Every finding on record at Montana Veterans Home N H

Based on interview and record review, the facility failed to protect residents from physical and verbal abuse for 2 (#s 25 and 63) of 22 sampled residents. Findings include:Review of the facility investigation for an incident involving residents #25 and #63 showed that a verbal and physical abuse incident occurred in the dining room on 6/13/26 at 5:35 p.m. The two residents had a verbal incident that quickly escalated into a physical altercation, with one resident being placed in a chokehold after receiving several hits to the face by the other resident. Staff intervened immediately and separated the two residents. Per staff witness statements, it was reported by staff that resident #63 was making mean faces at resident #25 (alleged perpetrator) and flipping him the bird while in the dining room. Both residents were assessed, and resident #63 had a skin tear to his neck from resident #25's wristwatch. No other injuries were identified during follow-up, and neither resident had any identified psychological effects. The document showed resident #63 had a history of verbal altercations. Both residents had medications reviewed, and the review resulted in effective medication changes as needed. Staff who witnessed the verbal and physical altercation had not anticipated or stopped the altercation prior to it occurring as soon as the men began to argue or show signs of acting out towards each other. The facility reported the incident to the required authorities, including the State Survey Agency, and completed an investigation. Shortly after the event, the residents had another verbal altercation with verbal threats while in the hall. Preventative interventions were put into place, including moving resident #25 to a different hall and having the two residents sit in the dining room on opposite sides of the room; they also entered on opposite sides of the dining room to prevent further incidents. There were no future plans to monitor the two men and evaluate the progress of the room change, separation in the dining room, and/or actions towards each other, other than monitoring right after the event occurred. During an interview on 8/12/26 at 4:02 p.m., staff member K stated both residents involved in the incident on 6/13/26 were doing better. Resident #25 had gotten better now that his pain had gone down, and resident #63 had calmed down with a medication change. Both residents were kept apart and monitored for behaviors without further incident.Review of the facility policy titled Abuse, last revised on 3/9/26, showed, Each resident has the right to be free from abuse, corporal punishment and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends or other individuals.

