had stopped doing the CPR after the first time I told them he was DNR. I didn't think the floor nurse was adequately alarmed about the situation. Nobody was in the room when he grabbed the second half of the sandwich and shoved it in his mouth. Review of Standing Orders for Physicians, last updated [DATE], showed, . 3. Diabetics: . 4. May check blood glucose levels for hypo or hyperglycemic symptoms. If blood glucose level <50 and resident is symptomatic, give food products (sandwich, orange juice, milk). *If blood glucose level does not respond to food products, give Glucose gel 15 gms PO if able to swallow. * Give [MEDICATION NAME] 1 mg subq or IM if altered level of consciousness makes it unsafe to swallow.

Based on observations, interviews, and record reviews, the facility failed to protect residents and adequately address those residents who displayed verbal, physical, and sexually abusive behaviors, which included 3 residents (#s 43, 74, and 76); and 2 residents were identified to have physical, mental, and psychosocial harm from the abusive aggressors (#s 73 and 77); the facility failed to protect a resident who was vulnerable, and who had safety deficits, for 1 (#4) who was repeatedly victimized by the aggressive residents; and, failed to ensure a resident was provided with a call light for 1 (#73) of 34 sampled and supplemental residents. The facility also failed to monitor, identify, plan, and implement interventions for the protection of residents residing on the secure Firefly unit, related to abuse and neglect occurrences, for 14 (#s 1, 4, 41, 43, 44, 52, 54, 58, 62, 69, 73, 74, 76, and 77) of 34 sampled and supplemental residents. The specific failures included: -Failed to ensure abuse occurrences were investigated thoroughly for the prevention of future abuse. -Failed to ensure all staff working on the Firefly unit were trained and knowledgeable relating to the unit's protocols, policies, and procedures relating to abuse prevention and the protection of the residents on the unit. - Failed to comprehensively assess high risk residents, and all residents who were victims of abuse, and identify risk factors, root causes, and the extent of the affects of abuse. - Failed to identify and implement individualized interventions, which were evaluated and modified, for effectiveness, for the safety and future protection of the residents. - Failed to evaluate Facility Reported Events as they occurred, to ensure steps taken were adequate for the prevention of abuse, relating to individual resident events, and failed to complete ongoing resident assessments after abuse occurred, and implement interventions, to prevent ongoing mental, physical, or psychosocial harm. - Failed to adequately monitor the daily activities and staff providing supervision on the Firefly unit, in an attempt to identify and address concerns relating to abuse. - Failed to adequately utilize the quality assurance process, to evaluate trends, patterns, or concerns, relating to Facility Reported Incidents, in an attempt to identify areas of needed change, for the protection of the residents on the Firefly unit, and the residents right to be free from abuse and neglect. Findings include: On 2/22/18 at 4:34 p.m., the facility Administrator and Director of Nursing were notified of an Immediate Jeopardy situation, which involved six residents relating to abuse occurrences, the prevention of abuse, and the protection of the residents on the Firefly unit. Six residents were included in the Immediate Jeopardy relating to individual abuse occurrences (#s 4, 43, 73, 74, 76, 77). Abuse and neglect concerns were also identified relating to the reportable abuse events on the Firefly unit, and actions taken by the facility for the prevention of abuse, and the protection of the resident, for 14 (#s 1, 4, 41, 43, 44, 52, 54, 58, 62, 69, 73, 74, 76, and 77), which included concerns relating to the oversight provided by administration, which was also considered to be at the level of Immediate Jeopardy. The Immediate Jeopardy concerns were identified to be at the Severity and Scope of K and upon removal of the immediacy, the Severity and Scope would be lowered to an H. a. A review of Facility Reported Incidents for resident #43 showed three events occurred, relating to the resident inappropriately acting out towards female residents in a sexual manner. These events occurred on 10/20/17, 10/30/17, and 11/17/17. The reports showed the resident had [DIAGNOSES REDACTED]. Details of the abuse occurrence reports showed: On 10/20/17 the resident inappropriately touched resident #77's buttock with one hand on her wrist and hugged her and tried to kiss her. The staff educated the resident on his behavior and documented to keep the two residents apart. The final five day report, showed the resident was put on 30 day monitoring for behaviors, and he was going to see the psychiatrist due to an increase in sexual behavior. He was to be care planned to remain at arms-length away from female peers. The report showed the female was to be monitored to keep off the male side of the unit, or within proximity of resident #43. The facility failed to determine if a root cause precipitated the event, or if the monitoring currently in place for resident #43 was adequate related to the resident's sexual behavior, and the prevention of future abuse occurrences. On 10/30/17, resident #43 grabbed the vaginal area of resident #77, and gave her a kiss. The female resident was clothed. Staff separated the two. A short time later resident #43 went into resident #77's room before 7:00 a.m., and he was observed to be kissing her and rubbing her vaginal area. The resident was laying on the bed trying to get away, saying, ouch, ouch, ouch. Staff separated the two residents. A few minutes later, the two residents were sitting at a table in the lounge together. Resident #43 asked resident #77 if she would perform a sexual act with him (he verbalized the sexual act). He immediately stood up, and walked down the hall into a fell ow female resident's room. He was found next to the resident's bed, attempting to remove the female resident's covers. Staff removed him from the room. Facility staff failed to protect the female residents from resident #43 on this day, and resident #43 was allowed to continue his inappropriate sexual behavior and abuse, without adequate staff monitoring, which had caused physical and mental harm to resident #77. During an interview on 2/22/18 at 4:34 p.m., staff member B stated the facility had not assessed resident #43's sexual preferences or needs thoroughly. Staff member B stated a care plan had been implemented for the resident to address his sexual behavior. On 11/17/17, resident #41 reported resident #43 touched her genitals. The resident (#43) was walking behind the female resident, and reached under her peri/buttock area, and touched her. Documentation showed a staff member was in front of resident #41, and another behind resident #43, but the interaction between the male and female still occurred. Staff allowed resident #43 to get within close-proximity to resident #41, and he was able to touch the female resident in the peri area, although the care plan for the male resident showed he should not have been within arms-length of her. Resident #43 was educated again to Keep away from women residents, although the resident had dementia. The female resident was assessed by the psychology specialist and moved to another unit due to the post psychology assessment which was completed to determine if the female had any outcomes from the event. The interventions implemented for the event were some of the same interventions implemented on the prior abuse occurrence, which had been unsuccessful in the prevention of sexual and psychosocial abuse by resident #43. A review of resident's #43's care plan, showed the resident had sexual behavior, and he was to be at arms-length from female peers, staff were to redirect the resident away from females, and he was not to be on the female side of the unit. The resident was to be in line of sight of staff at all times. The resident's care plan failed to show the extent of the risk the resident posed to other residents, or the resident's sexual preferences and current needs. The goal of the care plan addressed physical touching only. Interventions failed to include individualized interventions to address the resident's sexual habits or needs. The care plan failed to show dates the problems, goals, or approaches, were implemented, evaluated, or modified, to show the facility was attempting to update or modify the resident's interventions. b. Resident #73 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of resident #73's medical record showed she resided on the Glacier Way unit, but had recently moved off the Firefly unit. A review of Facility Reported Incidents, provided by the facility, and sent to the State Survey Agency, showed resident #73 had two altercations, in which other residents acted out against her. These included: On 1/27/18, another female, resident #58, wandered into resident #73's room. The other resident slapped resident #73 on the left jaw. Resident #73 informed staff, and the other resident was removed from her room. Resident #73 had pain to the jaw after the event. Resident #73 had been in the privacy of her own room, and the abuse was unprovoked. The occurrence documentation showed staff were to keep resident #58 at arms-length away from peers at all times, and resident #58 was to be in line of sight of staff. The facility increased the amount of staff on the unit to help monitor the residents, and 15-minute checks were to be completed for resident #58. The medical record for either resident #73 or #58 failed to show ongoing documentation for the 15-minute checks, except as noted intermittently on the weekly nursing summaries. The abuse event documentation did not show what action was taken by the facility relating to the abuse resident #73 experienced, and potential outcomes for the abuse. On 1/29/18, an event report showed resident #73 reported a male resident, #54, hit/punched her on the shoulder, and she presented with bruising to her breast. The actual date of the event was unknown. She had fallen during the abuse event and she hit the hard footboard of the bed as she fell . Immediate prevention efforts, implemented by the facility, included the request to have the resident report further abuse if it occurred, and to use her call light if other residents went in her room (which may not prevent abuse if the resident was at immediate risk). The facility also documented staff were to do room checks, monitor the Lounge, and the psychology specialist assessed resident #73 immediately after the event. Staff were educated on resident #54's behavior, checking rooms, 15-minute checks, and the amount of staff on the Firefly unit (CNAs) was increased to five. During an interview on 2/21/18 at 4:56 p.m., resident #73 was laying on her bed in her room with the door closed. She graciously greeted this writer, and agreed to visit about her stay. The resident explained her daily routine, her boredom, and this included her personal preference to stay in her room. Her conversation also addressed her fear of other residents. The resident explained that a female resident (#58) scared the crap out of me. Hit me so hard I almost fell over. She was hitting everyone that day, I'd stay away from her. The resident explained how her fear of the female resident would make her scoot along the wall in the hallway to avoid the female. She stated, The facility didn't do anything to help. I'd go out one door as she (#58) would come in, and she would come toward me. I'd go for help. She was in and out of my room all the time. She was in my room [ROOM NUMBER] to 4 times that day. The resident then explained an event occurred where, Even a guy hit me and punched me and I think I broke a rib because it still hurts. I landed when he hit me, and I fell into the footboard on the bed. He was just mean. She explained, If you were near him he would punch you. I still hurt every time I cough or sneeze. Hurts under my boob. They did remove the ones (residents) that were mean, but then the people would come right back. She stated the facility, did not talk to me about how upsetting it was, and would just say we will try to keep them out of the room. Every time he came around I'd run from him, it was constant. I am now in this room, and have not had one bad incident here. I was scared to death over there, afraid I'd be choked to death. The same lady would come in my room and lay in my bed, and she would get mad at me. Resident #73 stated resident #58 would strike out at her because she thought it was her room, and I'd head to the bathroom because I was scared. The resident stated she did not like to go to the dining room but staff made her. She stated this occurred on the Firefly unit, and her current unit. Resident #73 explained how, I get anxious, they do not understand that here. She stated she was .petrified. In my room I feel safe, no one bothers me on the new unit, I just hate it here. The resident began to cry several times during the interview, and expressed her discomfort for being in the public areas of the facility due to her fear of other residents. She would display a furrowed brow and appeared worried when she would discuss topics that were upsetting to her. When asked if she recalled the names of the residents who had abused her, she stated the name of resident #54, who she recalled very well. A review of resident #73's care plan, date of initiation unknown, failed to show the resident continued to have psychosocial, mental, or physical harm from the abuse events which had occurred on the Firefly unit. The facility had not adequately addressed her fear or anxiousness relating to the abuse events, and how this may have interfered with her daily routine. During an interview on 2/22/18 2:59 p.m., staff member C stated resident #73 had moved off the Firefly unit after the occurrences with the fell ow residents. When asked about the action taken after the events for resident #73, she stated, I assess for trauma. I do not assess for trauma on those severely demented, but may look for signs of trauma. I look for typical trauma symptoms, flashbacks, anxiety, depression, crying, and talk to them at length. If not cognitively intact, it is difficult to identify trauma vs normal behavior. The system we have (the facility) which started in (MONTH) (2017), included that the administrator decides who will have follow-up on abuse if they (the resident) has dementia. For resident #73, the staff member did assess her, and she stated the resident, did not feel safe, so she was moved to an alternate unit. No further assessment was completed after the initial assessment, relating to the abusive events or resident #73's psychosocial status. The resident had recently been added to the psychology specialist's caseload, but this pertained to areas unrelated to the abuse. During an observation and interview on 2/22/17 at 5:25 p.m., resident #73 did not have a call light cord available. Observed in the call light panel, on the wall, was a call light button. Resident #73 stated she gave her call light cord to her roommate because her roommate was calling for help and didn't have one. Resident #73's roommate had a call light cord. Resident #73 stated she had not had a call light for a couple of days. Review of resident #73's care plan did not include documentation that she could not have a call light cord. During an interview on 2/22/18 at 5:25 p.m., staff member M was assisting resident #73's roommate and stated resident #73 should have a call light cord, not a button. Staff member M obtained a call light cord for resident #73. The facility neglected the needs of the resident and failed to assess the resident for psychosocial harm, beyond the initial assessment, following the traumatic abuse events for resident #73. The abuse inflicted on resident #73 caused physical and psychosocial harm, and the fear escalated when she went out of her room. The resident's ongoing pain, from the injury to the rib area, in which she believed she fractured ribs, still occurred daily and hindered her comfort when she moved. The resident stated the facility failed to follow up adequately on the pain. The resident's medical record lacked information to show further action was taken during the month to determine if fractured ribs were a concern, such as a radiology report. During an observation on 2/21/18 at 3:15 p.m., the Firefly unit was observed. Upon entrance to the unit, several residents were wandering the hallway. No staff were in line of sight of the hall. In a room close to the nursing station, three staff members were talking. No staff were present in the Lounge area across from the nursing station or in the hall. After entering the nursing station, a few minutes later, a nurse approached and also entered the nursing station area. A few minutes later, three staff entered the Lounge area, and began talking to each other. The residents continued to wander about, and were sitting together at the tables in the Lounge. Activities were not occurring at the time of the observation. During a short time, the Lounge and hall were not monitored by staff. c. Resident #76 lived on the Firefly unit, and had a [DIAGNOSES REDACTED].#76's Physician Orders, showed the resident admitted in (MONTH) of (YEAR). During an observation and interview on 2/22/18 at 9:30 a.m., resident #76 was wandering up and down the hallway of the Firefly unit. Several residents were sitting in the social area of the unit, at tables, and moving up and down the halls. The nurse was behind the nursing station. As resident #76 neared the nursing station, the nurse came from behind the station, and stated to this writer that You may want to move out of his way and pointed to resident #76, and then she directed this writer to the Lounge area, which was out of the resident's direct path. The staff member, Q, who was being interviewed at the time, also moved out of the resident's way. During the interview, staff member V stated, He is in a mood today, not sure why. The staff member stated she had not attempted to determine why the resident was in a bad mood, and she did not believe any other staff working that day had either. She stated some days he just wakes up that way, in a mood, and there isn't anything you can do for him. She stated she would observe the resident's behavior, and try to keep him at arms-length from other residents. She stated she had not been trained on the MANDT behavior program utilized by the facility to help manage resident behaviors. She stated she had been working at the facility, on the Firefly unit, approximately one year. She stated she does not attend the facility trainings, but her employer trains her on what to look for regarding resident behavior. A review of the Facility Reported Incident for resident #76, showed six abuse events had been documented between 10/27/17 and 2/7/18. Details included: On 10/27/17, resident #76 grabbed the breast of resident #62. The two residents were in the lounge, sitting next to each other. The immediate intervention was to have the residents sit separately. The final report showed the aggressive resident was to be in line of sight of staff, and keep him away from the female when he is in the lounge area. Staff were educated on maintaining the line of sight monitoring. The report failed to show if the female resident was assessed for psychosocial harm, and the report failed to show if any action was taken for the female resident to ensure injury did not occur. On 1/5/18, resident #76 walked up to resident #4 and punched him in the chest. The action was unprovoked by resident #4. Resident #76 stated to staff, Keep him away from me, I don't like him. The plan to prevent future abuse included to keep the two men separated. The final report showed resident #76 was to be at arm's length away from others, and he was given a PRN [MEDICAL CONDITION] medication for his agitation. The Lounge watch was nearby, per the documentation, but the abuse event still occurred with the monitoring by staff. During an interview and observation on 2/22/18 at 9:13 a.m., staff member Q explained the purpose of the Lounge Watch. The designated employee was required to stand watch over the lounge area, and monitor the residents in the area for any concerns, and intervene in occurrences as needed. This was to help ensure resident safety if a conflict occurred. On 1/9/18, resident #76 was walking down the hall, and in an unprovoked manner, punched resident #69, who was exiting his room. The psychiatrist came to the facility to evaluate resident #76. The facility implemented one to one observations for resident #76, and the safety of others. He was also provided a new order for an antipsychotic medication, to help with his behaviors. The final report showed resident #76 had a recent gradual dose reduction, which had failed, and he was to be kept at arms-length away from peers. Medication adjustments were made. The report failed to show how or why prior interventions implemented were unsuccessful for the protection of the resident, or what root causes were identified relating to the event itself, other than the medication reduction. On 1/12/18, resident #76 was walking down the hall and he hit resident #4 on the left side of the chest, which was unprovoked. The immediate intervention to protect resident #4, and others, was to be arms-length away from peers although this had been unsuccessful