Based on interview and record review, the facility failed to recognize and prevent sexual abuse and neglect, and identify the residents' ability to consent to sexual activity, for 9 (#s 9, 12, 17, 44, 61, 77, 78, 80, and 89) of 28 sampled residents. This deficient practice resulted in residents participating in sexual activities who were unable to make their own decisions, which increased the risk of sexual abuse and psychosocial harm for residents, and this was identified to be an Immediate Jeopardy situation; and, based on observation, interview, and record review, the facility failed to ensure a resident was free from physical abuse by a staff member, which resulted in a skin tear on the resident's left hand for 1 (#20) of 28 sampled residents. On [DATE] at 9:58 a.m., the Administrator and facility management team were notified that an Immediate Jeopardy existed in the area of F600. related to the failure to address sexual activity amongst the residents. The Severity and Scope identified for the Immediate Jeopardy were identified to be at the level of a K, and when the immediacy was removed, lowered to an E. The facility provided a plan to remove the immediacy, which was accepted by the State Survey Agency and the CMS Kansas/Denver Regional Office, and the facility carried out the plan which was verified onsite on [DATE] at 12:52 PM. Findings include:1. Resident #17: During an interview on [DATE] at 11:37 a.m., staff member H stated there were many residents in the facility who participated in sexual activity with other residents. Staff member H stated resident #17, who resided in the SCU, had been with many other male residents and was “sucking on their penis, with multiple residents.” Staff member H stated they felt this behavior was wrong between the residents, as they were unable to consent for themselves. Staff member H stated they reported the sexual abuse to staff member B, but staff member B had told them the family was aware and had given consent on behalf of the residents. During an interview on [DATE] at 1:57 p.m., staff member L stated all the staff members knew about the sexual relationships between the residents, and staff member L stated, “Gosh I feel bad.” Staff member L stated resident #17 had been on another unit, and there had been a complaint from resident #77. The complaint was that resident #17 had said words that were inappropriate and with sexual innuendos towards him. Staff member L stated resident #17 was then moved to the SCU unit because it was a smaller unit and staff could keep a closer eye on him. Staff member L stated they had later received a report of an incident with resident #89 and resident #17, where resident #89 had no clothes on and resident #17 was on top of resident #89 performing oral sex. They stated this occurred about four months ago. Staff member L stated the POA was notified and moved resident #89 out within a few weeks. Staff member L stated about three weeks ago, resident #17 had went into resident #9’s room. Staff member L stated resident #17 had resident #9 on the bed with resident #9’s pants around his ankles and the brief open. Staff member L stated staff walked in just before sexual contact had been made. Staff member L stated resident #17 seemed like he attempted to lure other residents into his room. Staff member L stated the residents residing on the SCU were unable to consent for sexual activity for themselves. Review of resident #17’s chart showed the following nursing notes: -[DATE] – “… alleged accusation of [Resident #17] wandering into neighbors room [Resident #77] and laying in his bed, accusations of sexual innuendos … The resident stated he felt harassed, and he was teary during the interaction. The staff advised the house supervisor, who was staff member D The documentation did not show actions taken at that time to ensure the resident's safety. -[DATE] – Staff member D and staff member B met with resident #77, and he stated he felt unsafe with #17. The notes showed, [Resident #17] has gone into [Resident #77's] room multiple times thinking it's his room asking why he is in his bed. It was determined that [Resident #17] will move to SCU today. …” [sic] -[DATE] – “[Resident #17’s POA] made aware of new roommate …” [sic] -[DATE] – “[Resident #17] was found by CNA performing oral sexual activity to roommate [Resident #89] on roommate’s bed … Voicemail left to [Staff member B] …” [sic] -[DATE] – “[Staff member D] explained the situation to [Resident #17’s POA] who was shocked, but stated if parties consenting he just wants his [resident] to be happy. …” [sic] -[DATE] – “… CNA found other res. in [Resident #17's] rm laying with pants down & brief partially down. [Resident #17] was in the process of bending over his peri area without contact with res., when CNA stopped him. … Later, [Resident #17] was found with arm around [Resident #44's] waist walking toward [Resident #17's] bedroom with him …” [sic] -[DATE] – “… [Resident #17] is A&Ox1 (self). BIMS score is 9/15. Score indicates moderately impaired cognition. Mood/behavior concerns include recent sexual behaviors toward other residents & increasing self pleasure. …” [sic] -[DATE] – “… He has had some sexual contact with other residents. …” [sic] During an interview on [DATE] at 8:16 a.m., staff member M stated they had not been notified of any new issues with resident #17 since resident #89, and stated a nursing supervisor was typically called, but they would hear about any concerns in report as well. During an interview on [DATE] at 8:25 a.m., staff member N stated resident #17 had made sexual advances toward staff member N, but staff member N stated they were able to say no, and resident #17 would stop any action that made staff member N feel uncomfortable. Staff member N stated it would be tough for a vulnerable resident to speak up for themselves if they were unable to tell resident #17 “no.” During an interview on [DATE] at 9:30 a.m., NF2 stated resident #89 was only at the facility for a month and stated, “I don’t want to say everything was fine because it was not.” NF2 stated they were too uncomfortable to talk about anything further that happened with resident #89 at the facility. During an interview on [DATE] at 9:13 a.m., staff member O stated resident #17 had been with his roommate, resident #89, before he had moved out. Staff member O stated the facility should have never given resident #17 a roommate due to his known sexual behaviors. Staff member O stated there were more instances of sexual activities with resident #89, as he had been at the facility for about a month, and stated, Who knows what could have happened with the door closed. 2. Resident #89: During an interview on [DATE] at 1:30 p.m., staff member G stated some residents had been sexually active in the facility. Staff member G further stated he was instructed not to interrupt if the residents were found already in the act, but to redirect the residents before the act, if found. A review of an IDT progress note, dated [DATE] at 9:00 p.m., for resident #89 showed: “CNA called nurse to resident’s room. His roommate, [Resident #17] found on [Resident #89’s] bed. CNA reported that roommate was performing oral sexual activity to [Resident #89]. [Resident #89] laying on bed without clothes on. Roommate had his shirt with his pull up on. CNA told roommate to go back to his bed. By this time, CNA called RN as roommate [Resident #17] stopped the act after getting told by CNA. CNA reported there were no resistance or signs of struggle between the residents. No injury noted. RN helped [Resident #89] put his clothes on and directed him to sit on the recliner in the dining room. RN and CNA directed [Resident #17's] roommate to go back to bed as it was bedtime. [Resident #89] states ‘He is’ okay when RN asked. …Charge nurse notified for recommended actions. Voice Message left to Social Services and [Staff member B]. …” [sic] A review of an IDT progress note, dated [DATE] at 11:00 a.m., for resident #89 showed: “… [Staff member D] informed [NF2] of the situation that had occurred b/w [Resident #89] and his roommate. [NF2] was upset, stating her [family member] would never engage in such behaviors. [Staff member D] explained, based on notations from staff, [Resident #89] reports he wasn’t injured and was okay. It was documented there appeared to be no struggle or resistance. [NF2] again said [Resident #89] would never, and has never, engaged in such activity. This writer asked about [Resident #89’s] sexual orientation and stated maybe she wasn’t aware of his attraction to men, in which she said ‘Absolutely not.’ [Staff member D] informed [NF2] that [Resident #89] would be moved to another room within the unit and staff would monitor. …” [sic] A review of an IDT progress note, dated [DATE] at 11:25 a.m., for resident #89 showed: “IDT met for initial review of plan of care. [Resident 89, NF2, and NF3] present for care conference. Both [NF2 and NF3] expressed concerns Re: recent incident with [Resident #17]. …” [sic] A review of a facility document titled “Brief Interview for Mental Status (BIMS),” dated [DATE], for resident #89, showed a score of 3 out of 15, reflecting the resident had severe cognitive impairment. A review of a facility document titled “Mini-Mental State Examination (MMSE),” for resident #89, dated [DATE], showed a score of 13 out of 30, reflecting severe cognitive impairment. 3. Resident #80: During an interview on [DATE] at 11:37 a.m., staff member H stated resident #80 was currently on the 40-bed unit, had dementia, and had multiple sexual partners. Staff member H stated resident #80’s current partner, resident #78, had behavioral issues, was suicidal, and was found to have a butter knife in his shoe one time. Staff member H stated they felt resident #78 was unsafe for staff and other residents. Staff member H stated staff member B was aware of both instances and had told staff member H the interaction between the residents was okay because both POAs had given consent. Staff member H stated if resident #80 was caught in the act of any sexual activity, staff member B had told staff members to let it continue and close the door. Staff member H stated they were told to, “just keep an eye on them.” Review of resident #78’s chart showed the following incidents of aggression: -[DATE] – an email documentation which showed resident #78 was following a resident's family member out to their vehicles and was “hiding in the bushes and watches people.” -[DATE] – documentation of a timeline for resident #78 showed: “8/3 PM Yelling at [Resident #80], pacing, going into rooms … 8/5 AM Bullying, took [another resident's] gloves and threw them…” -A personal statement from staff showed: “… His behavior was very disturbing.” During an observation and interview on [DATE] at 12:03 p.m., resident #80 was sleeping in bed and in her pajamas. There was a sign on her door reflecting female caregivers only for care. During the interview with resident #80, she was confused and unable to answer any questions. During an interview on [DATE] at 1:43 p.m., staff member K stated resident #80 was sexually active with other residents in the past, but had not for several months, and her partners varied. Staff member K stated resident #80 sought out the residents and would take them back to her room. Staff member K stated they would look very intently into resident #80’s eyes and ask, “Do you want this person in this room?” Staff member K stated resident #80 would either say “yes” or “no” and the staff felt resident #80 was able to make her own decisions. Staff member K stated they would leave the door closed to provide privacy but would have to get resident #80 off the floor after their interaction. Staff member K stated it never caused any physical injury, so they thought the sexual acts were not a form of sexual abuse and were acceptable. Staff member K stated resident #80 had a relationship with resident #17 in the past. Staff member K stated they were worried about resident #80 and resident #78’s current relationship advancing to sexual activities because of her dementia and his aggression and strength. Staff member K stated, “That’s a hard problem,” when referring to whether resident #80 was able to consent for sexual activity or not based on her cognitive ability. Staff member K stated staff member B, the POA, staff member D, and their physician were all aware of what was occurring. Staff member K stated, “I would not (feel comfortable if this was her family member in this situation).” During an interview on [DATE] at 7:56 a.m., staff member G stated the sign on resident #80's door was because the resident feels uncomfortable being exposed in front of men. Staff member G stated, The sign was not there when I first started, and I went into her room to care for her, and she did not like it; she didn't like me. If she is out of her room, I will care for her, and she is fine with that. 4. Neglect - It was identified that the facility system to identify and address neglect of care and provide goods and services necessary to protect the residents. The concerns included: -The Administrator and Director of Nursing were aware of the sexual activities and did not address them to ensure residents were not subjected to potential abuse, and ensure necessary steps were taken, per the facility policies and procedures, to address the actions and behaviors of the residents. -Residents engaging in or exhibiting sexual behaviors were not assessed for the ability to consent to the activities. -Resident care plans did not include personalized information related to sexual encounters, personal preferences, risks, goals, or interventions for staff to utilize to ensure abuse/neglect did not occur for those wishing to engage in sexual activities. -When sexual encounters occurred between the residents, the staff did not act to protect the resident(s) involved or address the actions at the time, or after for future prevention of potential abuse. -The facility abuse and neglect policy was not comprehensive and lacked information related to alleged or potential sexual abuse. -The facility staff did not attempt to identify if the events between the residents were abuse or neglect of care, and abuse events were not reported to the State Survey Agency as required. Refer to F609 - Abuse/Neglect Reporting. -The abuse/neglect training was not sufficient to address alleged or potential sexual abuse. During an interview on [DATE] at 4:44 p.m., staff member A stated he was aware of the sexual encounters and behaviors exhibited by the residents on the SCU. He stated staff members B and D were aware. All three staff were administrative. The interview with staff members D and E on [DATE] at 4:56 p.m. included: -Staff member D stated there were no residents having sex at this time. Staff member D stated that resident #80 was able to consent for herself in the past and had declined cognitively in the last six months. Staff member D stated all of the POAs had been reached out to regarding their family members' sexual activity, and the POAs had all said if the acts were consensual, then it was okay for the resident to continue. Staff member D stated resident #80 felt comfortable talking with staff member D. Staff member D stated psychosocial assistance was provided to resident #80 by communication between staff member D and resident #80. Staff member D stated these conversations were documented in the interdisciplinary notes in resident #80’s chart. -Staff member D stated resident #17 had sexual relations with resident #12 two years ago, and resident #12 was able to consent for himself. Staff member D stated resident #80 also had relations with resident #61 in the past. -Staff member E stated resident #80 was started on Lexapro to decrease her libido. Staff member E stated the facility did not have a formal process (to address sexual activities), and residents having sexual activity was “a newer phenomenon.” Staff member E stated the facility never did any cognitive or physical assessments after the incidents. Staff member E stated there were young CNAs who were shocked by seeing the activities with the residents. Staff member E said resident #17 was moved to the SCU as he had exit-seeking behavior. Staff member E stated they thought resident #17 was showing sexual behaviors because his wife died, and he seemed to be looking for companionship. Staff member E stated that the incident with resident #17 and resident #89, was not a factor in #89's discharge, as resident #89 was only discharged to [Town Name] to be closer to family. Staff member E stated resident #17 then had another incident with resident #9, where resident #9’s pants were down while resident #9 was on the bed, and resident #9’s brief was open. Staff member E stated that after this incident, the facility implemented a bed alarm for resident #17. Staff member E stated the incident between residents #9 and #17 was not sexual abuse because there was no contact made between the residents. -Staff members D and E stated that only the incident on [DATE] could have been abuse, as there was physical contact. Both staff members D and E stated there had been an accident report, and the incident had been charted in each of the residents’ charts. Staff member D stated that resident #80’s sexual activity was consensual, and resident #9 did not show any signs of psychosocial stress. Staff members D and E stated the resident's giving consent was difficult, and “We try to prohibit this stuff from happening.” They stated resident #9 was unable to give consent. During an interview on [DATE] at 11:14 a.m., staff member E stated that sexual abuse was any sexual act done to anyone who does not consent. Staff member E stated no behavioral assessments, root cause analyses, or cognitive assessments were completed on the residents before the residents' involvement in sexual acts. During an interview on [DATE] at 3:02 p.m., staff member J stated all residents in the SCU were unable to give consent for sexual activity, and stated, they do not have a policy on it, and do not allow it anywhere in the facility. Staff member J stated the residents in the SCU had behaviors and may find a way to evade the nursing staff and begin sexual activity, but those were treated as behaviors. They stated the facility had effective measures to implement if the behaviors arose. Review of resident #9’s chart showed a BIMS of 3 (severe cognitive impairment), dated [DATE]. Review of resident #12’s chart showed a BIMS of 15 (cognitively intact), dated [DATE]. Review of resident #61’s chart showed a BIMS of 4 (severe cognitive impairment), dated [DATE]. Review of resident #17's chart showed a BIMS of 9 (moderate cognitive impairment), dated [DATE]; and a BIMS of 6 (severe cognitive impairment), dated [DATE]. Review of resident #78’s chart showed a BIMS of 12 (moderate cognitive impairment), dated [DATE]. Review of resident #44’s chart showed a BIMS of 3 (severe cognitive impairment), dated [DATE]. Review of resident #80’s chart showed a SLUMS of 6 (severe dementia), dated [DATE]. Review of resident #77 chart showed a BIMS of 11 (moderate cognitive impairment), dated [DATE]. 5. Facility Reported Incident Review of a Facility-Reported Incident, for resident #20, submitted to the State Survey Agency, on [DATE], showed the facility reported a staff member squeezed a resident’s hand and caused a skin tear while trying to retrieve Tylenol from the resident’s hand. The resident had a history of caching medications and was to only take medication while in the presence of a nurse. The report showed the staff member was immediately removed from caring for the resident. Review of resident #20's investigative file, dated [DATE], showed the facility reported staff member R came in to assist staff member S with retrieving medications from resident #20, who was refusing to take them, and he had a history of caching medications. During this time, staff member R held resident #20’s hand very tightly to get him to release the Tylenol. This caused a skin tear to resident #20’s left hand. Resident #20 then refused treatment to the wound. The investigative file showed that staff members R and S were immediately removed from caring for resident #20. During an observation and interview on [DATE] at 9:05 a.m., resident #20 had bruising and a large yellow scab raised on his left hand. Resident #20 stated, “I don’t care what happened to them (staff members R and S) as long as they don’t take care of me anymore… I am happy with the outcome. …” The investigative file for resident #20, dated [DATE], showed staff members R and S were immediately suspended pending the completion of the investigation. The file also showed staff members R and S were both terminated. The file also showed staff and residents were interviewed, and no other concerns were identified. Resident #20’s care plan was updated. The facility provided abuse training to all staff on [DATE]. Review of a facility policy titled Abuse-Resident” with a revision date of [DATE], showed: “Policy: Each resident has the right to be free from abuse… Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends or other individuals. Definitions of Abuse: Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Sexual Abuse includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault. …”