in the past. Staff member B documented on the final report, sent to the State Survey Agency, that the resident had assaulted other residents, and the MANDT (behavior program) hold was done to give an antipsychotic medication intramuscularly. Staff were educated, but the report does not show what the education was for and the resident's care plan or medical record did not reflect what the education pertained to. The report failed to show the facility attempted to identify the root cause of the event, and implement an individualized intervention for the protection of resident #4. On 2/7/18, a staff member was walking with resident #4, going by resident #76, when he took a step towards the staff member, and then he reached out and punched resident #4 in the back of the head. He stated, It was an accident. The action by resident #76 was unprovoked and purposeful. The immediate intervention to protect resident #4 was to separate the two residents when walking the halls. Staff were present at the time, and failed to prevent the abuse. Abuse inflicted on resident #4 was repeated by resident #76. The final report, sent to the State Survey Agency, showed the resident was to stay at arms-length away from others, and to keep the resident's in the line of sight of staff, and to keep them at other ends of the hallway when ambulating. The interventions, although unsuccessful, were utilized as interventions for the protection of resident #4. The facility continued to allow resident #4 to be at risk for continued harm. During an observation on 2/22/18 at 9:13 a.m., resident #4 was observed sitting in a recliner. The resident was wearing a helmet, which was the protective gear for the resident's head if he had a fall. The resident was rocking back and forth in the chair, with his head down. A review of resident #4's care plan failed to show the facility had identified resident #76 as a high-risk factor relating to abuse toward resident #4, and the need to protect resident #4 from resident #76. d. Resident #74 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was residing on the Firefly secured dementia unit from the time of her admission. During an observation and interview on 2/21/18 at 4:01 p.m., resident #74 was in her room with the door closed. Staff member W stated the resident was in bed asleep. The staff member stated the resident was on one to one observations all the time, but when the resident was in bed she was not monitored. A review of facility abuse occurrences, reported to the State Survey Agency, showed the following: On 1/27/18, resident #74 grabbed resident #58 tightly on her hands and would not let go. Staff had to remove the resident's hands to release resident #58. The plan to prevent future abuse, included to have resident #74 on one to one observations. The final report, showed the resident was scheduled to see the psychiatrist, and staff were encouraged to use available PRN's ([MEDICAL CONDITION] medications) if the resident was agitated. Staff were to encourage tactile objects, and distractions. The other resident, #58, was to remain at arms-length away from resident #74, Due to similar incidents where she is the aggressor. Staff were educated, although the documentation failed to show what education was provided. During an interview on 2/22/18 at 9:30 a.m., staff member V stated the nursing staff did not always like to give the resident's their PRN medication to help alleviate behaviors because it would sedate the resident. A review of resident #74's care plan, date unknown, showed the resident was to be on one to one observations when ambulating, and the resident had a history of [REDACTED]. She required two staff for assistance with ADL care. A review of resident #74's Psychiatric Preparation Sheet, date unknown, showed the resident had aggression towards others, and had previously been taken to a behavioral health unit, due to her behavior. Community placement was not an option due to her aggressive behavior towards others. The documentation showed (Resident) frequently requires 1-1 staff to protect herself and/or others. She will hit, grab, pinch, and punch others. On 1/28/18, resident #74 grabbed and twisted the hand of resident #4 and put her fingers in the holes of his protective helmet, pulling upward, in an attempt to pull the helmet off, although it was strapped on resident #4. Staff were required to release her hands from resident #4. The immediate intervention was to Keep (resident) from all residents which was an intervention utilized prior, and was not effective. The final report showed the same interventions were implemented as for the abuse event on 1/27/18. Staff education was documented as provided, but the medical record and investigation for abuse lacked evidence of what education included. The facility failed to identify the root cause of her behavior, although the resident had pain, and agitation is a symptom of pain. On 2/5/18, resident #74 got up, in an unprovoked manner, and approached resident #41 and slapped the female resident on the right and left side of the head with an open hand. The immediate intervention implemented showed, We have her 1-1. This intervention was not adequate to protect resident #41. The final report, sent to the State Survey Agency, showed the resident was evaluated by the medical provider, and an antipsychotic medication, [MEDICATION NAME], was ordered. The facility considered moving resident #41 to an alternate unit. The staff were to keep the residents at arms-length from each other, and in line of sight of staff while moving about the wing. Fifteen-minute checks were also in place for safety. The facility failed to show an investigation was completed regarding the root cause of why resident #74 acted out against resident #41. Interventions put in place to protect resident #41 initially, were already in place, and had shown to be ineffective. The resident's care plan failed to show the high risk she posed to other residents. The facility had implemented 1-1 observations, which were reflected on the care plan, but not utilized properly by staff, and the resident had periods where she was unsupervised by staff, and allowed to inflict abuse on others. During an interview on 2/22/18 at 9:13 a.m., staff member Q stated the unit had a Lounge Monitor, who was required to stand in the Lounge area all the time. The staff member did not have knowledge of the Hall walker or monitor on the Firefly unit. She stated she typically did not work on the Firefly unit, and showed this writer the Lounge Monitor expectations, which were posted on a document kept in the CNA documentation area. On the bottom of the form, was information showing the duty expectations of the Hall walker/monitor. The form showed staff were to ensure the hall was always in the line of sight of the staff member assigned to monitor the hall. At this time, the hall was observed, and it was found no staff were within line of sight of the hall, but one staff person was in the Lounge area, talking with several residents. This staff member was unable to see the hall from her location. Staff member Q stated the CNA was not able to see the hall in her location, therefore, resident oversight was not adequate. During an interview on 2/22/18 at 2:02 p.m., staff member X stated she was not trained to work specifically on the Firefly unit. She stated when she would work on the unit she would try to side track the resident's if they were fighting or arguing. She stated someone usually watched the hall and the dayroom (lounge). She stated the unit usually had five staff assigned, but often staff were pulled from the unit, so four staff would work and provide care and monitoring for the residents on the Firefly unit. e. A review of a Reporting Form, dated 10/14/17, for resident #44 (a female), showed the resident was invited into resident #52's room. Resident #52 was a male, and both residents resided on the Firefly unit. Resident #44 stated the male resident kissed her, and she stated, I did not know he was going to. The immediate intervention implemented to protect the resident from further sexual abuse included that staff educated the residents on staying on the opposite sides of the hall, and to have no physical contact, although they had cognitive deficits, and behaviors were a concern. The same day, the final report was completed by staff member B and showed the male resident was being moved to the secured unit. The report showed the female had invited the male into her room previously, and she had been educated not to, and she cannot have a relationship with male peers. The facility did not address the lack of monitoring related to the resident activities on the secured unit, the risk the female posed to the male, or the inadequate intervention used (education) to prevent future occurrences. f. A review of a Reporting Form, dated 12/3/17, showed resident #69 was sitting in a chair, and resident #1 .quickly went to the chair and pushed (resident #69) sideways he lost his footing as he stepped on mat (resident #69) yelled what the hell are you doing and (resident #1) pushed him backwards into the window then he slid down the wall over the heat register and sat on the floor. He had a small red area lower right back. The plan to prevent further abuse was to observe where resident #69 was sitting. On 12/4/17, staff member B documented the resident #1 owns a recliner in the public lounge area, and is territorial about the chair. The documentation on the abuse report showed resident #1 had a [MEDICAL CONDITION], and was unable to speak. Staff were re-educated to supervise residents to ensure no other residents sit in his chair. During an observation on 2/22/18 at 9:13 a.m., resident #1's chair was observed in the Lounge. The chair was located in a row of unmarked recliners, and was close to the large window area. The chair had no visible markings, and there were no barriers or obvious ways to tell the chair belonged to resident #1. During an interview on 2/22/18 at 2:59 p.m., staff member C stated resident #1 is very territorial of his chair, and he will punch someone if they get near it. During an observation on 2/22/18 at 9:30 a.m., resident #1 was sitting in a chair along the wall close to the nursing station, by the hallway. The resident was not sitting in his own recliner. The resident's personal recliner, remained unmarked, showing it was not designated for resident #1, so others may notice and not use the chair. During an interview on 2/22/18 at 4:34 p.m., staff member B stated the chair owned by resident #1 was not marked or clearly designated as resident #1's, and the resident had been at the facility for years. She stated she did not see why the cha (TRUNCATED)

Based on interview, record review, and observation, facility administration failed to provide adequate oversight for the prevention of abuse and neglect, and to ensure residents had the right to be free from abuse and neglect, which affected 6 (#s 4, 43, 73, 74, 76, and 77), which included both aggressors of abuse, and victims of abuse. Two residents (#s 73 and 77) were identified to have harm, which included mental, physical, and psychosocial harm relating to the abuse events. The facility administration also failed to adequately ensure systems were in place for the monitoring, identification, planning, implementation, correction, and individualized assessment and safety interventions, for the protection of residents relating to abuse occurrences, for those residing on the Firefly unit, which affected 14 (#s 1, 4, 41, 43, 44, 52, 54, 58, 62, 69, 73, 74, 76, and 77) of 34 sampled and supplemental residents. Refer to F600 for specific failures. Findings include: On 2/22/18 at 4:34 p.m., the facility Administrator and Director of Nursing was notified of an Immediate Jeopardy situation, which involved six residents relating to abuse occurrences, the prevention of abuse, investigation of abuse occurrences, and the protection of the residents on the Firefly unit. Six resident's were included in the Immediate Jeopardy relating to individual abuse occurrences (#s 4, 43, 73, 74, 76, 77). Concerns also involved the lack of facility administrative efforts to address repeated abuse occurrences on the Firefly unit which was identified to be at the level of Immediate Jeopardy. The Severity and Scope of the Immediate Jeopardy was found to be at the level of K, and upon the immediacy being removed, would be lowered to an H. 1. During an interview on 2/21/18 at 1:10 p.m., staff members A and B stated the facility had utilized the quality assurance process to review reportable abuse events, and had identified a concern relating to the events, which is why staffing had been increased on the unit. They stated they both intermittently monitored the Firefly unit, and would regularly conduct rounds on the unit. Other administrative staff were also required to conduct rounds on the unit, to help supervise resident care. Staff members A and B had not noted any further concerns relating to the Firefly unit, other than accidents and hazards. Both staff member's A and B felt the care provided on the Firefly unit met the individual resident needs. Staff member A stated she reviewed all the abuse reports for the facility. During an interview on 2/22/18 at 9:45 a.m., staff member T stated the CNA supervisors were providing oversight on the secured Firefly unit. The facility had implemented Lounge Watchers who were required to stand in the hall area, and observe the events in the Lounge. Staff member A stated the contracted staff were not required to attend the mandatory training's, but could come to any inservice's the facility held. She stated the contracted staff were trained by their employer. Staff member T stated resident #74 was not appropriate for placement at the facility, as the staff could not handle her care and behavior. She stated the resident needed 2 staff to provide care, and she was on 1-1 observations by staff, when she was not in bed. If up, staff member T stated the resident would get in trouble (have altercations). She stated they had not found resident #74 had caused harm to others as far as she knew. For resident #43, staff member T stated the facility moved the resident to prevent further abuse, due to resident #41's fear, and she was scared on the unit and of the residents. The facility attempted to keep the male resident, who had abused resident #41, at the other end of the hall, but he was very mobile and would move quickly, and was more alert and cognitive. Staff member T stated she will attend some of the interdisciplinary team meetings. Triggers were discussed at the meetings, relating to residents and their aggressive or abusive behaviors, and staff member T stated the nursing supervisors were assigned to document triggers and interventions, discussed during the team meetings, on the individual resident care plans. She stated at times, education was provided to staff relating to abuse events, but this was not usually documented, but rather was verbal education, or something posted on a sticky note at the staff documentation area. She was not aware of any other documentation to show where new interventions would be documented for resident safety. Staff member T stated the individual residents who sundown, .were wild in the afternoon, and up all night. She was not sure of any trends the facility had identified relating to care on the Firefly unit, and was not aware of educational concerns regarding the contracted staff. During an interview on 2/22/18 at 2:59 p.m., staff member C stated she does not assess for trauma on those residents who are severely demented, but may look for signs of trauma. She stated, if the resident is not cognitively intact, it is difficult to identify trauma vs normal behavior. The system the facility had, which started in (MONTH) (YEAR), required the administrator to decide who would have follow up on abuse occurrences. For resident #73, she was assessed, and the resident did not feel safe. Staff member C was not sure of a system for ongoing monitoring or assessment of a resident's mental health relating to abuse, if they resided on the Firefly unit. Staff member C stated the Firefly unit was a secured memory unit, with residents who had advanced dementia. She was not aware of a specific program or philosophy the facility utilized, or policies and procedures, for the provision of care on the specialized unit. She stated the focus of the unit, .is to be able to have the residents move about freely and manage the behavioral disturbances. Staff member C stated Administration would develop the interventions on the abuse reportable events, but she would occasionally have input, which she would give to administration. She stated the IDT team, which reviews abuse events, includes the administrator, director of nursing, social worker, dietary, and pretty much every department. Staff member C stated the social worker was responsible for the development of a resident's care plan for mood, behavior, and psychosocial concerns. A review of the facility abuse occurrences, showed 12 residents were affected by abuse, which included physical, mental, psychosocial, and sexual. Of these occurrences, two residents had identified harm, to include physical, mental, and psychosocial. For one, the harm was ongoing, due to the facility failing to adequately address the resident's ongoing needs relating to the abuse which occurred on the Firefly unit. During an interview on 2/22/18 at 4:34 p.m., staff member B stated the facility was the Last best place, and the residents had nowhere else to go, and they were a health facility. She stated she felt the staff, to include administration, had done what was needed, to include individualized care for the residents on the Firefly unit. Staff member B felt the facility had done the best that they could have done, under the circumstances, and that no one else would probably have taken the residents with aggression, but they had to. Staff member B did not appear to understand the concerns relating to abuse, and the Immediate Jeopardy situations. During an interview on 2/26/18 at 6:15 a.m. (return call), NF2 stated he had filed an official concern with the facility's leadership, which was the level above administration, relating to the oversight provided by facility administration. He stated the current administration has created a toxic environment and this was due to staff members A and B's leadership. He felt the leadership of administration was incompetent, and they make poor decision. He stated there was a lack of organization and training for staff. Another concern related to the lack of communication with the medical staff working on the floor, providing care to the residents. NF2 stated the facility had an excellent history regarding care, but this had declined with the current leadership. NF2 has considered severing the professional relationship with the facility due to the concerns with the lack of leadership with the current administration. 2. A review of the facility abuse occurrences showed: Resident #43 had three sexual abuse occurrences, where he was the aggressor, and acted out against resident #s 41 and 77, and a female not included in the IJ. Resident #43's occurrences caused fear and psychosocial harm for resident #77. Resident #73 had two residents act out aggressively toward her, #s 58 and 76. She had ongoing pain from the abuse, to include mental and psychosocial harm. The facility failed to provide ongoing assessment of the resident's mental health status related to the abuse, which she continued to struggle with. Resident #76 had six abuse occurrences, where he acted out aggressively, and spontaneously, towards other residents. One resident #4, was the victim to this aggression on four events. The other residents affected included #s 62 and 69. Resident #74 had two physical abuse occurrences, in which she acted out aggressively against resident #s 4 and 58. The staff on the unit did not feel the resident was appropriate for the facility's level of care. The resident's spontaneous behavior put others at risk daily. Resident #52 had two abuse events, in which he was the victim of potential sexual abuse from resident #44, and he acted out in a sexual manner towards a fell ow female (not on the sample). Resident #1 had acted out aggressively on two occasions, towards resident #s 54 and 69, relating to his recliner, which was in the Lounge area. For further details on the abuse events, refer to F600 and F610. Further review of 18 abuse occurrences showed: For resident #s 1, 4, 41, 43, 44, 52, 54, 58, 62, 69, 73, 74, 76, and 77, the abuse investigations showed on 13 occasions the administrator and other officials, such as the Ombudsman or local authorities were not notified of the events. On one event, dated 1/9/18, a final summary of the event was not provided to the State Survey Agency, and was not included in the information received from the facility during the survey. For four of the events, staff member B completed the final five day summary and documented the interventions implemented. A complaint survey had been completed at the facility on 6/23/17, and an Immediate Jeopardy situation was announced relating to abuse. The date of compliance for the complaint survey, was identified to be 9/6/17. During the recertification survey, it was found the facility administration had failed to maintain the systems implemented during the complaint survey for the deficient practices, for resident abuse the prevention of abuse, and the protection of the residents on the Firefly unit.