Based on interview and record review, the facility failed to thoroughly investigate allegations and resident actions of sexual abuse for 3 (#s 9, 17, and 89) out of 28 sampled residents. This deficient practice increased the risk of incidents occurring in the future for these residents, and others, and the residents were identified to be vulnerable and unable to consent to sexual activity. The facility staff did not identify the resident actions as potential abuse or protect them, and staff were aware of the resident actions but did not address the alleged potential abuse, reflecting the facility's abuse education program was not sufficient to ensure resident safety. Findings include: During an interview on 8/13/25 at 1:57 p.m., staff member L stated they received a report of an incident with resident #89 and resident #17, where resident #89 had no clothes on, and resident #17 was on top of resident #89 performing oral sex. This had occurred four months prior, and approximately three weeks ago, resident #17 went into resident #9's room, and staff found resident #9 in the bed. Resident #9's pants were around his ankles, and his brief was open. Staff member L stated staff walked in on the two residents just before sexual activity occurred. Staff member L stated the residents on the SCU were not able to consent to sexual activity due to cognitive deficits.During an interview on 8/13/25 at 4:43 p.m., staff member A stated he was aware of some resident sexual relations between the residents, but not aware of the extent of the resident sexual relationships. Staff member A was to be notified of all alleged or potential abuse for the facility.During an interview on 8/13/25 at 4:56 p.m., staff members D and E stated the sexual acts between the residents were not considered sexual abuse due to no physical contact being made between the residents. Staff member E stated the facility never completed a root cause analysis investigating why the events were occurring or to identify concerns related to them and the facility did not identify or address any behavioral assessments for #17 related to his sexual advances and activities. The staff did not identify the sexual acts between the two residents as alleged abuse and did not ensure protective measures were implemented to prevent potential abuse.During an interview on 8/19/25 at 9:13 a.m., staff member O stated resident #17 never should have been given a roommate due to his behaviors. Staff member O stated there were more instances of sexual activities with resident #89, as he had been at the facility for about a month. The facility moved resident #17 to an area of the facility where there were vulnerable residents, without addressing the risk factors related to #17's sexual behaviors, or the behavior of those on the SCU. A request was made on 8/14/25 for documentation of the Facility Reported Incidents and investigations with resident #17's sexual behavior towards other residents. None were provided by the end of the survey, as the facility did not identify the events as potential or alleged abuse. The facility did not follow the abuse reporting requirements or thoroughly investigate the events. During an interview on 8/19/25 at 8:37 a.m., staff member C stated the facility did not contact law enforcement, Adult Protective Services, or the State Survey Agency regarding any sexual abuse with resident #17. It was identified the facility did not respond to alleged or potential sexual abuse allegations and have evidence that all alleged violations were thoroughly investigated, and report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.