Based on observation, interview, and record review, the facility failed to adequately respond to allegations of abuse, take appropriate action for the prevention of abuse, and protection of the residents on the Firefly unit, and have evidence that all alleged violations were investigated thoroughly; and, the facility failed to show all allegations were reported to the required officials, to include the Administrator, Ombudsman, or the local authorities, as deemed necessary, for resident abuse, for 6 (#s 4, 43, 73, 74, 76, and 77) residents of 34 sampled and supplemental residents. Findings include: On 2/22/18 at 4:34 p.m., the facility Administrator and Director of Nursing were notified of an Immediate Jeopardy situation, which involved six residents relating to abuse occurrences, the prevention of, investigation of abuse occurrences, and the protection of the residents on the Firefly unit. Six resident's were included in the Immediate Jeopardy relating to individual abuse occurrences (#s 4, 43, 73, 74, 76, 77). Concerns also involved the lack of facility administration, and efforts to address repeated abuse occurrences on the Firefly unit, which also was identified to be at the level of Immediate Jeopardy. The Severity and Scope of the Immediate Jeopardy was found to be at the level of K, and upon the immediacy being removed, would be lowered to an H. a. A review of Facility Reported Incidents for resident #43 showed three events occurred, relating to the resident inappropriately acting out towards female residents in an abusive sexual manner. These events occurred on 10/20/17, 10/30/17, and 11/17/17. On 10/20/17 resident #43 inappropriately touched resident #77's buttock with one hand on her wrist and hugged her and tried to kiss her. The facility failed to determine if a root cause precipitated the event, or if the monitoring currently in place for resident #43 was adequate related to the resident's sexual behavior. Residents continued to be at risk, due to the inadequate investigation and action taken by the facility. On 10/30/17, resident #43 grabbed the vaginal area of resident #77, and gave her a kiss. Staff separated the two. A short time later resident #43 went into resident #77's room before 7:00 a.m., and he was observed to be kissing her and rubbing her vaginal area. The resident was laying on the bed trying to get away, saying, ouch, ouch, ouch. Staff separated the two residents. A few minutes later, the two residents were sitting at a table in the lounge together. Resident #43 asked resident #77 if she would perform a sexual act with him. He immediately stood up, and walked down the hall into a fell ow female resident's room. He was found next to the resident's bed, attempting to remove the female resident's covers. Staff removed him from the room. The female resident no longer resides at the facility. The facility staff failed to protect the female residents from resident #43 on this day, and resident #43 was allowed to continue his inappropriate sexual behavior and abuse, without adequate staff monitoring, which caused harm to resident #77. Residents on the Firefly unit continued to be at risk, due to the inadequate investigation and action taken by the facility. During an interview on 2/22/18 at 4:34 p.m., staff member B stated the facility had not assessed resident #43's sexual preferences thoroughly, in an attempt to determine his sexual preferences or needs. Staff member B stated a care plan had been implemented for the resident to protect female residents. On 11/17/17, resident #41 reported resident #43 touched her genitals. The male resident was walking behind the female resident, and reached under her peri/buttock area, and touched her. Documentation showed a staff member was in front of resident #41, and another behind resident #43, but the interaction between the male and female still occurred. The interventions implemented for the event were some of the same interventions implemented on the prior event, which had been unsuccessful in the prevention of sexual and psychosocial abuse by resident #43. The facility had not identified the ongoing pattern of unsuccessful interventions, and issues with the lack of resident monitoring by staff, for safety of other residents. A review of resident #43's care plan, showed interventions, which were not dated, in an attempt to determine if the interventions had been evaluated or monitored for effectiveness. The interventions were carried over from one event to the next event, although unsuccessful. The resident's care plan failed to show the extent of the risk the resident posed to other residents. Interventions failed to include individualized interventions to address the resident's personal sexual preferences, habits, or needs, identified by the facility. b. A review of Facility Reported Incidents involving resident #73 showed the resident had two abuse occurrences. These included: On 1/27/18, another female, resident #58, wandered into resident #73's room. The other resident slapped resident #73 on the left jaw. Resident #73 informed staff, and the other resident was removed from her room. Resident #73 had pain to the jaw after the event. Resident #73 had been in the privacy of her own room, and the abuse was unprovoked. The medical record for resident #73 or #58 failed to show the ongoing documentation for the 15 minute checks. The event documentation did not show what action was taken by the facility relating to the abuse resident #73 experienced, or outcomes from the abuse. On 1/29/18, an event report showed resident #73 reported a male resident, #54, hit/punched her on the shoulder, and she presented with bruising to her breast. The actual date of the event was unknown. She had fallen during the abuse event and she hit the hard footboard of the bed as she fell . Immediate prevention efforts, implemented by the facility, included the request to have the resident report further abuse if it occurred, and to use her call light if other residents went in her room. Room checks, and the lounge on the unit was to be monitored. The psychology specialist assessed resident #73 immediately after the event (but no further assessments for her were completed). Staff were educated on resident #54's behavior, checking rooms, 15 minute checks, and the amount of staff was increased to five, although later found to be decreased at times due to staffing concerns. Refer to F600 for detail. The facility failed to ensure adequate monitoring of the residents occurred to prevent abuse events, and failed to follow up adequately on the residents pain related to the fall and injury to her rib and breast area. During an interview on 2/21/18 at 4:56 p.m., resident #73 explained her fear of other residents. The resident explained that a female resident (#58) scared the crap out of me. Hit me so hard I almost fell over. She was hitting everyone that day, I'd stay away from her. The resident explained how her fear from the female resident would make her scoot along the wall in the hallway to avoid the female if she was going down the hall or due to other residents. She stated, The facility didn't do anything to help. I'd go out one door as she (#58) would come in, and she would come toward me. I'd go for help. She was in and out of my room all the time. She was in my room [ROOM NUMBER] to 4 times that day. The resident then explained an event occurred where, Even a guy hit me and punched me and I think I broke a rib because it still hurts. I landed when he hit me, and I fell into the footboard on the bed. He was just mean She explained, If you were near him he would punch you. I still hurt every time I cough or sneeze. Hurts under my boob. They did remove the ones (residents) that were mean, but then the people would come right back. She stated the facility, did not talk to me about how upsetting it was, and would just say we will try to keep them out of the room. Every time he came around I'd run from him, it was constant. I am now in this room, and have not had one bad incident here. I was scared to death over there, afraid I'd be choked to death. The same lady would come in my room and lay in my bed, and she would get mad at me. Resident #73 stated resident #58 would strike out at her because she thought it was her room, and I'd head to the bathroom because I was scared. Resident #73 explained how, I get anxious, they do not understand that here. She again explained how she was .petrified. When asked if she recalled the names of the resident's who had abused her she stated the name of resident #54, who she recalled very well. The facility failed to adequately address the abusive events for resident #73 so she would be able to feel safe in her environment, and failed to ensure she received adequate services for her mental and psychosocial health after the events occurred. The resident was still upset over the abuse events almost a month later, and still had pain regularly to her rib/breast area. A review of the resident #73's care plan, date unknown, failed to show the resident continued to have psychosocial, mental, or physical harm from the events which had occurred on the Firefly unit. During an interview on 2/22/18 at 2:59 p.m., staff member C stated she did assess resident #73 after the event, and said the resident did not feel safe, so she was moved to an alternate unit. No further assessment was completed after the initial assessment, relating to the abusive events, or resident #73's psychosocial or mental status relating to the abuse. During an interview on 2/22/18 at 2:18 p.m., staff member U stated usually four staff worked the Firefly unit unless there were call offs, so sometimes only three staff would be working the floor. c. Resident #76 lived on the Firefly unit, and had a [DIAGNOSES REDACTED].#76's Physician Orders, showed the resident admitted in (MONTH) of (YEAR). During an observation and interview on 2/22/18 at 9:30 a.m., resident #76 was wandering up and down the hallway of the Firefly unit. Several residents were sitting in the social area of the unit, at tables, and also moving up and down the halls. The nurse was behind the nursing station. During the interview, staff member V stated He is in a mood today, not sure why. The staff member stated neither she, nor any staff member she had knowledge of that day on shift, had attempted to determine why resident #76 was in a mood. She stated some days he just wakes up that way, and there isn't anything you can do for him. She stated she had not been trained on the MANDT behavior program utilized by the facility, to help manage resident behaviors. She stated she had been working at the facility, on the Firefly unit, approximately one year. She stated she does not attend the facility training's, but her employer trains her on what to look for regarding resident behavior. A review of the Facility Reported Incidents, for resident #76, showed six abuse events had been documented between 10/27/17 and 2/7/18. Details included: On 10/27/17, resident #76 grabbed the breast of resident #62. The two residents were in the lounge, sitting next to each other. The immediate intervention was to have the residents sit separately. The report failed to show if the female resident was assessed for psychosocial harm, and the report failed to show if any action was taken for the female resident to ensure injury did not occur. On 1/5/18, resident #76 walked up to resident #4 and punched him in the chest. The action was unprovoked by resident #4. Resident #76 stated to staff, Keep him away from me, I don't like him. The facility failed to ensure residents were monitored adequately, and staff prevented abuse, when the occurrence took place in the Lounge area, which was to be monitored by staff at all times. During an interview and observation on 2/22/18, at 9:13 a.m., staff member Q explained the purpose of the Lounge Watch. This designated employee, was required to stand watch over the lounge area, and monitor the residents in the area for any concerns. This was to help ensure resident safety if a conflict occurred. On 1/9/18, resident #76 was walking down the hall, and in an unprovoked manner, punched resident #69, who was exiting his room. The report failed to show how or why prior interventions implemented were unsuccessful for the protection of the resident, and new assessments or interventions identified relating to root causes potentially identified for the event. On 1/12/18, the resident was walking down the hall and he hit resident #4 on the left side of the chest, which was unprovoked. The investigation failed to show root cause analysis on the event, in an attempt to identify preventative interventions, and for the protection of resident #4. The facility allowed residents to continue to be at risk related to resident #76's behavior. On 2/7/18, a staff member was walking with resident #4, going by resident #76, when he took a step towards the staff member, and then he reached out and punched resident #4 in the back of the head. He stated, It was an accident. The action by resident #76 was unprovoked and purposeful. The facility, again failed to adequately protect resident #4 by conducting a thorough investigation, and failed to identify root causes for the behavior and aggression, and failed to implement adequate monitoring and protection for resident #4. A review of resident #4's care plan failed to show the facility had identified resident #76 as a high risk factor relating to abuse toward resident #4, and the need to protect resident #4 from resident #76. d. During an observation and interview on 2/21/18 at 4:01 p.m., resident #74 was in her room with the door closed. Staff member W stated the resident was in bed asleep. The staff member stated the resident was on one to one observations all the time, but when the resident was in bed she was not monitored. A review of facility abuse occurrences, reported to the State Survey Agency, showed the following: On 1/27/18, resident #74 grabbed resident #58 tightly on her hands and would not let go. Staff had to remove the resident's hands to release resident #58. The plan to prevent future abuse, included to have resident #74 on one to one observations. The facility failed to identify root causes for the resident's behavior toward resident #58. The final report, showed the resident was scheduled to see the psychiatrist, and staff were encouraged to use available PRN's ([MEDICAL CONDITION] medications) if the resident was agitated. Staff were documented as educated, although the documentation failed to show what education included. A review of resident #74's care plan, date unknown, showed the resident was to be on one to one observation when ambulating, that she had a history of [REDACTED]. The care plan did not adequately show the risk the resident posed to others by her spontaneous aggressive behavior. A review of resident #74's Psychiatric Preparation Sheet, date unknown, showed (Resident) frequently requires 1-1 staff to protect herself and/or others. She will hit, grab, pinch, and punch others. On 1/28/18, resident #74 grabbed and twisted the hand of resident #4 and put her fingers in the holes of his protective helmet, pulling upward, in an attempt to pull the helmet off, although it was strapped on resident #4. Staff were required to release her hands from resident #4. The final report showed the same interventions were implemented as for the abuse event on 1/27/18. Staff education was documented as provided, but the medical record and investigation for abuse lacked evidence of what education included, and did not show root causes were identified for the resident's aggressive behavior. On 2/5/18, resident #74 got up, in an unprovoked manner, and approached resident #41 and slapped the female resident on the right and left side of the head with an open hand. The immediate intervention implemented showed, We have her 1-1. The facility failed to show an investigation was completed regarding the root cause of why resident #74 acted out against resident #41. Interventions put in place to protect resident #41 initially, were already in place, and had shown to be ineffective. The resident's care plan failed to show the high risk she posed to other residents. The facility had implemented 1-1 observations, which were reflected on the care plan, but not utilized properly by staff, and the resident had periods where she was unsupervised by staff, and allowed to inflict abuse on others, shown by the abuse occurrences. During an interview on 2/22/18 at 9:13 a.m., staff member Q stated the unit had a Lounge Monitor, who was required to stand in the Lounge area all the time. The staff member did not have knowledge of the Hall walker or monitor on the Firefly unit. She stated she typically did not work on the Firefly unit. The staff member, providing oversight for staff on the unit, was not fully educated on the unit's processes. On 2/22/18 at 2:02 p.m., staff member U stated she was not trained to work specifically on the Firefly unit. She stated the unit usually had five staff assigned, but often staff were pulled from the unit, so four staff would work and provide care and monitoring for the residents on the Firefly unit. Refer to F600 for more detail on abuse and neglect.

Based on observation, interview, and record review, the facility failed to utilize the QAA/QAPI process to identify resident to resident behaviors as a risk to residents residing on the Firefly (secured dementia care) unit. This led to a failure to implement resident-centered assessments and root cause analysis of behaviors, development of individualized interventions, and implementation of comprehensive plans to keep residents free from abuse, which affected 14 residents (#s 1, 4, 41, 43, 44, 52, 54, 58, 62, 69, 73, 74, 76, and 77); failed to identify, implement, and monitor an affective system for the assessment, identification, and intervention of pain, for residents with and without communication deficits, for 3 (#s 73, 74 and 76); and failed to comprehensively assess, identify, and provide interventions which were monitored and modified based on the resident's fall history, for 2 (#s 4 and 74) of 34 sampled and supplemental residents. All of the affected residents were residing on the Firefly unit at the time of the identified failures, or ongoing outcomes, which had the potential to affect all residents residing on the unit. Findings include: 1. A review of Facility Reported Incidents for resident #43 showed three events occurred, relating to the resident inappropriately acting out towards female residents in a sexual manner. These events occurred on 10/20/17, 10/30/17, and 11/17/17. The reports showed the resident had [DIAGNOSES REDACTED]. Details of the abuse occurrence reports showed: On 10/20/17 the resident inappropriately touched resident #77's buttock with one hand on her wrist and hugged her and tried to kiss her. The facility failed to determine if a root cause precipitated the event, or if the monitoring currently in place for resident #43 was adequate related to the resident's sexual behavior, and the prevention of future abuse occurrences. On 10/30/17, resident #43 grabbed the vaginal area of resident #77, and gave her a kiss. The female resident was clothed. Staff separated the two. A short time later resident #43 went into resident #77's room before 7:00 a.m., and he was observed to be kissing her and rubbing her vaginal area. The resident was laying on the bed trying to get away, saying, ouch, ouch, ouch. Staff separated the two residents. A few minutes later, the two residents were sitting at a table in the lounge together. Resident #43 asked resident #77 if she would perform a sexual act with him (he verbalized the sexual act). He immediately stood up, and walked down the hall into a fell ow female resident's room. He was found next to the resident's bed, attempting to remove the female resident's covers. Facility staff failed to protect the female residents from resident #43 on this day, and resident #43 was allowed to continue his inappropriate sexual behavior and abuse, without adequate staff monitoring, which had caused physical and mental harm to resident #77. During an interview on 2/22/18 at 4:34 p.m., staff member B stated the facility had not assessed resident #43's sexual preferences or needs thoroughly. Staff member B stated a care plan had been implemented for the resident to address his sexual behavior. On 11/17/17, resident #41 reported resident #43 touched her genitals. The resident (#43) was walking behind the female resident, and reached under her peri/buttock area, and touched her. Documentation showed a staff member was in front of resident #41, and another behind resident #43, but the interaction between the male and female still occurred. The interventions implemented for the event were some of the same interventions implemented on the prior abuse occurrence, which had been unsuccessful in the prevention of sexual and psychosocial abuse by resident #43. A review of resident's #43's care plan, showed the resident had sexual behavior, and he was to be at arms-length from female peers, staff were to redirect the resident away from females, and he was not to be on the female side of the unit. The resident was to be in line of sight of staff at all times. The resident's care plan failed to show the extent of the risk the resident posed to other residents, or the resident's sexual preferences and current needs. The goal of the care plan addressed physical touching only. Interventions failed to include individualized interventions to address the resident's sexual habits or needs. 2. A review of Facility Reported Incidents, provided by the facility, and sent to the State Survey Agency, showed resident #73 had two altercations, in which other residents acted out against her. These included: On 1/27/18, another female, resident #58, wandered into resident #73's room. The other resident slapped resident #73 on the left jaw. Resident #73 informed staff, and the other resident was removed from her room. Resident #73 had pain to the jaw after the event. The medical record for either resident #73 or #58 failed to show ongoing documentation for 15-minute checks which had been implemented, except as noted intermittently on the weekly nursing summaries. The abuse event documentation did not show what action was taken by the facility relating to the abuse resident #73 experienced, and potential outcomes for the abuse. On 1/29/18, an event report showed resident #73 reported a male resident, #54, hit/punched her on the shoulder, and she presented with bruising to her breast. The actual date of the event was unknown. She had fallen during the abuse event and she hit the hard footboard of the bed as she fell . During an interview on 2/21/18 at 4:56 p.m., resident #73 was laying on her bed in her room with the door closed. During the interview, resident #73 explained her fear of other residents. The resident stated a female resident (#58) scared the crap out of me. Hit me so hard I almost fell over. She was hitting everyone that day, I'd stay away from her. The resident explained how her fear of the female resident would make her scoot along the wall in the hallway to avoid the female. She stated, The facility didn't do anything to help. I'd go out one door as she (#58) would come in, and she would come toward me. I'd go for help. She was in and out of my room all the time. She was in my room [ROOM NUMBER] to 4 times that day. The resident then explained an event occurred where, Even a guy hit me and punched me and I think I broke a rib because it still hurts. I landed when he hit me, and I fell into the footboard on the bed. He was just mean. She explained, If you were near him he would punch you. I still hurt every time I cough or sneeze. Hurts under my boob. They did remove the ones (residents) that were mean, but then the people would come right back. She stated the facility, did not talk to me about how upsetting it was, and would just say we will try to keep them out of the room. Every time he came around I'd run from him, it was constant. I am now in this room, and have not had one bad incident here. I was scared to death over there, afraid I'd be choked to death. The same lady would come in my room and lay in my bed, and she would get mad at me. Resident #73 stated resident #58 would strike out at her because she thought it was her room, and I'd head to the bathroom because I was scared. She would display a furrowed brow and appeared worried when she would discuss topics that were upsetting to her. When asked if she recalled the names of the residents who had abused her, she stated the name of resident #54, who she recalled very well. A review of resident #73's care plan, date of initiation unknown, failed to show the resident continued to have psychosocial, mental, or physical harm from the abuse events which had occurred on the Firefly unit. The facility had not adequately addressed her fear or anxiousness relating to the abuse events, and how this may have interfered with her daily routine. During an interview on 2/22/18 2:59 p.m., staff member C stated for resident #73, the staff member did assess her, and she stated the resident, did not feel safe, so she was moved to an alternate unit. No further assessment was completed after the initial assessment, relating to the abusive events or resident #73's psychosocial status. The resident felt the facility neglected her needs, and it was identified the facility failed to assess the resident for psychosocial harm, beyond the initial assessment, following the traumatic abuse events for resident #73. The resident's ongoing pain, from the injury to the rib area, in which she believed she fractured ribs, still occurred daily and hindered her comfort when she moved. The resident stated the facility failed to follow up adequately on the pain. The resident's medical record lacked information to show further action was taken during the month to determine if fractured ribs were a concern, such as a radiology report. The abuse inflicted on resident #73 caused physical and psychosocial harm. During an observation on 2/21/18 at 3:15 p.m., the Firefly unit was observed. Upon entrance to the unit, several residents were wandering the hallway. No staff were in line of sight of the hall. The residents continued to wander about, and were sitting together at the tables in the Lounge. Activities were not occurring at the time of the observation. During a short time, the Lounge and hall were not monitored by staff. The facility failed to provide adequate monitoring for the residents on the Firefly unit, for the prevention of resident to resident abuse. 3. A review of the Facility Reported Incident for resident #76, showed six abuse events had been documented between 10/27/17 and 2/7/18. Details included: On 10/27/17, resident #76 grabbed the breast of resident #62. The two residents were in the lounge, sitting next to each other. The immediate intervention was to have the residents sit separately. The final report showed the aggressive resident was to be in line of sight of staff, and keep him away from the female when he is in the lounge area. The report failed to show if the female resident was assessed for psychosocial harm, and the report failed to show if any action was taken for the female resident to ensure injury did not occur. On 1/5/18, resident #76 walked up to resident #4 and punched him in the chest. The action was unprovoked by resident #4. Resident #76 stated to staff, Keep him away from me, I don't like him. The plan to prevent future abuse included to keep the two men separated. The final report showed resident #76 was to be at arm's length away from others, and he was given a PRN [MEDICAL CONDITION] medication for his agitation. The Lounge watch was nearby, per the documentation, but the abuse event still occurred with the monitoring by staff. During an interview and observation on 2/22/18 at 9:13 a.m., staff member Q explained the purpose of the Lounge Watch. The designated employee was required to stand watch over the lounge area, and monitor the residents in the area for any concerns, and intervene in occurrences as needed. This was to help ensure resident safety if a conflict occurred. During an observation and interview on 2/22/18 at 9:30 a.m., resident #76 neared the nursing station, the nurse came from behind the station, and stated to this writer that You may want to move out of his way and pointed to resident #76, and then she directed this writer to the Lounge area, which was out of the resident's direct path. The staff member, Q, who was being interviewed at the time, also moved out of the resident's way. During the interview, staff member V stated, He is in a mood today, not sure why. The staff member stated she had not attempted to determine why the resident was in a bad mood, and she did not believe any other staff working that day had either. She stated some days he just wakes up that way, in a mood, and there isn't anything you can do for him. She stated she would observe the resident's behavior, and try to keep him at arms-length from other residents. She stated she had not been trained on the MANDT behavior program utilized by the facility to help manage resident behaviors. She stated she had been working at the facility, on the Firefly unit, for approximately one year. She stated she does not attend the facility training's, but her employer trains her on what to look for regarding resident behavior. The facility failed to identify contributing factors for the alleviation of behaviors exhibited by the resident and failed to ensure staff were trained adequately. On 1/9/18, resident #76 was walking down the hall, and in an unprovoked manner, punched resident #69, who was exiting his room. The psychiatrist came to the facility to evaluate resident #76. The facility implemented one to one observations for resident #76, and the safety of others. He was also provided a new order for an antipsychotic medication, to help with his behaviors. The report failed to show how or why prior interventions implemented were unsuccessful for the protection of the resident, or what root causes were identified relating to the event itself, other than the medication reduction. On 1/12/18, resident #76 was walking down the hall and he hit resident #4 on the left side of the chest, which was unprovoked. Staff member B documented on the final report, sent to the State Survey Agency, that the resident had assaulted other residents. The report failed to show the facility attempted to identify the root cause of the event, and implement an individualized intervention for the protection of resident #4. On 2/7/18, a staff member was walking with resident #4, going by resident #76, when he took a step towards the staff member, and then he reached out and punched resident #4 in the back of the head. He stated, It was an accident. The action by resident #76 was unprovoked and purposeful. The facility failed to adequately assess, identify, and implement interventions to adequately prevent abuse for resident #4, and others. A review of resident #4's care plan failed to show the facility had identified resident #76 as a high-risk factor relating to abuse toward resident #4, and the need to protect resident #4 from resident #76. b. During an observation and interview on 2/22/18 at 9:30 a.m., resident #76 was wandering up and down the hallway of the Firefly unit. As resident #76 neared the nursing station, the nurse came from behind the station, and stated You may want to move out of his way and pointed to resident #76. She directed this writer to the Lounge area, which was out of the resident's direct path. The staff member, Q, who was being interviewed at the time, also moved out of the resident's way. During the interview, staff member V stated, He is in a mood today, not sure why. A review of resident #76's current Care Plan showed the resident exhibited a history of back and shoulder pain, and he was to be kept in line of sight of staff and at arms length away from peers. The care plan showed the resident had impaired cognition and communication, and he was unable to communicate his needs well. A review of the resident's ADL care plan showed a goal that resident #76 would let staff know if he was having pain,The plan did not show how staff were to anticipate the resident's pain, how the resident may exhibit pain, or what staff would do if the resident had pain during the provision of ADL care. During an interview on 2/22/18 at 9:30 a.m., staff member V stated neither she, nor the staff working on that day, attempted to determine why the resident was in a bad mood, and she did not believe any other staff working that day had either. She stated some days he just wakes up that way, in a mood, and there isn't anything you can do for him. She stated she had not been trained on the MANDT behavior program utilized by the facility to help manage resident behaviors. A review of resident #76's Nursing Notes showed, from 1/27/18 to the date of the survey: - He displayed pacing in social areas/halls, agitation, restlessness, attempting to hit at staff, cursing, not sleeping, and also pacing in his room at night. Behaviors exhibited did not prompt staff to assess for pain, per the nursing notes. - 2/7/18 The MDS Quarterly assessment showed documentation of, He has no signs or symptoms of pain. - 2/11/18 Angry this morning, walking way stooped over. Staff did not assess for pain at the time related to the resident's stooping. - 1/9/18 The resident had increased agitation, pacing, combative, yelling at staff to leave him alone. The resident was given an antipsychotic medication, by injection, to help calm him. The resident did calm, but continued to pace in his room. The staff did not show they assessed for potential pain. A review of resident #76's Pain Flow Sheet, showed pain was monitored from 1/2/18 to 1/15/18, only seven times. Pain was not documented on the form after 1/15/18 to the date of the survey. The documentation showed the resident was having pain in right shoulder ., walking and holding arm ., c/o pain ., and saying yes to pain questions. Documentation for a (MONTH) (YEAR) Pain Flow Sheet was not provided by the facility for review. A review of the resident's Medication Administration Record, [REDACTED] - For (MONTH) (YEAR), the resident was given [MEDICATION NAME] for pain or fever five times out of 180 opportunities. - For (MONTH) (YEAR), the resident was given [MEDICATION NAME] for pain or fever 15 times out of 96 opportunities. During an interview on 2/22/18 at 2:59 p.m., staff member C stated she had not worked with the resident in an attempt to assist with behavior management, as the resident was very demented. Staff member C explained she did not typically work with the demented residents as they did not retain information well. A review of resident #76's ADL Narrative documentation, completed by the CNAs, showed the resident had behaviors, but staff did not document pain was considered when the behaviors occurred. Behaviors included pacing, inability to sleep, aggression, and abuse towards staff and other residents. During an interview on 2/21/18 at 3:15 p.m., staff member D stated the resident told staff he was upset, you could tell if there was something going on with him. He may have increased agitation if upset, and he may self isolate or may be fidgety. The staff member did not state pain would be assessed if behaviors occurred. 4. During an observation and interview on 2/21/18 at 4:01 p.m., resident #74 was in her room with the door closed. Staff member W stated the resident was in bed asleep. The staff member stated the resident was on one to one observations all the time, but when the resident was in bed she was not monitored. a. A review of facility abuse occurrences, reported to the State Survey Agency, showed the following: On 1/27/18, resident #74 grabbed resident #58 tightly on her hands and would not let go. Staff had to remove the resident's hands to release resident #58. During an interview on 2/22/18 at 9:30 a.m., staff member V stated the nursing staff did not always like to give the resident's their PRN medication to help alleviate behaviors because it would sedate the resident. A review of resident #74's care plan, date unknown, showed the resident was to be on one to one observations when ambulating, and the resident had a history of [REDACTED]. She required two staff for assistance with ADL care due to combativeness. A review of resident #74's Psychiatric Preparation Sheet, date unknown, showed (Resident) frequently requires 1-1 staff to protect herself and/or others. She will hit, grab, pinch, and punch others. On 1/28/18, resident #74 grabbed and twisted the hand of resident #4 and put her fingers in the holes of his protective helmet, pulling upward, in an attempt to pull the helmet off, although it was strapped on resident #4. Staff were required to release her hands from resident #4. The immediate intervention was to Keep (resident) from all residents which was an intervention utilized prior, and was not effective. The final report showed the same interventions were implemented as for the abuse event on 1/27/18. The facility failed to identify the root cause of her behavior, although the resident had pain, and agitation is a symptom of pain. The facility failed to protect resident #4 from the aggressive behavior displayed by resident #74 although she was required to be on one to one monitoring. On 2/5/18, resident #74 got up, in an unprovoked manner, and approached resident #41 and slapped the female resident on the right and left side of the head with an open hand. The immediate intervention implemented showed, We have her 1-1. This intervention was not adequate to protect resident #41. The facility failed to show an investigation was completed regarding the root cause of why resident #74 acted out against resident #41. Interventions put in place to protect resident #41 initially, were already in place, and had shown to be ineffective. The resident's care plan failed to show the high risk she posed to other residents. The facility had implemented 1-1 observations, which were reflected on the care plan, but not utilized properly by staff, and the resident had periods where she was unsupervised or monitored by staff and allowed to inflict abuse on others. During an interview on 2/22/18 at 9:13 a.m., staff member Q stated the unit had a Lounge Monitor, who was required to stand in the Lounge area all the time. The staff member did not have knowledge of the Hall walker or monitor on the Firefly unit. At this time, the hall was observed, and it was found no staff were within line of sight of the hall, but one staff person was in the Lounge area, talking with several residents. This staff member was unable to see the hall from her location. Staff member Q stated the CNA was not able to see the hall in her location, therefore, resident oversight was not adequate. During an interview on 2/22/18 at 2:02 p.m., staff member X stated she was not trained to work specifically on the Firefly unit. She stated when she would work on the unit she would try to side track the residents if they were fighting or arguing. She stated someone usually watched the hall and the dayroom (lounge). She stated the unit usually had five staff assigned, but often staff were pulled from the unit, so four staff would work and provide care and monitoring for the residents on the Firefly unit. b. During an interview on 2/21/18 at 3:40 p.m., staff member Y stated resident #74 would hit, grab, pinch, bite, scratch, and she had to keep her away from other residents. She stated she may be more agitated before dinner, such as around 4:00 p.m. She stated caring for the resident, and other residents on the secure dementia unit, was like caring for a two year old. She stated to manage resident behaviors, the staff member had been trained on the curriculum for the MANDT, behavioral management program. A review of resident #74's seven page care plan, showed the line items addressing pain, which included, aggressive and combative at times and assess for pain et (and) report forward. The plan did not show how the facility had identified how the resident exhibited pain, or how staff may anticipate and address pain. The resident often required two people during the provision of ADL care, due to aggressive behaviors during ADL care. A review of resident #74's Psychology Preparation Sheet (undated) showed the resident had an unsteady gait, she was aggressive, and had behaviors towards others. She was also weepy, and would communicate with primarily word salad. The ability for staff to understand her was severely compromised. The facility frequently required one to one observations to protect the resident, and others, due to her aggressiveness. During an interview on 2/21/18 at 4:01 p.m., staff member W stated resident #74 was on one to one care at all times. She stated she did not know the resident well enough to provide any report on her. A review of resident #74's Care Area Assessment Documentation, showed pain was not addressed on the assessments. A review of resident #74's Pain Flow Sheet showed she was assessed only three times during her stay, all in February, which occurred on 2/1/18, 2/21/18, and 2/22/18. The documentation was incomplete. A review of resident #74's Medication Administration Records for (MONTH) and (MONTH) (YEAR), showed the resident received antipsychotic mediation consistently, but pain was not assessed or addressed as a contributing factor for the resident's aggressive behaviors (Refer to F697 for more detail on MAR). A review of resident #74's Nursing Notes showed, from admission to the date of the survey, the resident consistently had aggressive behaviors almost daily. The behaviors were often unalterable, and PRN (as needed) antipsychotic medications would be utilized to treat the resident's behaviors. The nursing documentation failed to show the nursing staff attempted to assess the resident's pain, when behaviors were exhibited by the resident, to determine if pain was a potential causal factor. The resident also had multiple falls, hitting her knees, head, shoulders, or hips (Refer to F689 for Falls and F697 for more detail on Nursing Notes). A review of resident #74's Nursing Weekly's Med/Prep forms, showed pain was not assessed thoroughly as a potential factor for the resident's behaviors which were exhibited daily. During an interview on 2/22/18 at 2:59 p.m., staff member C stated We try to train on dementia and emphasis on behavior, knowing the stages of the disease ., and it helps if staff have training to identify the root cause of behaviors. During an interview on 2/22/18 at 4:05 p.m., staff member O stated the staff did feel the resident had some pain, but the extent was unknown. c. Review of resident #74's Accident or Incident Report Forms showed she had six falls since her admitted [DATE]. Review of resident #74's Incident Report, dated 1/22/18, showed the resident stood up and tipped to the left side and fell . The documentation for the event failed to show the facility attempted to determine why she was tipping to the left side and why she had the fall. The interventions implemented to the fall did not show the facility addressed the resident comprehensively. Review of resident 74's Incident Report dated, 1/23/18, showed the resident lost her balance and fell on her right side. The facility failed to show they attempted to identify the root cause for the loss of balance, and fall to the right side, or that the resident was assessed for contributing factors. Review of resident #74's Incident Report, dated 1/28/18, showed the resident appeared to have thrown herself backwards, and landed on her buttocks. No root cause or interventions were identified as to why the resident was acting out and throwing herself backwards. Review of resident #74's Incident Report, dated 1/30/18, showed the resident tripped over a peer's feet, but the 1-1 observer, if in place, failed to ensure the resident did not trip on the peer's feet. Review of resident #74's Incident Report, dated 2/10/18, showed the resident was walking towards the nurses' station and fell into the wall, and fell to the floor landing face down. The fall resulted in a bump with red abrasion to left forehead. The facility failed to identify why the resident fell into the wall. The intervention, would not address mobility issues. During an interview on 2/22/18 at 9:30 a.m., staff member V stated nursing staff did not like to give the resident PRN, as needed (antipsychotic), medications because it would sedate resident #74. Staff member V stated the resident was unstable and wobbly when walking, and when she would observe the residents for pain, if they could not communicate, she would watch the resident's facial expressions. She would also watch for weakness or gait instability. She would watch to see if a resident pointed to a part of their body. During an observation and interview on 2/22/18 at 2:40 p.m., resident #74 had two black eyes. Staff member F stated the black eyes looked much better than a week ago. Review of resident #74's Fall Risk Assessment, dated 1/22/18, showed a low risk for falls had been identified. The Fall Risk Assessment was not updated after any of resident #74's six falls. Review of resident #74's Care Plan, dated 2/2018, showed (Resident) has an unsteady gait and balance at times. She received stand-by assist by staff and a handled gait belt with ambulation and transfers. She wears padded pants and a soft helmet. She has had falls with no serious injuries. She is resistive to redirection at times. Interventions to avoid falls included interventions to protect the resident from injury after a fall, and two for when staff assessed her (Refer to F689 for falls). The Care Plan for resident #74 did not show the facility identified and comprehensively addressed, anticipated, or intervened, for the resident's individualized risk factors relating to her poor safety awareness, mobility deficits, and behavior, contributing to her falls. The interventions were not individualized to address the extent of monitoring needed for the prevention of falls, to include when 1-1 was provided. The resident's fall history, was not reflected on the plan, showing the problem, goals, or approaches were evaluated and modified adequately for the prevention of falls. 5. A review of a Reporting Form, dated 10/14/17, for resident #44 (a female), showed the resident was invited into resident #52's room. Resident #52 was a male, and both residents resided on the Firefly unit. Resident #44 stated the male resident kissed her, and she stated, I did not know he was going to. The facility did not address the lack of monitoring related to the resident activities on the secured unit, the risk the female posed to the male, or the inadequate intervention used (education) to prevent future occurrences. 6. A review of a Reporting Form, dated 12/3/17, showed resident #69 was sitting in a chair, and resident #1 .quickly went to the chair and pushed (resident #69) sideways he lost his footing as he stepped on mat (resident #69) yelled what the hell are you doing and (resident #1) pushed him backwards into the window then he slid down the wall over the heat register and sat on the floor. He had a small red area lower right back. The event occurred, although the facility was to have a monitor at all times in the social area, for the prevention of altercations, between the residents. During an interview on 2/22/18 at 2:59 p.m., staff member C stated resident #1 is very territorial of his chair, and he will punch someone if they get near it. During an observation on 2/22/18 at 9:30 a.m., resident #1 was sitting in a chair along the wall close to the nursing station, by the hallway. The resident was not sitting in his own recliner. The resident's personal recliner, remained unmarked, showing it was not designated for resident #1, so others may notice and not use the chair. The facility failed to ensure the chair had appropriate designation to ensure others did not sit in the chair, and continue to be at risk of abuse by resident #1. During an interview on 2/22/18 at 4:34 p.m., staff member B stated the chair owned by resident #1 was not marked or clearly designated as resident #1's, and the resident had been at the facility for years. She stated she did not see why the chair needed to be marked as everyone on the Firefly unit knew it was resident #1's chair. During an interview on 2/22/18 at 3:00 p.m., staff members A and B stated they had not identified resident to resident behaviors as an area of concern. Staff member B stated the facility was the receiving facility for residents who had failed in other settings due to their mental health and behavior issues. She stated behaviors were an ongoing concern in the