Based on interview and record review, the facility failed to ensure the care plan contained a care area and interventions regarding sexual behaviors and interactions between residents, for 2 (#s 17 and 80) of 28 sampled residents. Findings include:During an interview on 8/13/25 at 11:37 a.m., staff member H stated there were many residents who participated in sexual activity who were unable to consent.A review of resident #17's care plan problem, goals, and interventions, all undated, showed the resident had a history of sexual behaviors that were exhibited towards other residents. There was no information for if he was a risk to other residents or himself. The goal was documented as the resident would have fewer episodes, but the goal did not show what episodes would be fewer or how this would be measured. The goal did not include information about the residents' safety. The interventions listed did not include any interventions related to protecting other residents from potential sexual abuse, or if the resident was able to consent to the sexual activities. During an interview on 8/13/25 at 4:52 p.m., staff member D stated resident #80 was able to consent for sexual activity for herself. Staff member D stated, I don't know if we ever put it on there, when referring to #80's care plan, and if sexual behaviors and preferences were added to the plan. Review of resident #80's care plan, dated 7/21/25, showed under the ADLs that she preferred female caregivers, and the care plan did not show other areas, concerns, or interventions related to the resident's sexual behaviors or the ability to consent. A request was made on 8/13/25 for all the care plans for residents who displayed sexual interactions towards others. The care plans provided by the facility were updated with new information for the residents' sexual interaction history and provided on 8/18/25. The updates did not occur until the facility completed a plan to remove immediacy for the Immediate Jeopardy situation identified in F600 - Abuse and Neglect.

Based on interview and record review, the facility failed to provide the required forms to residents who were ending skilled Medicare Part A services, to allow the resident or responsible party the opportunity to accept the discontinuation of coverage decision, appeal the decision, or agree to pay privately out of pocket, for ongoing services; and the facility failed to obtain the necessary signatures on these ABN and NOMNC forms, for 3 (#s 9, 11, and 113) of 3 sampled residents for the completion of the forms. This deficient practice may affect others ending skilled Medicare A services, due to the system failures identified with the handling of the forms. Findings Include: A. Review of resident #9's SNF Beneficiary Protection Notification Review form, was filled in showing the last covered day was 5/21/24 as a facility-initiated discharge from Medicare part A services. This required an ABN and NOMNC form were required to be filled out and given prior to the resident's discharge. Resident #9's, ABN form, showed, as of 5/22/24, the care being discontinued as Nursing Care, and the reason for stopping Medicare Part A was, Skilled Care not required at this time. The estimated cost was $481.65. The three options for accepting, appealing, or paying out of pocket were not selected; no additional information was provided, and no representative signature, date, or documentation of notification was completed on the form. Resident #9's NOMNC showed, staff member L made a note on 5/17/24 that she called resident #9's representative to let them know he was being taken off of skilled care services. No signature from the representative or date showing they received the notice. B. Review of resident #11's SNF Beneficiary Protection Notification Review form, was filled in showing the last covered day was 3/13/24, as a facility-initiated discharge from Medicare part A services. This required an ABN form and a NOMNC form to be filled out and given prior to the resident's discharge. Resident #11's ABN form, showed, as of 3/14/24, the care being discontinued as, Nursing Care, and the reason for stopping Medicare Part A was, Skilled Care not required at this time. The estimated cost was $441.62. The three options for accepting, appealing, or paying out of pocket were not selected; no additional information was provided, and no representative signature, date, or documentation of notification was completed on the form. Review of resident #11's, NOMNC form, showed, staff member L wrote a note for calling resident #11's representative on 3/8/24, showing resident #11 would be taken off of skilled care services. No signature or date by the representative showed they received the notice. C. Review of resident #113's SNF Beneficiary Protection Notification Review form was filled in showing the last covered day was 6/4/24, as a facility-initiated discharge from Medicare part A services. This required an ABN, and a NOMNC form, to be filled out and given prior to the resident's discharge. Resident #113's NOMNC form, showed, staff member L called resident #113's representative on 5/31/24 and told them resident #113 would be taken off of skilled care services. The form was not signed or dated by the representative showing they received the notice. Resident #113's ABN form showed the care being discontinued as, Nursing Care, and the reason for stopping Medicare Part A was, Skilled Care not required at this time. The estimated cost was $481.65. The three options for accepting, appealing, or paying out of pocket for services were not selected; no additional information was provided, and no representative signature or date or documentation of notification was completed on the form. During an interview on 7/17/24 at 11:04 a.m., staff member L stated, she provided the beneficiary notice by calling the power of attorney of the resident. Staff member L stated she would write a note on the from when she called the power of attorney, and she then would mail the forms to them for signatures. Staff member L stated the forms rarely were signed and sent back. Staff member L stated she did not know the ABN form had different options the power of attorney had to choose from for services. During an interview on 7/18/24 at 9:22 a.m., staff member B stated when the facility gathered the forms for the survey entrance request, they realized they did not have any of the selected resident's forms filled out completely with representative signatures. Staff member B stated they did not have a high skilled care census and were not well versed in the NOMNC and ABN form process. Staff member B stated they were coming up with a plan to correct the issue of representatives signing and returning the forms. Staff member B stated they did not have a specific policy for the beneficiary notices.

Based on observation, interview, and record review, the facility failed to properly label medications by only using the residents last name on medications removed from their original container and failed to properly store a narcotic during the practice of pre-pouring medications during the morning medication pass, for the residents on the 400 hall. This deficiency increased the risk of medication administration errors, and the potential for a narcotic medication to be mishandled. Findings include: During an interview on 6/21/23 at 7:40 a.m., staff member N stated, I already have the medications poured. We are allowed to pre-pour medications here, everything but narcotics During an interview and observation on 6/21/23 at 8:30 a.m., staff member N stated, she puts the resident's morning medications in a plastic medication cup, then places a paper medication cup on top of the medications with the resident's last name handwritten inside the paper cup. There were several cups in the top drawer of her cart arranged as she had described. Each cup had the resident's last name handwritten inside of it. She stated this method helps her know to whom the medications belong. The medication cart contained medications for the 24 residents in the 400 hall. Staff member N stated pre-pouring medications saved time. She stated not all the nurses do medication pass the same way. During an observation and interview on 6/21/23 at 8:39 a.m., staff member N was standing at the cart. Staff member N opened the drawer to the cart, removed a cup of medications, and stated she had already crushed and prepared the medications for resident #33. Staff member N verbalized the list of medications she had prepared in the cup and stated there was a Percocet in the cup. The Percocet was not in a separate locked area of the cart. The medication cup, and the contents of the cup, were placed in the top drawer of the medication cart. When asked by the surveyor about the Percocet, staff member N stated she had added it before the surveyor arrived, but she didn't feel like it was considered being pre-poured because she added it after she prepared resident #33's other morning medications. Record review of a facility policy, titled Medication Administration, revised date 7/20/20, failed to show a procedure for pre-pouring of medications, the policy failed to include the rights of medication administration and failed to include acceptable labeling of medications. A request was made for a facility Policy and Procedure for Pre-Pouring medication administration. The facility provided a document titled, Quality Assurance Division, Certification Bureau, Provider Information Notice #032917. This document showed: The focus of medication administration is to ensure the process is performed correctly, safely and without errors while maintaining the security of the medications . medication pass process will focus on the established standard of practice that includes the Seven Rights of Medication Administration: -right resident -right drug -right dose -right route -right time -right documentation -right evaluation of Efficacy of the Medication Facilities who have staff utilize the pre-pouring of medications should develop policies and procedures on the practice, and should ensure that staff are appropriately trained on the facility's policy. [sic] No facility Policy and Procedure for the practice of Pre-pouring medications was provided to the survey team prior to the end of survey. A request was made for nurse training regarding the practice of pre-pouring medications. A document titled, Nurses Meeting March 13, 2023, was provided. The document showed, pre-pour of medication - only next pass, no narcotics, mark with resident's name. There was no other information regarding the practice of Pre-Pouring medications. There was no sign in sheet to show meeting attendees. Review of Montana Board of Pharmacy Rules, dated June 30, 2021, section 24.174.832, showed: .(1) On prescription drugs, the label shall contain the name, address and phone number of the dispenser, name of prescriber, name of patient, name and strength of the drug, directions for use and date of filling. (2) The prescription label must be securely attached to the outside of the container in which the prescription is dispensed.