Based on observation, interview, and record review, the facility failed to comprehensively assess residents with dementia, communication deficits, and who exhibited behaviors which were often aggressive and put the resident and others at risk for harm, almost daily; and the residents exhibited pain symptoms, to include during the provision of ADL care, had a history of [REDACTED].¹ The facility staff provided PRN antipsychotic medications for behaviors, prior to showing pain was assessed or considered as a contributing factor to the behaviors, for 2 (#s 74 and 76); and, failed to address recurring pain for a resident who had an abuse event occur, in which she was injured, and had [MEDICATION NAME] pain after the event, for 1 (#73) of 34 sampled and supplemental residents. Findings include: 1. Resident #74 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. A review of resident #74's Admission Information, from an alternate behavioral unit and facility, dated 10/25/17, showed the behavioral facility did not identify pain as a contributing factor in relation to the resident's behaviors. The facility had identified the resident had worsening behaviors in the afternoons and evenings. The resident did have PRN medication for pain available at the behavioral unit. The documentation showed antipsychotic medications were adjusted several times, to included adding or stopping new types, but pain was not addressed. During an interview on 2/21/18 at 3:40 p.m., staff member Y stated resident #74 would hit, grab, pinch, bite, scratch, and she had to keep her away from other residents. She stated she may be more agitated before dinner, such as around 4:00 p.m. She stated caring for the resident, and other residents on the secure dementia unit, was like caring for a two year old. She stated to manage resident behaviors, the staff member had been trained on the curriculum for the MANDT, behavioral management program. A review of resident #74's seven page care plan, showed the line items addressing pain, which included, aggressive and combative at times and assess for pain et (and) report forward. The plan did not show how the facility had identified how the resident exhibited pain, or how staff may anticipate and address pain. The resident often required two people during the provision of ADL care, due to aggressive behaviors during ADL care. A review of resident #74's Psychology Preparation Sheet (undated) showed the resident had an unsteady gait, she was aggressive, and had behaviors towards others. She was also weepy, and would communicate with primarily word salad. The ability for staff to understand her was severely compromised. The facility frequently required one to one observations to protect the resident, and others, due to her aggressiveness. During an interview on 2/21/18 at 4:01 p.m., staff member W stated resident #74 was on one to one care at all times. She stated she did not know the resident well enough to provide any report on her, but does know she is not to have any physical interaction with other residents, so staff step between her and other residents. A review of resident #74's Care Area Assessment Documentation, showed pain was not addressed on the assessments. During an interview on 2/22/18 at 9:30 a.m., staff member V stated nursing staff did not like to give the resident PRN, as needed, medications because it would sedate resident #74. Staff member V stated the resident was unstable and wobbly when walking, and when she would observe the residents for pain, if they could not communicate, she would watch the resident's facial expressions. She would also watch for weakness or gait instability. She would watch to see if a resident pointed to a part of their body. A review of resident #74's Pain Flow Sheet showed she was assessed only three times during her stay, all in February, which occurred on 2/1/18, 2/21/18, and 2/22/18. The documentation was incomplete. A review of resident #74's Medication Administration Records for (MONTH) and (MONTH) (YEAR), showed: - On admission, the physician had ordered [MEDICATION NAME] for [MEDICAL CONDITION] pain, which was to be given three times a day. [MEDICATION NAME] was to be given in the morning and evening. - The [MEDICATION NAME] and [MEDICATION NAME] was provided, as ordered, until 2/6/18, which is when the medications were discontinued, due to a new order of APAP ([MEDICATION NAME]/[MEDICATION NAME]), for pain. - In January, the [MEDICATION NAME], for anxiety and agitation, ordered to be given only as needed, was frequently provided two times a day. The [MEDICATION NAME], for anxiety and agitation, which was to be given as needed, was also given daily, and on occasion twice a day. -The PRN Nurses Medication Notes, showed the resident had the two medications 26 times from 1/24/18 to 1/31/18, which was documented as frequently not effective. -The resident had [MEDICATION NAME] (Tylenol) given only two times for pain, and on one of those, the medication effect was documented as sleeping. - In February, the Nursing Documentation Notes showed the behavioral medications were given 14 times, not always effective. PRN pain medication was not documented as given during the month of (MONTH) (YEAR), at any time. A review of resident #74's Nursing Notes showed, from admission to the date of the survey, the resident consistently had aggressive behaviors almost daily.¹ The behaviors were often unalterable, and PRN (as needed) antipsychotic medications would be utilized to treat the resident's behaviors. The nursing documentation failed to show the nursing staff attempted to assess the resident's pain, when behaviors were exhibited by the resident, to determine if pain was a potential causal factor. The nursing notes showed: - The resident had multiple falls, hitting her knees, head, shoulders, or hips (Refer to F689 for Falls). - The resident was consistently combative during ADL care, and staff failed to consider pain caused the resident discomfort during the provision of ADL care. - Antipsychotic medications, [MEDICATION NAME] and [MEDICATION NAME], were utilized consistently, often documented as not effective to alleviate the resident's behaviors. This in turn, caused prompted nursing staff to give more antipsychotic medication, but the nursing staff did not show pain was assessed or considered as a potential root cause for the behaviors. - The resident had multiple resident abuse events, where she was the aggressor, and acted out against others, grabbing or pulling at them. The staff did not consider pain was a contributing factor for her behavior. - The resident would cry or weep, and the staff did not assess for potential pain. - On 1/30/18, nursing staff documented [MEDICATION NAME] was given to the resident for possible aches. After this date, nursing staff began to provide [MEDICATION NAME], in an attempt to provide relief for the resident's behavior. The medication, seemed to help per the nurse on 2/2/18, although it was not effective on 2/3/18. On this day, the resident was given a dose of [MEDICATION NAME] and then two different types and doses of antipsychotic medications. The staff member did not consider the pain medication was not strong enough to provide adequate relief. - On 2/4/18, the resident's behavior became very aggressive, and a B52 was given intramuscularly. The B52 injection contained [MEDICATION NAME] ([MEDICATION NAME]), [MEDICATION NAME] (antipsychotic), and [MEDICATION NAME] (antianxiety), mixed together. The staff did not show in the documentation the assessment or consideration of potential pain, prior to the use of the injection. - On 2/6/18, the MDS assessment documentation did not show pain was addressed. - On 2/6/18, the resident was ordered [MEDICATION NAME], to be given in the morning and at supper. The physician also ordered [MEDICATION NAME], 5/325 mg, twice a day, which would treat pain. A review of resident #74's Nursing Weekly's Med/Prep forms, showed pain was documented on, but the records failed to show the staff assessed the resident's pain thoroughly as a potential factor for her behaviors exhibited. Documentation showed: - 1/26/18 - No pain, but behaviors included hitting, slapping, pinching, and the need to be on one to one care. - 1/30/18 - No pain, but behaviors included combativeness with staff and hitting peers. The resident was either on 1-1 or 2-1 observations by staff. The nurse documented the resident tripped easily. - 2/5/18 - No pain voiced but the resident was started on [MEDICATION NAME] twice a day, and had an increase in [MEDICATION NAME] and APAP. The resident's behaviors continued to be crying, hitting, punching, slapping, biting, decreased appetite, restless moving, and biting. - 2/13/18 - The nurse documented the change in [MEDICATION NAME], and pain was not documented as assessed. The resident continued to have behaviors of combativeness, kicking, biting, and chasing others, daily. - 2/19/18 - No pain, and the resident was pacing and pounding the floors and chairs. During an interview on 2/22/18 at 2:59 p.m., staff member C stated the resident was aggressive and had falls. She stated there was a tiny improvement in the resident's behavior since the implementation of the [MEDICATION NAME]. She stated the [MEDICATION NAME] and other psych meds were not effective for the resident. She stated, when discussing how staff anticipate resident needs, We try to train on dementia and emphasis on behavior, knowing the stages of the disease ., and it helps if staff have training to identify the root cause of behaviors. Staff member C did not feel the resident's behavior was potentially related to pain. During an interview on 2/22/18 at 4:05 p.m., staff member O asked What can I do for the resident and her behaviors? Staff member O referenced she could provide more antipsychotic medications to help behaviors, which would in turn sedate the resident more, but did not feel this was the best option. Pain, as a contributing factor to a resident's behavior, was discussed, to include the lack of documentation in the medical records to show pain was comprehensively assessed for a resident who exhibited behaviors, and for a resident who was unable to communicate pain when present. Staff member O stated that could be considered in the future (referring to the review of pain as a contributor to behavior), and commented the staff did feel the resident had some pain, but the extent was unknown. 2. Resident #76 was admitted to the facility with [DIAGNOSES REDACTED]. During an observation and interview on 2/22/18 at 9:30 a.m., resident #76 was wandering up and down the hallway of the Firefly unit. As resident #76 neared the nursing station, the nurse came from behind the station, and stated You may want to move out of his way and pointed to resident #76. She directed this writer to the Lounge area, which was out of the resident's direct path. The staff member, Q, who was being interviewed at the time, also moved out of the resident's way. During the interview, staff member V stated, He is in a mood today, not sure why. A review of resident #76's current Care Plan showed the resident exhibited a history of back and shoulder pain, and he was to be kept in line of sight of staff and at arms length away from peers. This was due to his combativeness and aggression towards others. The care plan showed the resident had impaired cognition and communication, and he was unable to communicate his needs well. A review of the resident's ADL care plan showed a goal that resident #76 would let staff know if he was having pain, although he had the communication deficits, and he had a history of [REDACTED]. An intervention included a PRN pain medication and other non-medicinal comfort measures for the treatment of [REDACTED]. During an interview on 2/22/18 at 9:30 a.m., staff member V stated neither she, nor the staff working on that day, attempted to determine why the resident was in a bad mood, and she did not believe any other staff working that day had either. She stated some days he just wakes up that way, in a mood, and there isn't anything you can do for him. She stated she would observe the resident's behavior, and try to keep him at arms-length from other residents though. She stated she had not been trained on the MANDT behavior program utilized by the facility to help manage resident behaviors. A review of resident #76's Nursing Notes showed, from 1/27/18 to the date of the survey, the resident had repeated altercations with other residents, had repetitive behaviors, and had fallen. The notes included: - He displayed pacing in social areas/halls, agitation, restlessness, attempting to hit at staff, cursing, not sleeping, and also pacing in his room at night. Behaviors exhibited did not prompt staff to assess for pain, per the nursing notes. - 2/7/18 The MDS Quarterly assessment showed documentation of, He has no signs or symptoms of pain. - 2/11/18 Angry this morning, walking way stooped over. Staff did not assess for pain at the time related to the resident's stooping. - 1/9/18 The resident had increased agitation, pacing, combative, yelling at staff to leave him alone. The resident was given an antipsychotic medication, by injection, to help calm him. The resident did calm, but continued to pace in his room. The staff did not show they assessed for potential pain. A review of resident #76's Pain Flow Sheet, showed pain was monitored from 1/2/18 to 1/15/18, only seven times. Pain was not documented on the form after 1/15/18 to the date of the survey. The documentation showed the resident was having pain in right shoulder ., walking and holding arm ., c/o pain ., and saying yes to pain questions. Documentation for a (MONTH) (YEAR) Pain Flow Sheet was not provided by the facility for review. A review of the resident's Medication Administration Record, [REDACTED] - For (MONTH) (YEAR), the resident was given [MEDICATION NAME] for pain or fever five times, out of 180 opportunities, to provide pain medication. The Nursing Medication Notes did not show why the [MEDICATION NAME] was given. - For (MONTH) (YEAR), the resident was given [MEDICATION NAME] for pain or fever 15 times, out of 96 opportunities. The Nursing Medication Notes showed the medication was helpful most of the time. During an interview on 2/22/18 at 2:59 p.m., staff member C stated she had not worked with the resident in an attempt to assist with behavior management, as the resident was very demented. Staff member C explained she did not typically work with the demented residents as they did not retain information well. A review of resident #76's ADL Narrative documentation, completed by the CNAs, showed the resident had behaviors, but staff did not document pain was considered when the behaviors occurred. Behaviors included pacing, inability to sleep, aggression, and abuse towards staff and other residents. During an interview on 2/21/18 at 3:15 p.m., staff member D stated the resident told staff he was upset, you could tell if there was something going on with him. He may have increased agitation if upset, and he may self isolate or may be fidgety. The staff member did not state pain would be assessed if behaviors occurred. A review of resident #76's CNA flowsheet documentation for (MONTH) (YEAR) failed to show the resident had pain concerns relating to the provision of care, or at any time. 3. On 1/29/18, an event report showed resident #73 reported a male resident, #54, hit/punched her on the shoulder, and she presented with bruising to her breast. The actual date of the event was unknown. She had fallen during the abuse event and she hit the hard footboard of the bed as she fell . During an interview on 2/21/18 at 4:56 p.m., resident #73 was laying on her bed in her room with the door closed. During the interview, resident #73 stated, Even a guy hit me and punched me¹ and I think I broke a rib because it still hurts. I landed when he hit me, and I fell into the footboard on the bed. He was just mean. She explained, If you were near him he would punch you. I still hurt every time I cough or sneeze. Hurts under my boob. They did remove the ones (residents) that were mean, but then the people would come right back. A review of resident #73's care plan, The resident felt the facility neglected her needs. The resident's ongoing pain, from the injury to the rib area, in which she believed she fractured ribs, still occurred daily and hindered her comfort when she moved. The resident stated the facility failed to follow up adequately on the pain. The resident's medical record lacked information to show further action was taken during the month to determine if fractured ribs were a concern, such as a radiology report. The abuse inflicted on resident #73 caused physical and psychosocial harm. Reference: ¹Nursing home residents with dementia gradually lose the ability to process information so that they are less likely to express pain in typical ways. These residents may express pain through disruptive behaviors because they cannot appropriately verbalize their pain experience Residents with more severe pain are less likely to display wandering behaviors .but more likely to display aggressive and agitated behaviors. The relationship between pain and disruptive behaviors depends on the type of behaviors. Pain is positively correlated with disruptive behaviors that do not involve locomotion (e.g., aggression and agitation), but negatively related to disruptive behaviors that are accompanied by locomotion (e.g., wandering). These findings indicate that effective pain management may help to reduce aggression and agitation, and to promote mobility in persons with dementia. Hyochol Ahn and Ann Horgas, The relationship between pain and disruptive behaviors in nursing home residents with dementia BMC Geriatrics 3:14, https://doi.org/10.1186/1471-2318-13-14, Copyright Ahn and Horgas; licensee BioMed Central Ltd., 2013

Based on observation, interview, and record review, the facility failed to develop a comprehensive care plan that identified the use of medication(s) with potentially significant adverse side effects for 1 (#66) and also for one who exhibited symptoms of drowsiness and drooling, (#36); failed to include goals and interventions for physical and verbal behaviors for 1 (#13); failed to address pain symptoms exhibited, and interventions to alleviate pain for 1 (#74); failed to identify a resident was at high risk for others acting out against him, and identify and provide adequate staff interventions for the protection of a resident, for 1 (#4); and failed to adequately address aggressive behavior towards others, specifically resident #4, and for the resident's pain, for 1 (#76) resident of 18 sampled residents. Findings include: 1. Resident #36 was admitted to the facility on [DATE], and was re-admitted on [DATE] after an in-patient stay at a psychiatric hospital. Her [DIAGNOSES REDACTED]. During an observation and interview on 2/21/18 at 7:45 a.m., resident #36 was observed to be drowsy, frequently closing her eyes, with her head lowering towards her chest. Resident #36 was also observed to have spittle drooling from the left side of her mouth. Resident #36 stated she thought the drowsiness and drooling were side effects of her medications. Review of resident #36's (MONTH) (YEAR) MAR indicated [REDACTED] -[MEDICATION NAME] (an antipsychotic) twice a day and prn; -[MEDICATION NAME] (an antipsychotic) twice a day; -[MEDICATION NAME] (used to treat mood disorders and prevent [MEDICAL CONDITION]) twice a day; -[MEDICATION NAME] (used to treat mood disorders and prevent [MEDICAL CONDITION]) once a day; -[MEDICATION NAME] (used to treat anxiety) every 6 hours prn. During an interview on 2/22/18 at 8:55 a.m., staff member F stated there was no documentation to show daily monitoring for potential adverse side effects, but there were several places a nurse would document the presence of adverse side effects, if any were observed. She stated the weekly nursing summaries, the nurse's notes, and hot charting sheets were all used to document findings such as the presence of adverse side effects. She stated she would notify the physician of possible adverse side effects by calling the provider or by sending a fax message. She stated there was no evidence to show that monitoring for potential adverse side effects was ongoing daily, except for the hot charting which was done when a resident was newly admitted , experienced a change of condition, or had a new medication ordered. Staff member F stated an AIMS test was done upon admission and at other times, but she did not know how often. She stated the physician also monitored for adverse side effects during routine visits, generally done every two months. Staff member F stated some of the psychoactive medications required routine lab tests to monitor for adverse effects, and the labs were done routinely according to the physician's orders [REDACTED]. She stated there was no need to monitor for adverse side effects of a medication used long-term because adverse side effects would not occur after long-term use. After further discussion, staff member F stated, Oh, you are talking about EPS and those kind of side effects. She stated EPS and other side effects could occur after long-term use of psychoactive medications. During an interview on 2/22/18 at 3:00 p.m., staff member B stated monitoring of adverse medication side effects was ongoing and was documented if adverse side effects were noted. She stated the nurses documented in the hot charting notes when there was a new medication or a change of medication. Staff member B stated the care plan showed when the resident was receiving a psychoactive medication that required ongoing monitoring for adverse side effects. Review of resident #36's care plan, with an implementation date of (MONTH) (YEAR), showed a problem/need for the use of multiple types of psychoactive medications. The only goal for the problem was to reduce the intensity of hallucinations, delusions and anxiety. The care plan did not show the potential for adverse side effects, the need for ongoing monitoring, or which side effects were associated with the types of psychoactive medications resident #36 was receiving. The care plan did not show the need for AIMS testing, or lab testing. 