Based on observation, interview, and record review, the facility failed to adhere to professional standards of care during medication administration pass and medications were pre-poured. This deficiency resulted #11 being handed the wrong cup of medications to take during morning med pass, and the medications were for resident#58. This practice had the potential to affect #58 or others residing on the 400-hall. Findings include: During an interview on 6/21/23 at 7:40 a.m., Staff member N stated, I already have all the medications poured. We are allowed to pre-pour medications here, everything but narcotics. She asked the surveyor to return at 8:30 a.m. for the medication pass. During an interview and observation on 6/21/23 at 8:30 a.m., staff member N stated, she puts the resident's morning medications in a plastic medication cup, then places a paper medication cup on top of the medications with the residents last name handwritten inside the paper cup. There were several cups in the top drawer arranged as she had described. She stated this method helps her know to whom the medications belong to. The medication cart contained medications for the 24 residents in the 400 hall. Staff member N stated pre-pouring medications saves time. She stated not all the nurses do medication pass the same way. During an observation on 6/21/23 at 9:00 a.m., staff member N removed a cup of medications from the top drawer of her cart. She approached resident #11 who was sitting at a table in the dining room with several other residents. Staff member N stated resident #11 takes all his medications in the morning because that is the only time, he will take them. Staff member N handed the cup of medications to resident #11 stating, Here are your pills, they have your name on them. Staff member N did not ask the resident to state his name. Resident #11 looked in the cup and pointed at the medications. The resident said something to staff member N. Staff member N reassured the resident and asked him to take the medication. As the resident was lifting the cup to his mouth, staff member N stated, Wait a minute, let me have those back, there is a pink one in there, and I don't think you are supposed to have a pink one. Let me double check. Staff member N took the cup of medications from resident #11 and went back to the medication cart. Staff member N said she accidentally took the cup for resident #58 and gave it to resident #11. Staff member N stated, That was my fault for talking and not paying attention. During an interview on 6/21/23 at 9:22 a.m., staff member B said the nurse would not necessarily be expected to report the incident with resident #11 because he did not actually swallow the medication. She did not feel it was a medication error. Staff member B stated the nurse could report it as a near miss if she wanted, but that was not an expectation. Staff member B stated, That kind of thing happens sometimes, you know, human error. Record review on 6/21/23 of resident #11's MAR, showed, resident #11 should receive Aspirin 81 mg, Atorvastatin 40 mg, Losartan Potassium 100 mg, Norvasc 2.5 mg, and Remeron 15 mg in his morning medication pass. Record review on 6/21/23 of resident #58's MAR, showed, resident #58 should receive Atorvastatin 40 mg, Azithromycin 250 mg (every Monday, Wednesday, and Friday), Furosemide 60 mg, Calcium Carbonate 500 mg, Guaifenesin 600 mg, and Sildenafil Citrate 20 mg in his morning medication pass. Record review of a facility policy, titled Medication Administration, revised date 7/20/20, failed to show a procedure for pre-pouring of medications, the policy also failed to include the rights of medication administration. A request was made for a facility Policy and Procedure for Pre-Pouring medication administration. The facility provided a document titled, Quality Assurance Division, Certification Bureau, Provider Information Notice #032917. This document showed: . The focus of medication administration is to ensure the process is performed correctly, safely and without errors while maintaining the security of the medications . medication pass process will focus on the established standard of practice that includes the Seven Rights of Medication Administration: -right resident -right drug -right dose -right route -right time -right documentation -right evaluation of Efficacy of the Medication . Facilities who have staff utilize the pre-pouring of medications should develop policies and procedures on the practice, and should ensure that staff are appropriately trained on the facility's policy. [sic] No facility Policy and Procedure for the practice of Pre-pouring medications was provided to the survey team prior to the end of survey. A request was made for nurse training regarding the practice of pre-pouring medications. A document titled, Nurses Meeting March 13, 2023, was provided. The document showed, .pre-pour of medication - only next pass, no narcotics, mark with resident's name . There was no other information regarding the practice of Pre-Pouring medications. There was no sign in sheet to show who attended the meeting.

Based on interview and record review, the facility failed to protect residents from verbal and physical abuse, perpetuated by a staff member, for a resident with dementia, for 1 (#12) of 4 sampled residents. Findings include: Review of a Facility Reported Incident, dated 3/2/23, showed NF3 was observed by another staff member to flick resident #12 in the throat. He then wrote the words, You're being an asshole on the resident's white board and showed it to him. Resident #12 had dementia and was being combative with cares. Review of the facility investigation file, dated March 2023, showed the incident had been immediately reported, investigated, and the staff accused was suspended. NF3 no longer worked at the facility. Review of the facility's policy, titled: Abuse-Resident, with a revision date of 7/22/20, showed: - Abuse means the willful infliction of injury . verbal abuse is defined as the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents . regardless of their age, ability to comprehend . During an interview on 6/21/23 at 1:40 p.m., staff member J stated the incident had been one isolated occurrence of abuse. The QA team had reviewed the incident and investigation. No other residents, upon interview, had concerns indicative of abuse from NF3. All staff were up to date on abuse training and reporting. Review of Facility Reported Incidents for the months of April, May, and June 2023, showed no other instances of staff to resident abuse occurred.

Based on observation, interview, and record review, the facility failed to implement a person-centered care plan to meet the resident's mental and psychosocial well-being for a resident with PTSD, and the resident voiced concerns related to triggers occurring, for 1 (#58) of 3 sampled residents. Findings include: During an observation and interview on 6/19/23 at 3:53 p.m., resident #58 was sitting in his room, looking out the window. Resident #58 stated he prefers to stay in his room most of the time. Resident #58 stated he did not like to be around a lot of people; it made him nervous. A review of resident #58's admission diagnosis list, dated 3/8/23, showed: - Depression - PTSD During an interview on 6/21/23 at 1:20 p.m., Resident #58 stated, No one has ever talked to me about PTSD since I have been here. Resident #58 stated he does have some PTSD triggers, such as being around a lot of people makes him nervous; noises at night; and the news or current events can trigger his PTSD. Resident #58 was tearful as he discussed Vietnam and his PTSD triggers. A review of resident #58's care plan, dated 3/21/23, showed no goals or interventions identifying concerns with the resident's PTSD or trauma, triggers, or psychosocial well-being. A review of a facility policy, titled, Interdisciplinary Care Process, revision date of 3/10/22, showed: [Facility Name] considers the entire resident record to comprise the Plan of Care to ensure all care needs are met . - .5. An interdisciplinary care planning session for new residents shall be scheduled within 21 days of admission. a. Each discipline shall complete an assessment and outline of plans and goals with interventions for the identified resident's needs . b. Each discipline shall be responsible for filling in their part of the care plan .

Based on interview and record review, the facility staff failed to identify and address PTSD, provide trauma-informed care, and meet professional standards that accounted for the resident's experiences and preferences to manage and prevent or attempt to minimize PTSD triggers, for 1 (#58) of 3 sampled residents, and the triggers, especially at night or news, would cause him panic at times. Findings include: During an interview on 6/21/23 at 1:20 p.m., Resident #58 stated, No one has ever talked to me about PTSD since I have been here. Resident #58 stated during his time in Vietnam and Korea, he had taken 'heavy fire from the [NAME] Cong' and did not know if he was going to make it home alive or if he was ever going to see my family again. Resident #58 stated being around a lot of people; noises at night; and the news or current events can trigger his PTSD. Resident #58 stated at night he would sometimes be woken up by staff making loud noises, and this would cause a panic like reaction. During an interview on 6/21/23 at 2:27 p.m., staff member J stated, [Resident #58 's] wife passed away, which was traumatic for him. Staff member J stated there was an extensive application process (to admit the facility), which included evaluating medical records, interviews with residents, and family members. Staff member J stated, I am not sure how this was missed with [Resident #58]. During an interview on 6/21/23 at 3:04 p.m., staff member B stated trauma care is headed up by Social Services. Staff member B stated when someone is admitted they are assessed. Staff member B stated, Some (residents) want to tell you everything and others don't want to talk about it. A review of a facility document, titled, Trauma-Informed Care, with no dates, showed: - .Trauma-informed care is a person-centered approach to meeting the needs of our residents, taking into consideration the traumatic events our residents have been through. The trauma-informed approach is guided by four assumptions, known, as the 'Four R's: Realization about trauma, and how it can affect people and groups, recognizing the signs of trauma, having a system which can respond to trauma, and resisting re-traumatization. [sic] A request for a trauma care policy and PTSD policy was requested on 6/21/23. On 6/21/23 at 3:30 p.m., staff member B stated they do not have any policies about trauma care or PTSD.

Based on interview and record review, the facility failed to act on an allegation of staff to resident abuse, and the resident had a mental illness and complained about a staff member's interactions with her on more than one occasion, and the resident considered it ongoing mental abuse; and, the facility failed to show why the allegation of abuse was not substantiated, for 1 (#29) of 6 sampled residents. Findings include: 1. Review of a facility reported incident reported to the State Survey Agency, dated 6/15/21, showed resident #29 reported to the MD that NF2 would not give her a requested PRN medication for pain, which should be given with food. The report showed, The RN may have misunderstood whether the resident had eaten or not. Resident #29 stated staff member NF2 was curt and sarcastic with her on a regular basis. The resident reported feeling mentally abused. The findings of the investigation showed, It seems no abuse occurred. Staff member NF2 will return to work. RN supervisor will work with staff member on customer service and approach with resident #29 in the future. The report did not include a discussion with resident #29 about how she felt about the continued sarcasm and alleged mental abuse. Interventions were not addressed with NF2 to alleviate resident #29's allegation. Review of a written phone conversation between the evening RN supervisor and NF2, dated 6/16/21, showed NF2 stated he had not seen resident #29 eat anything, so could not give her the pain medication. NF2 stated, She told me she had eaten but I wasn't buying it .This is just her way of getting more meds, lets have a pity party for me when referencing resident #29's feelings/action. Review of NF2's written witness statement, dated 6/17/21, showed, Furthermore, if resident would have asked for something to eat, I would have been happy to oblige her request and would have given the PRN Naproxen . I believe I acted appropriately. During an interview on 7/7/22 at 12:30 p.m., staff member A stated the abuse was not substantiated because resident #29 has a mental illness, and it was only her perception she was mistreated. 2. Review of a facility Grievance/Complaint Report, dated 7/12/21, showed resident #29 wrote that, NF2 has continued to treat me with absolutely no respect and I do not deserve that kind of treatment in my life right now. Something needs to be done about it soon. He first needs to be reprimanded for it in some way to make him see how he makes me feel all the time. Review of the follow-up for resident #29's grievance, dated 7/13/21, showed the RN evening supervisor talked to NF2. NF2 states he has been more objective about resident #29 and documented any odd behaviors. He understands she has a mental illness and probably often feels left out. He understands that he should not stereotype the resident as a drug seeker. I asked him to try to seek out something positive to say to her. He said he usually isn't like that and I agreed. The allegation of mental abuse was not reported to the State Survey Agency. Review of resident #29's Quarterly MDS, with the ARD of 5/16/21, showed the resident had no cognitive deficits. During an interview on 7/7/22 at 10:12 a.m., resident #29 stated NF2 made her feel 'not good' all the time, and she was glad he no longer worked at the facility. She chose to not elaborate on her feelings. During an interview on 7/7/22 at 12:35 p.m., staff member A stated she felt the incident did not rise to the level of abuse, so it was not reported, because it was a grievance. During a phone interview on 7/11/22 at 11:16 a.m., NF1 stated NF2 had other resident complaints regarding his behaviors, and NF1 thought the facility was going to terminate him, but they brought him back to continue working. No documentation was provided to show interventions were implemented to protect resident #29's psychosocial/mental status, or monitoring of staff NF2 and resident #29's interactions.