2. Resident #66 was admitted to the facility on [DATE]. He had a [DIAGNOSES REDACTED]. Review of resident #66's physician's orders [REDACTED]. Review of the Nursing (YEAR) Drug Handbook, provided by staff member F as the resource used by the nursing staff for medication information, showed bruising and bleeding as potential adverse effects of Eliquis. The Drug Handbook showed the need to monitor for signs of bruising and bleeding. During an interview on 2/22/18 at 3:00 p.m., staff member B stated the use of anticoagulant medications and the need to monitor for bruising, bleeding, and other adverse side effects should be included on resident #66's care plan. Review of resident #66's undated care plan did not show use of an anticoagulant medication, or the need to monitor for signs of bruising or bleeding. An updated care plan, with a problem/need dated 2/22/18, for the use of the anticoagulant medication was provided by the facility prior to the end of the survey. 3. Resident #13 was admitted with a [DIAGNOSES REDACTED]. During the initial dining observation on 2/20/18 at 12:10 p.m., the resident was seated at a table by himself. Resident #13 would occasionally call out and ask staff where he was. Several times staff redirected him to eat his lunch, and reoriented him to his location in the dining room. Review of resident #13's Annual MDS, with an ARD of 11/28/17, reflected the resident had continuous disorganized thinking and difficulty focusing his attention. Section E reflected resident #13 had physical behavioral symptoms 4-6 days during the 7 day look back period of the assessment. Section E reflected the resident rejected care 4-6 days during the 7 day look back period of the assessment. Review of the facility form titled Nursing Weeklies/MD Prep, for the months of (MONTH) and (MONTH) (YEAR), showed resident #13 was resistive to cares, and would strike out, bite, kick, and spit out his medications. Review of resident #13's care plan, with a review date of 1/28/18, showed a problem area of a history of verbal and physical aggression. The residents care plan did not show goals, or interventions regarding what staff were to do when resident #13 was physically and verbally aggressive. During an interview on 2/22/28 at 12:50 p.m., staff member B stated the care plan was created by the MDS coordinator. She stated the care plan was initiated upon admission, then each department head wrote their care plan area for the resident. 4. During an interview on 2/21/18 at 3:40 p.m., staff member Y stated resident #74 would hit, grab, pinch, bite, scratch, and she had to keep her away from other residents. She stated she may be more agitated before dinner, such as around 4:00 p.m. A review of resident #74's Care Area Assessment Documentation, showed pain was not addressed on the assessments. During an interview on 2/22/18 at 9:30 a.m., staff member V stated nursing staff did not like to give the resident PRN, as needed, medications (for behaviors) because it would sedate resident #74. Staff member V stated the resident was unstable and wobbly when walking, and when she would observe the residents for pain, if they could not communicate, she would watch the resident's facial expressions. She would also watch for weakness or gait instability. She would watch to see if a resident pointed to a part of their body. A review of resident #74's nursing notes, for (MONTH) and (MONTH) (YEAR), showed she had multiple falls, and concerns with her mobility. A review of resident #74's seven page care plan, showed two small line items addressing pain, which was, aggressive and combative at times and assess for pain et (and) report forward. The plan did not show how the facility had identified how the resident exhibited pain, or how the staff may anticipate and address the resident's pain. The resident would require two people to provide activity of daily living cares, at times, due to the aggressive behaviors. A review of resident #74's Nursing Notes showed, from admission to the date of the survey, the resident consistently had aggressive behaviors almost daily. The behaviors were often unalterable, and PRN (as needed) antipsychotic medications would be utilized to treat the resident's behaviors. A review of resident #74's care plan failed to show adequate interventions for how staff should meet the resident's needs if behaviors were exhibited, to include during ADL cares. During an interview on 2/22/18 at 2:59 p.m., staff member C stated the resident was aggressive and had falls. She stated there was a tiny improvement in the resident's behavior since the implementation of the [MEDICATION NAME]. She stated the [MEDICATION NAME] and other psych meds were not effective for the resident. She stated, when discussing how staff anticipate resident needs, We try to train on dementia and emphasis on behavior, knowing the stages of the disease ., and it helps if staff have training to identify the root cause of behaviors. 5. A record review for resident #4 showed on 2/7/18, a staff member was walking with resident #4, going by resident #76, when #76 took a step towards the staff member and then he reached out and punched resident #4 in the back of the head. He stated, It was an accident. The action by resident #76 was unprovoked and purposeful. The immediate intervention to protect resident #4 was to separate the two residents when walking the halls. Staff were present at the time, and failed to prevent the abuse. A review of the abuse events between resident #4 and #76 showed there were multiple events where #4 was a victim of abuse from resident #76 and also from resident #74. The final reports for the events showed staff were to keep resident #s 4, 74, and 76, at arms-length away from others, to keep the residents in the line of sight of staff, and to keep #4 and 76 at opposite ends of the hallway when ambulating. The interventions, had not been successful, per the repeated events where #4 was a victim, and where #76 acted out aggressively towards others. During an observation on 2/22/18 at 9:35 a.m., resident #4 was sitting in a recliner, in the corner, by the windows. The resident had his buttocks placed at the edge of the recliner seat, and he was rocking back and forth. The resident had a helmet on, which resembled a bicycle helmet, and he had his head down. The resident did not look up when this writer approached the area. A review of resident #4's care plan failed to show the variety of specific behaviors identified by the staff were addressed in the resident's care plan. The facility had not identified resident #76 as a high-risk factor relating to resident #4's safety, and the need to protect resident #4 from resident #76. The care plan documentation did not show interventions were always dated for the initiation date of problems, goals, or approaches, and the reader was unable to determine when interventions were evaluated or modified for success or failure. 6. During an observation and interview on 2/22/18 at 9:30 a.m., resident #76 was wandering up and down the hallway of the Firefly unit. As resident #76 neared the nursing station, the nurse came from behind the station, and stated You may want to move out of his way and pointed to resident #76. Staff member Q, who was being interviewed at the time, also moved out of the resident's way. During the interview, staff member V stated, He is in a mood today, not sure why. During an interview on 2/22/18 at 9:30 a.m., staff member V stated neither she, nor the staff working on that day, attempted to determine why the resident was in a bad mood, and she did not believe any other staff working that day had either. She stated some days he just wakes up that way, in a mood, and there isn't anything you can do for him. A review of resident #76's current Care Plan showed the resident exhibited a history of back and shoulder pain, and he was to be kept in line of sight of staff and at arms length away from peers. This was due to his combativeness and aggression toward others. The care plan showed the resident had impaired cognition and communication, and he was unable to communicate his needs well. A review of the resident's ADL care plan showed a goal that resident #76 would let staff know if he was having pain, although he had the communication deficits, and he had a history of [REDACTED]. An intervention included a PRN pain medication and other non-medicinal comfort measures for the treatment of [REDACTED]. The plan did not show what staff would do if the resident had exhibited pain. A review of resident #76's Nursing Notes showed, from 1/27/18 to the date of the survey, the resident had repeated altercations with other residents and staff, which included: - He displayed pacing in social areas/halls, agitation, restlessness, attempting to hit at staff, cursing, not sleeping, and also pacing in his room at night. Behaviors exhibited did not prompt staff to assess for pain, per the nursing notes. - 1/9/18 The resident had increased agitation, pacing, combative, yelling at staff to leave him alone. The resident was given an antipsychotic medication, by injection, to help calm him. The resident did calm, but continued to pace in his room. The staff did not show they assessed for potential pain. - 2/7/18 The MDS Quarterly assessment showed documentation of, He has no signs or symptoms of pain. - 2/11/18 Angry this morning, walking way stooped over. Staff did not assess for pain at the time related to the resident's stooping. A review of resident #76's care plan failed to show the resident's spontaneous unprovoked behavior put others at risk, and how staff should be on the alert for this spontaneous aggressive behavior. The plan did not show the facility attempted to identify interventions detailing what behavior the resident may exhibit prior to his unprovoked abusive events.

Based on interview and record review, the facility failed to identify abuse occurred, and protect the resident(s) from potential future abuse by staff, and failed to notify the Stage Agency within 24-hours of allegations of abuse, and provide the State Agency with a final summary of the allegations within five days of the alleged event, for 5 of 8 sampled residents. Findings include: -An allegation of mistreatment and neglect, involving 1 (#1) resident, which caused psychosocial harm to the resident who felt terrorized and threatened by the staff member; and the resident was left unattended for up to an hour in a lift, and pain was inflicted on the resident during the process of this. -The allegation of neglect of care, related to 1 (#5) resident, when the staff member failed to assist the resident with the use of a device, which caused the resident to urinate on himself, his clothing and his equipment. - An allegation of physical and verbal abuse for 1 (#6) resident, and the resident was was free from physical and verbal abuse, when the staff member pushed the resident in bed and yelled at her. The facility failed to ensure 1 (#7) resident was free from physical abuse, when the staff member twisted the resident's limb and held the resident in bed; and the facility failed to protect and utilize the least restrictive form of restraint for an upset resident, for 1 (#4), and the resident was physically restrained by staff. Facility administration failed to ensure protective measures were implemented for the victims, or other residents, prior to the alleged staff members being allowed to have direct care contact. This occurred during and after allegations were received, and investigated. Findings include: IMMEDIATE JEOPARDY On 6/22/17 at 1:45 p.m., an Immediate Jeopardy was announced in the area of Resident Behavior & Facility Practices; Abuse, for F225 Not Employ Abusers, Reporting/Investigate, and F226 Abuse Policies and Procedures. These were found to be at the Severity and Scope of K. PLAN TO REMOVE IMMEDIACY The facility submitted an acceptable plan to remove the immediacy on 6/22/17 at 6:00 p.m. After the plan was accepted, the Severity and Scope was reduced to an H for both F225 and F226. Refer to F000 for the Plan to Remove the Immediacy. 1. Resident #1 reported alleged physical abuse by a staff member on 6/5/17. Review of the facility's form Resident Rights Grievance Report Form, showed: -Staff member D interviewed resident #1 on 6/5/17 regarding an allegation of staff abuse. The allegation of abuse would be the start of the 24-hour timeline, for the required abuse reporting. -Staff member B interviewed resident #1 about the allegation of staff abuse on 6/7/17. This was 48 hours after the allegation was voiced. -Staff member A documented the alleged staff member received a due process letter on 6/12/17; seven days after the allegation was received. -Staff member A documented the alleged staff member responded, in writing, to the alleged allegation on 6/19/17. As of this time, 14 days had passed. -Staff member A documented the investigation into the alleged abuse of resident #1 continued on 6/19/17. No measures were taken for the protection of the resident during this time, or for other residents at the facility receiving care from the alleged staff member. Refer to F224 for more detail. Review of the facility's 24-hour report form showed this incident was not reported to the State Agency, as required. 2. During a review of resident #4's medical record, the Interdisciplinary Progress Notes, showed: -Staff member B requested resident #4 turn over a debit card he had received in the mail from his bank. -Resident #4 crossed his arms over chest and refused the request. -Staff members physically held resident #4's hands, restraining him, while his debit card was removed from his wallet. Refer to F221 for more information relating to the use of restraints. During an interview on 6/21/17 at 8:00 a.m., staff member B said, Resident #4 was hitting at staff. We held his hands, retrieved his wallet from him, and removed his debit card from his wallet. Staff member B said resident #4 was not placed in Mandt. Staff member B did not feel holding resident #4's hands was a physical restraint. On 6/23/17 at 9:30 a.m., staff member A stated physical restraints were not tolerated at the facility. Staff member A stated she was unaware resident #4 had been physically restrained by staff members. Review of the facility's 24-hour reports, sent to the State Agency and investigated by the facility, failed to show this incident had been identified by the staff at the facility as a reportable event, or that it needed to be reported to the State Agency as an alleged physical restraint of a resident by staff. 3. Review of the facility's form Resident Rights Grievance Report Form, showed resident #5 reported alleged neglect by a CNA when she refused to assist him with toileting. The form showed: -Staff member D interviewed resident #5 on 5/21/17 regarding an allegation of staff neglect. -Staff member D documented staff was educated on resident #5's preferences and abilities for ADL care, per the resident's care plan. -Staff member A documented staff was to follow resident #5's care plan. Staff member A documented that staff was educated. The facility did not show documentation of this incident being investigated as alleged resident neglect, or that it was reported to the State Agency, or alternate agencies, as required. 4. Review of the facility's Resident Rights Grievance Report Form, showed resident #6 reported alleged physical and verbal abuse by a CNA, when the CNA went to wake her at 4:00 a.m., and the staff member pushed and yelled at the resident. The form included: -Staff member Q interviewed resident #6 on 9/22/16 regarding the allegation of physical and verbal abuse by staff. -Staff member B documented on 10/5/16: Nursing supervisor investigated and will speak with CNA re: waking the resident at 4:30 a.m. to toilet. Will re-evaluate toileting plan at night to help preserve resident sleep. The abuse was not addressed by staff member B. -Staff member A documented that the CNA was spoken to, but the abuse was not addressed by staff member A. The Resident Rights Grievance Report Form, showed no protective measures were implemented to prevent future harm to resident #6, or other residents receiving care from the CNA involved. The facility's documentation did not show this incident had been identified as abuse, investigated as physical and verbal abuse of a resident, or reported as abuse by a staff member. 5. Review of the facility's Resident Rights Grievance Report Form, showed resident #7 reported an alleged physical abuse by two CNAs, and included: -Staff member D interviewed resident #7 on 9/21/16 regarding an allegation of physical abuse by two CNAs. -Staff member A documented to see attached note. -Staff member C documented on the attached note on 10/3/16, which was over ten days later, that she spoke with the two CNAs involved in the alleged incident. Staff member C's recommendation was to move one staff member to another wing. Staff member C documented this was not the first grievance filed against these two CNAs. The form did not show protective measures to prevent future harm to resident #7. It was unclear if the CNA was removed from the unit per the recommendation. During an interview on 6/21/17 at 8:50 a.m., staff member A said, When an allegation of (staff to resident) abuse has been reported, we sometimes suspend the staff or the staff is moved to another wing while the investigation is going on. These residents have mental issues so we are not always sure if the allegation is true. Staff member A said the facility did not have an Abuse Coordinator or someone who oversaw resident abuse allegations from the beginning of the reporting process to the end of the investigation process. Staff member A said she would be the person, as administrator, who would oversee the process for managing abuse in the facility. During an interview on 6/21/17 at 12:30 p.m., staff member E explained the process for an investigation of an alleged staff to resident abuse. Staff member E said the resident would complete a form called Resident Rights Grievance Report Form, and the resident would document the abuse and what happened. Staff member E said he would then notify the alleged staff member of the grievance. The alleged staff member would document what happened with the resident, to get the facts straight. Staff member E said the Resident Rights Grievance Report Form did not encompass all the aspects of the abuse investigation process. Staff member E said he did not know of a staff member ever being removed from direct resident care during an alleged staff to resident abuse investigation. Staff member E said he knew of staff members being moved to other wings during an alleged resident abuse investigation. He did not know how the facility protected residents on other wings from the staff member under investigation for alleged resident abuse, when this occurred. Staff member E said five entities, including the State Agency, received 24 hour reports on incidents. Staff member E said the five day follow-up report was included on the 24-hour report, because the report was not submitted to the appropriate agencies until the investigation was complete. Due to this, the final summaries were not received by the State Agency in the timeline required by CMS. During an interview on 6/21/17 at 12:30 p.m., staff member F said he had been a CNA at the facility for seven years. Staff member F said he had never been suspended or moved to another wing when he had been under investigation for alleged resident abuse. Staff member F said he had received abuse training within the last 12 months. Staff member F said he had never received abuse re-education during an alleged resident abuse investigation. Staff member F said he had received an abuse identification brochure in the past, which was attached to his due process letter, when he was involved in an alleged resident abuse investigation. Refer to F224 for more information on staff member F. During an interview on 6/21/17 at 1:00 p.m., staff member G said the facility had not notified her of resident #5's grievance of neglect. Staff member G said she had never been suspended or moved to another wing due to a resident allegation of abuse. Refer to F224 for more information on staff member G. During an interview on 6/21/17 at 1:30 p.m., staff member A said staff to resident allegations are not reported to the State Agency until the investigation was complete, and the allegation against the staff member had been substantiated. Staff member A said incidents were reported to five different agencies. Staff member A said the facility did not report to adult protective services. Due to this, the facility was not meeting the reporting requirements for abuse. During an interview on 6/21/17 at 5:00 p.m., staff member D was informed that the allegations of staff to resident abuse had not been reported to the State Agency, as required, staff member D said, I don't do the reporting, I just fill out the grievance form and put copies in staff member A and staff member B's mailboxes, in the copy room. Staff member D said staff member A and B did all the investigation and reporting for the facility's allegations. During an interview on 6/22/17 at 9:45 a.m., staff member C said staff members under investigation for alleged resident abuse receive a Due Process letter, hand delivered, two to five days after the investigation into alleged resident abuse had begun. Staff member C said the Due Process letter did have an abuse pamphlet attached to it. Staff member C said the expectation of the human resource department, was that a supervisor would re-educate a staff member under investigation for alleged resident abuse. Staff member C said, When an allegation of resident abuse is reported to the social worker, staff did not always get moved from the wing, but a staff member may be moved to another designated section of the wing, and told not to have contact with the resident who filed the allegation. Due to the delayed timeline for initiating the due process letter, the resident's who alleged abuse continued to be at risk, as were other residents of the facility. Review of the facility's policy #1104, Abuse, Misappropriations, and/or Neglect of Residents, Investigation/Reporting, B, states: Once the investigation has been completed the Superintendent or designee (Director of Nursing, RN Nurse Supervisor, Charge Nurse) will send a final report of the incident by completing the 5 Day Investigation Results Report on the Resident Abuse/Neglect/Exploitation Reporting Form. Contact information and telephone numbers were provided within the content of the policy for each agency the facility was required to report abuse to. A review of the facility's policy, #1104, Abuse, Misappropriations, and/or Neglect of Residents, Investigation/Reporting, C, showed, The Superintendent or designee shall determine the need for immediate removal of the suspected employee from the work place after notification of an incident. During an interview on 6/21/17 at 1:30 p.m., staff member A could not recall ever suspending or removing an employee suspected of resident abuse from the facility.

Based on interview and record review, the facility failed to operationalize necessary components of abuse, some of which were documented in the facility abuse policy, relating to: The identification of staff to resident abuse, ensuring resident safety during, and after, an allegation of abuse is received from a resident; thorough and timely investigations of abuse; and timely reporting, investigation, and completion of abuse allegations. This failure had the potential to affect all residents who came in contact with the alleged staff members, and specifically included 5 (#s 1, 4, 5, 6, and 7) of 8 sampled residents. Findings include: IMMEDIATE JEOPARDY On 6/22/17 at 1:45 p.m., an Immediate Jeopardy was announced in the area of Resident Behavior & Facility Practices; Abuse, for F225 Not Employ Abusers, Reporting/Investigate, and F226 Abuse Policies and Procedures. These were found to be at the Severity and Scope of K. PLAN TO REMOVE IMMEDIACY The facility submitted an acceptable plan to remove the immediacy on 6/22/17 at 6:00 p.m. After the plan was accepted, the Severity and Scope was reduced to an H for F225 and F226. Refer to F000 for the Plan to Remove the Immediacy. A review of facility allegations showed: 1. Resident #1 reported an allegation of staff abuse to the facility on [DATE], on the Resident Rights Grievance Report Form. Review of the facility's abuse reports showed this incident was not reported to the State Agency. 2. Resident #4 was physically restrained by staff members, on 4/25/17. This incident was documented, in resident #4's medical record, on a facility form Interdisciplinary Progress Notes. The facility did not investigate this incident as an alleged physical restraint of a resident by staff members. Review of the facility's abuse reports failed to show this incident had been identified and reported as an alleged physical restraint of a resident by staff members. The event was not investigated. Protective measures were not implemented for the resident(s). 3. Resident #5 reported an incident of alleged neglect on 5/21/17, on the Resident Rights Grievance Report Form. Review of the facility's abuse reports failed to show this incident had been identified to be neglect, or that the event was thoroughly investigated as neglect. The event was not reported to the State Agency as abuse/neglect, and protective measures were not implemented for the resident to prevent future neglect of care. 4. Resident #6 reported alleged physical and verbal abuse on 9/22/16, on a Resident Rights Grievance Report Form. The facility's documentation failed to show this incident had been investigated as physical and verbal abuse of a resident by a staff member, or that protective measures had been taken for the resident. A review of the facility's abuse reports failed to show this incident had been reported to the State Agency as required as alleged physical and verbal abuse of a resident by a staff member. 5. Resident #7 reported alleged physical abuse on 9/21/16, on a Resident Rights Grievance Report Form. The facility's documentation failed to show this incident had been identified as abuse, or investigated as physical abuse of a resident by two staff members. Review of the facility's abuse reports failed to show this incident had been reported to the State Agency as alleged physical abuse of a resident by two staff members. During an interview on 6/21/17 at 1:30 p.m., staff member A said staff to resident allegations are not reported to the State Agency until the investigation was complete, and the allegation against the staff member had been substantiated. Staff member A said incidents were reported to five different agencies. Staff member A said the facility did not report to adult protective services. During an interview on 6/21/17 at 12:30 p.m., Staff member E said the five day follow-up was included on the 24-hour report, both sent at the same time, because the report was not submitted to the appropriate agencies until the investigation was completed. Staff member E said this was the training he received when he started working at the facility. During an interview on 6/21/17 at 5:00 p.m., staff member D she puts copies of the resident grievances, which included the abuse allegations, in staff member A and staff member B's mailboxes, in the copy room. Staff member D said staff member A and B did all the investigation and reporting for alleged abuse. Review of sections within the facility policy, #1104, titled Abuse, Misappropriations, and/or Neglect of Residents, showed: -C, shows: The supervisor will inform the Superintendent or designee (Director of Nursing, RN Nurse Supervisor, Charge Nurse) shall send an initial report of the allegation (pending further investigation) by completing a Resident Abuse/Neglect/Exploitation Reporting Form (Attachment #1) and faxing the form . The contact information was provided for the various agencies. The policy showed this was to occur .by the end of the next day. -B, showed: Once the investigation has been completed the Superintendent or designee (Director of Nursing, RN Nurse Supervisor, Charge Nurse) will send a final report of the incident by completing the 5 Day Investigation Results Report on the Resident Abuse/Neglect/Exploitation Reporting Form (Attachment #1) and faxing the form to The contact information was provided on the policy. Although the facility policy showed steps to be taken, facility administration failed to follow these steps to ensure the components of abuse were met adequately.

Based on observation, record review, and interview, the facility failed to ensure residents were free from mistreatment and neglect, which caused psychosocial harm, fear, mental anguish, and fear of retaliation by staff, when the resident's filed grievances to inform the facility of the concerns with staff, which included: -A staff member terrorized and threatened a resident; inflicted pain on the resident during transfers with a lift; neglected and left the resident alone, for up to an hour, while the resident was suspended in the lift; ignored complaints of pain during care and that the resident voiced the care was abusive, all of which caused the resident to be traumatized by the events involving the alleged staff member, for 1 (#1) of 8 sampled residents; -A staff member neglected a resident's request for assistance with a device to relieve himself, which caused the resident to urinate on himself, his clothing, and his wheelchair, which was upsetting for the resident, for 1 (#5) of 8 sampled residents; - A staff member shoved and and yelled at a resident during care, and the resident then reported abuse had occurred, for 1 (#6) of 8 sampled residents; - Two staff members' twisted a resident's limbs and held the resident down during care, and the resident felt abused, for 1 (#7) of 8 sampled residents. -The facility also failed to monitor staff who had access to the resident's during and after allegations of abuse were received, and failed to identify and implement interventions to prevent future abuse to the resident's voicing allegations of abuse, and residents who may have had contact with the alleged staff. Findings include: During an interview on 6/21/17 at 8:50 a.m., staff member A said, When an allegation of abuse has been reported, we sometimes suspend the staff. Sometimes we move the staff to another wing while the investigation is going on. These residents have mental health issues so we are not always sure if the allegation is true. Staff member A did not provide information for how the resident was protected, if a staff member was not removed from direct resident care. During an interview on 6/21/17 at 10:30 a.m., staff member C said, Staff member F is only allowed to work on the E and G wings because residents can report if abuse occurs. Staff member C said, The facility keeps it in the back of their mind that he (staff member F) could abuse another resident. That's why he can't work on unit F. That's the dementia unit, and those residents can't self-report abuse. During an interview on 6/21/17 at 12:30 p.m., staff member E said he was not aware of any staff being removed from direct patient care during an abuse investigation. Staff member E said a staff member would be moved to another wing if there was alleged abuse. If the staff member moved to an alternate unit, direct patient care would continue by the alleged staff member, and staff member E said the facility could not assure the other residents were protected during the abuse investigation process. During an interview on 6/21/17 at 12:50 p.m., staff member F said he worked at the facility for seven years. Staff member F said he had several resident abuse allegations, which were documented in his human resource file. Staff member F said none of the resident abuse allegations against him had ever been substantiated. Staff member F said he did not remember being moved to another wing during an abuse investigation. The facility had not removed the staff member from the location where the resident who alleged abuse resided, or taken measures to protect other residents who may have been at risk for abuse by staff member F, during or after, abuse investigations occurred. During an interview on 6/22/17 at 9:45 a.m., staff member C said when an abuse allegation was reported to the social worker, the direct care staff member, who was the alleged abuser, would not always get moved from the wing where the resident who alleged the abuse resided. Staff member C said each wing had designated sections which staff were assigned to. Staff member C said the alleged staff member may be put within another section, on the same unit. The staff member may be told not to have contact with the resident who filed the allegation. Staff member C gave no information to show the staff member was monitored, to ensure the alleged staff member did not approach the alleged victim or continue the alleged abuse. Resident Concerns: 1. Review of resident #1's Quarterly MDS, with an ARD of 5/23/17, showed the resident was cognitively intact with a BIMS of 15. This MDS also showed resident #1 needed extensive assistance of two staff when toileting. Review of the facility's Resident Rights Grievance Report Form, dated 6/5/17, showed staff member D interviewed resident #1 on an abuse concern the resident had. The form showed resident #1 said, A guy, with a bald head that works mornings, terrorizes me. Resident #1 said the male staff member would leave me on the toilet for hours at a time, he finds excuses to say that it is right - but it is wrong. A section of the grievance form, labeled, Superintendent Review and/or Comment, failed to show staff member F had been re-educated regarding physical abuse, verbal abuse, mental abuse, or mistreatment of [REDACTED]. This section of the report also failed to show any measures put in place, by the facility, to protect the resident from future abuse by the staff member. Review of investigation notes, dated 6/7/17, showed staff member B interviewed resident #1, about the incident reported on 6/5/17, by staff member D. Staff member B asked resident #1 what happened. The resident told staff member B that a male staff member with a bald head was abusing him. Staff member B said several staff names to resident #1. When staff member B said (staff F's name), resident #1 said, Yes! (Staff name) that's who it is. No hair on top. Resident #1 identified staff member F. Resident #1 said staff member F would use the sit to stand lift to get him out of his wheelchair for toileting. Resident #1 said staff member F would lift me up and He leaves me there (hanging in the lift) for hours at a time. Resident #1 would tell staff member F This hurts! This hurts! Staff member F would tell resident #1 It's part of my training. Resident #1 said he told staff member F it was abuse. Resident #1 told staff member B, Not only once did he (staff member F) do it, but time and time again. Staff member B asked if staff member F had another CNA with him when he used the lift for resident #1. Resident #1 said, He does the lift all by himself. He's all alone when he does this. During an interview on 6/21/17 at 12:50 p.m., staff member F said he had received abuse training within the last 12 months. Staff member F refused to answer questions in relation to resident #1, or his allegations of mistreatment, abuse, and the infliction of pain with the use of the lift. During an interview on 6/21/17 at 4:45 p.m., resident #1 was observed laying on his left side in bed. Resident #1 said staff member F would use the sit to stand lift to take him to the locker room, which was identified to be the bathroom. Resident #1 said two staff were supposed to be with him when he used the lift, but staff member F always used the lift by himself. Resident #1 said staff member F used the lift to raise him up out of his wheelchair. He would then push the lift into the bathroom, and then left the resident hanging in the lift for an hour. Resident #1 said he told staff member F it hurts so much. Resident #1 said staff member F laughed at his pain and told resident #1 I know. Resident #1 said this was not the first time staff member F had done this to him. Resident #1 said staff member F threatened him, saying You did something to my wife a long time ago. Resident #1 said he did not know who staff member F's wife was or what he supposedly did. Resident #1 said, I'm very afraid of staff member F and Every time someone comes in my room, I'm afraid it's going to be him. Resident #1 said he was told staff member F would not be on resident #1's unit, but resident #1 said, I see him over here all the time, and I'm afraid he's going to do something to me. During an anonymous interview on 6/22/17 at 10:30 a.m., it was said that resident #1 was severely mentally traumatized by the incident with staff member F. Resident #1 was very fearful of staff member F, and of having any contact with staff member F. 2. Review of resident #5's Admission MDS, with an ARD of 5/2/17, showed the resident's BIMS score was a 15; cognitively intact. The MDS also showed the resident needed extensive assistance of one staff member when toileting. Review of the facility's Resident Rights Grievance Report Form, dated 5/21/17, showed staff member D interviewed resident #5 on a concern the resident had. Resident #5 said he requested assistance with toileting from staff member G. Resident #5 said staff member G told him to toilet himself using his urinal. Resident #5 said, I explained it was very hard to do one handed with a pull-up on and shorts. I have tried repeatedly since, and everything pops back when I grab the urinal. Resident #5 said, Therefore, I keep wetting my pull-up, shorts, and the pillow case covering my chair pad. The section of the grievance form, labeled, Superintendent Review and/or Comment, failed to show interventions taken by the facility to address or educate staff member D regarding neglect or the provision of necessary ADL care for the resident, during or after the allegation investigation was completed. This section of the report also failed to show measures put in place, by the facility staff, to protect other residents who may have received care from staff member G, for the prevention of neglect of care. Review of resident #5's care plan showed the resident was to have the assistance of one or two staff members when toileting. The care plan showed the resident was to have a urinal at bedside to use at night. No staff assistance was shown to be needed when it was used. Review of the Resident Rights Grievance Report Form dated 5/21/17, showed some employees had received education on the resident's care plan, but upon review, the facility was unable to provide evidence of the education. During an interview on 6/21/17 at 1:00 p.m., staff member G said she did not know resident #5 had filed a grievance against her. Staff member G said no one told her about the grievance relating to neglect of care. Staff member G said no one had provided education on resident #5's care plan, toileting needs, or neglect. Staff member G stated that if she heard a staff member telling a resident to toilet themselves, after the resident requested staff assistance, that would be neglectful of the resident's needs. During an interview on 6/22/17 at 10:45 a.m., resident #5 was observed sitting upright in his wheel-chair. Resident #5 said staff member G refused to help him in the bathroom, relating to the event documented on the grievance form. Resident #5 said, She told me to use the urinal. Resident #5 said he peed his pants because staff member G would not help him to the toilet. Resident #5 said, I need staff to help to get on the toilet because I can't get out of my wheelchair by myself. Resident #5 said he cannot use his urinal by himself when he is sitting in his wheelchair. Resident #5 said, I can't keep my shorts out of the way and hold the urinal at the same time. 3. Review of resident #6's Admission MDS, with an ARD of 5/30/17, showed resident #6 was scored a 5 for the BIMS assessment, therefore, the resident's cognition was severely impaired. The MDS also showed resident #6 needed the extensive assistance of one staff member for toileting. Review of the Resident Rights Grievance Report Form, dated 9/22/16, showed resident #6 was concerned and upset that a staff member had shoved and yelled at her to get up. Staff member Q had completed the form and documented that he spoke with nursing staff on the unit about the event. The day shift staff had identified a CNA that worked night shift, as the alleged employee who may have interacted with the resident during the event. Day shift staff said resident #6 was on a toileting program and was to be toileted at 4:00 a.m. Staff member Q also interviewed resident #6's roommate. The roommate said she couldn't see what happened, but she woke up because someone was yelling at resident #6. The grievance form showed the nursing supervisor spoke with the CNAs about waking resident #6 at 4:00 a.m. The toileting plan at night was re-evaluated to help preserve the resident's sleep. The section of the grievance form, labeled, Superintendent Review and/or Comment, failed to show any staff member had been addressed or educated regarding the potential verbal and physical abuse toward resident #6. This section of the report also failed to show any measures implemented by the facility, in an attempt to protect the resident(s) of the facility from future abuse. During an interview on 6/21/17 at 4:55 p.m., resident #6 was unable to recall the incident she reported on 9/22/16. 4. Review of resident #7's Quarterly MDS, with an ARD of 8/16/16, showed resident #7 was scored as having a BIMS of 7; severely impaired cognition. The MDS also showed resident #7 needed extensive assistance of two staff for transfers. During an interview on 6/21/17 at 1:20 p.m., staff member S said resident #7 had passed away on 5/1/17. Review of the Resident Rights Grievance Report Form, dated 9/21/16, showed resident #7 voiced a concern regarding treatment by two staff members (F and P). Staff member D completed the form and documented resident #7 saying, I've been abused. Staff member D documented resident #7 stated, They twisted my hands and wrists to hold me in bed. Resident #7 told staff member D It was the big girl, and the man who works with her. Staff member D documented she referred this incident to the director of nursing for suspected abuse follow-up. The section of the grievance form, labeled, Superintendent Review and/or Comment, failed to show any staff members had been addressed or educated on the care provided to the resident, or action taken for the future prevention of abuse of the resident. The report also failed to show any measures put in place to protect the other residents of the facility from future abuse from staff member F or P. During an interview on 6/22/17 at 8:25 a.m., staff member P stated she had two grievances filed against her from two different residents that I abused them. One resident said I grabbed and twisted her hand. The other resident said I was racist and prejudiced against his race. Staff member P also stated that management came to her to investigate the twisting of the hand incident, but I did not receive abuse training at that time and the staff member was moved off that wing. The other resident event was not addressed relating to the potential abuse. During that same interview, staff member P stated that she and staff member F were not allowed to work together, and separated, because We were abusive to residents. Staff member P stated that while working on the unit, Glacier Way, staff member P said she and staff member F had a resident in the bathroom who became combative. The resident ended up with bruising on his arms due to the incident. Staff member P also stated that she received a letter from the facility, showing she needed to respond to the allegation of resident abuse. The staff member continued providing resident care, although the facility had not provided any form of education or implemented any form of an intervention to protect the resident(s). Review of the facility's policy, #1104, Abuse, Misappropriations, and/or Neglect of Residents, showed the definitions of abuse as: Abuse shall be defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish. This also includes the deprivation by and (sic) individual, including a caretaker, or goods or services that are necessary to attain or maintain physical, mental, and psychosocial well being. This presumes that instances of abuse of all residents, even those in a coma, cause physical harm, or pain or mental anguish. Verbal abuse is defined as the use of oral, written or gestured language willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. Physical abuse includes hitting, slapping, pinching, and kicking. It also includes controlling behavior through corporal punishment. Mental abuse included, but is not limited to, humiliation, harassment, and threat of punishment or deprivation. Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness.

Based on observation, record review and staff interview, the facility failed to identify, address and implement interventioms concerning a one-piece restraint to prevent a decline in the residents urinary function for 1 (#13) of 27 sampled and supplemental residents. Resident #13 was admitted to the facility on [DATE], with the following Diagnoses: [REDACTED]. The "Physician's Telephone Orders" dated 10/3/13 showed an order for a "one piece, as needed." There was no medical condition listed. On 4/9/14 at 12:55 p.m., an observation was made of resident #13's wearing the one piece outfit. The outfit was made of sweat pant-like fabric for the bottoms and soft knitted T-shirt fabric for the top, which were sown together at the waist. A visible zipper was sewn in the back from the neck to mid-back, making it difficult for a cognitively impaired resident to independently remove this garment. Review of the "ADL and Treatment Sheet", reflects the decline of the residents' urinary incontinence. In September 2013, the resident was completely continent. In October 2013 the one-piece outfit was ordered. In November 2013, the resident was incontinent six days. In March 2014, the resident was incontinent of urine for 30 days. 2/2013 - 5/2013: 6 a.m., continent, 6 p.m., continent. 6/2013: 6 a.m. incontinent on 6/3 and 6/4, otherwise continent, 6 p.m. incontinent on 6/15 and 6/16, otherwise continent. 7/2013 - 9/2013: 6 a.m. continent, 6 p.m. continent. 10/2013: 6 a.m., incontinent on 10/20 and 10/21, otherwise continent, and 6 p.m., continent. The one-piece outfit was ordered on [DATE]. 11/2013: 6 a.m., incontinent on 11/19, 11/21, 11/24, 11/25, 11/29 & 11/30, otherwise continent, 6 p.m., continent. 12/2013: 6 a.m. incontinent on 12/8, 12/10, 12/12, 12/22-12/213, 12/30-12/31, otherwise continent, 6 p.m. continent. 1/2014: 6 a.m. incontinent 23 days, 6 p.m. incontinent 25 days. The format changed for the ADL and Treatment Sheet and directs the resident's toileting schedule to be completed every morning, before lunch and after super and at bedtime. 2/2014: 6 a.m. incontinent 23 days, 6 p.m. incontinent 19 days. 3/2014: 6 a.m. incontinent 22 days, 6 p.m. incontinent 30 days. The MDS, section H0200, showed the following documentation regarding urinary incontinence: - 10/8/13 recorded as always continent, - 1/7/14 recorded as frequently incontinent, - 4/9/14 recorded as always incontinent. Review of the care plan for resident #13, dated 1/14, showed the following evidence regarding elimination issues: - Problems/Needs: "toilets in inappropriate places" - Goal: none noted in regards to the elimination - Interventions: "Toilet when awakens, after breakfast, before lunch and super and at night...wears pull-up and attends...toilet if awakens at night, check and change as needed," - Restraints: one-piece outfit as needed - Elimination: two person assist, due to aggression and resistiveness, and - Incontinence: frequent of bowel and urine. Documents provided to the surveyor via fax on 4/14/14 at 2:00 p.m., included a document titled, "Functional Incontinence." Highlighted was the restraint usage, with considerations 1-7 listed: 1 - Medical symptoms that lead to the use of a restraint? The physician order [REDACTED]. . 2 - Can the medical symptoms be reduced? The MDS document called, the "Physical Restraints (MDS 2.0 Rap Module)," dated on 10/3/13 indicates "...urinating in inappropriate places" as the behavior which required a restraint. 3 - Did the facility use alternatives to avoid the decline in physical function? There are no interventions on the current care plan, dated 1/2014, to address the resident's increased incontinence after starting the use of the one-piece outfit on 10/3/13. 4 - Least restrictive for the least amount of time? The facility document titled, the "ADL and Treatment Sheet" records the application and use of the one piece outfit. The one piece outfit was ordered "...as needed," but the documentation for the following five months shows that the one piece outfit was not applied on 2/10/13 through 10/14/13 and 3/29/14, for a total of five days. 5- Legal surrogate informed and made a choice? On 10/3/13 information about the potential negative outcomes from the use of the one-piece outfit was given, and was approved per phone conversation by the resident's legal representative. 6 - Were the CAAs used to evaluate restraint use? The CAA dated 1/7/14, under ADL Function/Rehabilitation Potential, showed the following documentation: "...He is frequently incontinent of bowel and bladder. He is toileted every two hours and as needed while awake at night. He wears adult pull ups and at times adult briefs...He wears a one piece outfit as he toilets in inappropriate places..." On 1/2014 the format changed for the "ADL and Treatment Sheet," and guides toileting to be completed every morning, before lunch and after super and at bedtime. There was no evidence on the CAA regarding the absence or presence of any medical, functional or behavioral problems, time and duration for the use of restraints or alternative interventions implemented to change the resident's behavior. Specifically, no identification and/or interventions were put in place to address the resident's increased incontinence, after initiating the use of the one piece outfit on 10/3/13. 7 - Re-evaluate the need for the restraint? The MDS document titled, "Physical Restraints (MDS 2.0 Rap Module)," dated on 10/3/13, outlined the details regarding the use of one-piece outfit. There was no evidence in the medical record that a reassessment or update had been completed. See F221. Staff member G, the DON, stated during interview on 4/10/14 at 9:35 a.m., that the document titled "Behaviors and Restraints", was used quarterly, for a seven day assessment in conjuncture with the MDS assessments. - On 5/2/13, review of the "Interdisciplinary Progress Notes" indicated, "...continent of bowel and bladder." - On 5/5/13, review of the "Interdisciplinary Progress Notes"indicated, "Start trial of toilet log ...to target problem of urinate at inappropriate places." - Review of the "Interdisciplinary Progress Notes," on 5/6, 5/7, 5/8, 5/11, and 5/13/13 did not show any documentation regarding the toilet log, initiated on 5/5/13. - On 5/17/13, review of the "Interdisciplinary Progress Notes", reflected, "...In the past week (the resident's) urinating in inappropriate places has increased. Spoke with (the resident) in both Spanish and English about the importance of urinating in the toilet and the consequences of not - showed him a onesy (one piece outfit). Very difficult to understand if he understood. Will keep talking with him." - On 7/17/13, the "Quarterly Review," indicated, "...urinating in appropriate areas...provide with pull ups due to incontinence." However, the "ADL and Treatment Sheet", dated 7/13 through 9/2013 for 6 a.m./6 p.m. records the resident as continent. - On 11/26/13, the "Progress Notes," reflected, "...We are using a one piece suit because of inappropriate voiding." - On 1/16/14, the annual review in the "Interdisciplinary Progress notes," indicated, "...He is frequently incontinent of bowel and bladder...He wears a one-piece outfit due to toileting in inappropriate places." - On 2/28/14, review of the "Interdisciplinary Progress Notes", indicated, "...incontinent of stool, in One Piece, on therapeutic toileting plan." The documentation provided by the facility via fax on 4/14/14 at 2:00 p.m., did not contain information regarding attempts made to change the resident's behaviors, redirection and/or a bathroom/toileting schedule during September 2013, in the MDS document called, the "Physical Restraints."

Based on observation, record review and staff interview, the facility failed to ensure that 1 (#13) of 27 sampled and supplemental residents received appropriate assessments and interventions to maintain as much normal bladder function as possible. Resident #13 was admitted to the facility on [DATE], with the following Diagnoses: [REDACTED]. The "Physician's Telephone Orders" dated 10/3/13 showed an order for a "one piece, as needed." There was no medical condition listed. On 4/9/14 at 12:55 p.m., an observation was made of resident #13's wearing the one piece outfit. The outfit was made of sweat pant-like fabric for the bottoms and soft knitted T-shirt fabric for the top, which were sown together at the waist. A visible zipper was sewn in the back from the neck to mid-back, making it difficult for a cognitively impaired resident to independently remove this garment. Review of the "ADL and Treatment Sheet", reflects the decline of the residents' urinary incontinence. In September 2013, the resident was completely continent. In October 2013 the one-piece outfit was ordered. In November 2013, the resident was incontinent six days. In March 2014, the resident was incontinent of urine for 30 days. 2/2013 - 5/2013: 6 a.m., continent, 6 p.m., continent. 6/2013: 6 a.m. incontinent on 6/3 and 6/4, otherwise continent, 6 p.m. incontinent on 6/15 and 6/16, otherwise continent. 7/2013 - 9/2013: 6 a.m. continent, 6 p.m. continent. 10/2013: 6 a.m., incontinent on 10/20 and 10/21, otherwise continent, and 6 p.m., continent. The one-piece outfit was ordered on [DATE]. 11/2013: 6 a.m., incontinent on 11/19, 11/21, 11/24, 11/25, 11/29 & 11/30, otherwise continent, 6 p.m., continent. 12/2013: 6 a.m. incontinent on 12/8, 12/10, 12/12, 12/22-12/213, 12/30-12/31, otherwise continent, 6 p.m. continent. 1/2014: 6 a.m. incontinent 23 days, 6 p.m. incontinent 25 days. The format changed for the ADL and Treatment Sheet and directs the resident's toileting schedule to be completed every morning, before lunch and after super and at bedtime. 2/2014: 6 a.m. incontinent 23 days, 6 p.m. incontinent 19 days. 3/2014: 6 a.m. incontinent 22 days, 6 p.m. incontinent 30 days. The MDS, section H0200, showed the following documentation regarding urinary incontinence: - 10/8/13 recorded as always continent, - 1/7/14 recorded as frequently incontinent, - 4/9/14 recorded as always incontinent. Review of the care plan for resident #13, dated 1/14, showed the following evidence regarding elimination issues: - Problems/Needs: "toilets in inappropriate places" - Goal: none noted in regards to the elimination - Interventions: "Toilet when awakens, after breakfast, before lunch and super and at night...wears pull-up and attends...toilet if awakens at night, check and change as needed," - Restraints: one-piece outfit as needed - Elimination: two person assist, due to aggression and resistiveness, and - Incontinence: frequent of bowel and urine. Documents provided to the surveyor via fax on 4/14/14 at 2:00 p.m., included a document titled, "Functional Incontinence." Highlighted was the restraint usage, with considerations 1-7 listed: 1 - Medical symptoms that lead to the use of a restraint? The physician order [REDACTED]. . 2 - Can the medical symptoms be reduced? The MDS document called, the "Physical Restraints (MDS 2.0 Rap Module)," dated on 10/3/13 indicates "...urinating in inappropriate places" as the behavior which required a restraint. 3 - Did the facility use alternatives to avoid the decline in physical function? There are no interventions on the current care plan, dated 1/2014, to address the resident's increased incontinence after starting the use of the one-piece outfit on 10/3/13. 4 - Least restrictive for the least amount of time? The facility document titled, the "ADL and Treatment Sheet" records the application and use of the one piece outfit. The one piece outfit was ordered "...as needed," but the documentation for the following five months shows that the one piece outfit was not applied on 2/10/13 through 10/14/13 and 3/29/14, for a total of five days. 5- Legal surrogate informed and made a choice? On 10/3/13 information about the potential negative outcomes from the use of the one-piece outfit was given, and was approved per phone conversation by the resident's legal representative. 6 - Were the CAAs used to evaluate restraint use? The CAA dated 1/7/14, under ADL Function/Rehabilitation Potential, showed the following documentation: "...He is frequently incontinent of bowel and bladder. He is toileted every two hours and as needed while awake at night. He wears adult pull ups and at times adult briefs...He wears a one piece outfit as he toilets in inappropriate places..." On 1/2014 the format changed for the "ADL and Treatment Sheet," and guides toileting to be completed every morning, before lunch and after super and at bedtime. There was no evidence on the CAA regarding the absence or presence of any medical, functional or behavioral problems, time and duration for the use of restraints or alternative interventions implemented to change the resident's behavior. Specifically, no identification and/or interventions were put in place to address the resident's increased incontinence, after initiating the use of the one piece outfit on 10/3/13. 7 - Re-evaluate the need for the restraint? The MDS document titled, "Physical Restraints (MDS 2.0 Rap Module)," dated on 10/3/13, outlined the details regarding the use of one-piece outfit. There was no evidence in the medical record that a reassessment or update had been completed. See F221. Staff member G, the DON, stated during interview on 4/10/14 at 9:35 a.m., that the document titled "Behaviors and Restraints", was used quarterly, for a seven day assessment in conjuncture with the MDS assessments. - On 5/2/13, review of the "Interdisciplinary Progress Notes" indicated, "...continent of bowel and bladder." - On 5/5/13, review of the "Interdisciplinary Progress Notes"indicated, "Start trial of toilet log ...to target problem of urinate at inappropriate places." - Review of the "Interdisciplinary Progress Notes," on 5/6, 5/7, 5/8, 5/11, and 5/13/13 did not show any documentation regarding the toilet log, initiated on 5/5/13. - On 5/17/13, review of the "Interdisciplinary Progress Notes", reflected, "...In the past week (the resident's) urinating in inappropriate places has increased. Spoke with (the resident) in both Spanish and English about the importance of urinating in the toilet and the consequences of not - showed him a onesy (one piece outfit). Very difficult to understand if he understood. Will keep talking with him." - On 7/17/13, the "Quarterly Review," indicated, "...urinating in appropriate areas...provide with pull ups due to incontinence." However, the "ADL and Treatment Sheet", dated 7/13 through 9/2013 for 6 a.m./6 p.m. records the resident as continent. - On 11/26/13, the "Progress Notes," reflected, "...We are using a one piece suit because of inappropriate voiding." - On 1/16/14, the annual review in the "Interdisciplinary Progress notes," indicated, "...He is frequently incontinent of bowel and bladder...He wears a one-piece outfit due to toileting in inappropriate places." - On 2/28/14, review of the "Interdisciplinary Progress Notes", indicated, "...incontinent of stool, in One Piece, on therapeutic toileting plan." The documentation provided by the facility via fax on 4/14/14 at 2:00 p.m., did not contain information regarding attempts made to change the resident's behaviors, redirection and/or a bathroom/toileting schedule during September 2013, in the MDS document called, the "Physical Restraints."