Based on interview and record review, the facility failed to report a resident allegation of mistreatment and potential mental abuse to the State Survey Agency for 1 (#29) of 6 sampled residents. Findings include: Review of a hand-written allegation of mistreatment/mental abuse, dated 7/12/21, by resident #29, showed the resident stated staff member NF2 continues to treate her with absolutley no respect, and she did not deserve that kind of treatement. It was having a negative impact on her life, by her feeling 'not good.' Review of a Facility Reported Incident, dated 6/15/21, showed resident #29 voiced a similar allegation with no documented resolution for the resident. During an interview on 7/7/22 at 12:30 p.m., staff member A stated the 7/12/21 allegation did not rise to the level of abuse, and was just a resident grievance, and so it was not reported to the State Survey Agency.

Based on interview and record review, the facility failed to thoroughly investigate two allegations of mistreatment and potential mental abuse, allowing the mistreatment and potential mental abuse to continue, for 1 (#29) of 6 sampled residents. Findings include: 1. Review of the Facility Reported Incident, dated 6/15/21, showed resident #29 reported to her physician that NF2 refused to give her a PRN pain medication. She also stated he was curt and sarcastic when interacting with her. The report showed the allegation of potential mental abuse was not substantiated, but did not include the information the facility used to reach their conclusion. No documentation was provided regarding resident #29's psychosocial status or further monitoring of NF2 for the protection of the resident. 2. Review of a second allegation, on a facility Grievance/Complaint form, dated 7/12/21, showed resident #29 stated she continued to be treated with disrespect at all times from NF2, and that she did not need that treatment in her life. Review of the response from the facility was a typed conversation staff member J had with NF2, dated 7/13/21. It showed, I let him read the most recent complaint, and that I hoped he will work on their nurse/patient relationship. I asked him to try to seek out something positive to say to (resident #29). He said he usually isn't like that and I agreed. No documentation was received for further investigation, protective interventions for resident #29, or monitoring of NF2 and his performance and interactions related to this resident, or other residents.

Based on observation, interview, and record review, the facility failed to establish consent or develop a facility policy for continuous camera/video monitoring of residents, potentially violating a residents' right to privacy, for 2 (#s 23 and 47) of 2 sampled residents. Findings include: A. During an observation on 7/7/22 at 9:18 a.m., resident #47 was visualized sitting in the recliner in his room via a camera monitor that was placed at the nurses' station. During an interview on 7/7/22 at 9:46 a.m., staff member K stated staff will turn off the cameras during care. She was not sure about any consents for the residents to be continuously monitored by camera/video. Review of resident #47's medical record showed consents signed by his POA for psychotropic medications and position change alarms. There was no consent for video monitoring. B. During an interview on 7/7/22 at 10:20 a.m., staff member J stated the video monitors were interventions for fall prevention. Staff member J stated they did not have the requested facility policy for the monitors or visual monitoring in resident rooms. During an observation on 7/7/22 at 10:35 a.m., resident #23 was sitting in the living room recliner near the television, with a small monitor at his chairside. He was being observed from an additional monitor placed at the nurses' station. A copy of resident #23's consent form for video monitoring was requested. Supplied by the facility was a form titled, Authorization for the Use and Disclosure of Name/Picture Displays. Review of this form, signed by resident #23's POA on 3/14/2016, showed, I give permission to the [facility name] to display my name and/or picture in the following way(s) while residing at this facility; pictures taken during [facility name] activities and outings, name/picture by room door, name/picture for media use (i.e., TV, radio, newspaper), name on birthday cards/boards, calendars, barbershop list, sign-out sheets, name on dietary table placement care/kitchen serving trays, names provided to service groups for gift purposes. Review of resident #23's medical record showed a lack of documentation or consent related to being under continuous camera/video surveillance. Review of care plans for resident #47 and resident #23 did not list camera/video monitoring as an intervention for falls or other behaviors.

Based on observation, interview, and record review, the facility failed to manage oxygen therapy for 1 (#8) of 2 sampled residents, which could lead to an upper respiratory infection and exacerbation of respiratory symptoms due to low oxygen saturation for the resident(s). Findings include: During an observation on 7/5/22 at 3:56 p.m., inside the smoking door area, there was one oxygen canister with a mask hung on a nail touching the wall with no cover. The portable oxygen canister the mask was connected to, was low on oxygen, and still running with a buildup of white condensation on it. Another portable oxygen canister had a cannula, with an orange tinge to it, and no cover, slung over the railing, touching the bottom of the wall along the floor. During an observation on 7/5/22 at 4:04 p.m., resident #8 let himself in the smoking door. The resident then put on the oxygen mask that was running and touching the wall, without sanitizing his hands, and continued to go to his room. No staff checked his oxygen levels. Resident #8 had a slow, shuffling pace, and on observation he had a yellow pallor to his skin. During an interview on 7/6/22 at 2:30 p.m., staff member A stated, the facility staff tried to check the oxygen saturation levels of a resident if they were having an acute issue. For two residents who smoke, including resident #8, staff attempted to check the oxygen saturation frequently. Staff member A stated for oxygen management the resident was to hang the cannula over the rack holding the oxygen, not the railing, and no one else was to touch it. The facility staff may not see the residents coming back from the smoke shack to check the oxygen. During an observation on 7/7/22 at 10:41 a.m., resident #8 was walking down a hallway with oxygen on. Resident #8 then leaned on the nurses' station and when this surveyor tried to converse and the resident could not make coherent words. The resident had a yellow pallor to his skin. A CNA then came to the resident and tried to check his oxygen levels. The CNA stated she had just refilled his oxygen and called over a nurse manager because she did not know what to do with resident #8. She stated his oxygen saturation was still dropping and lowering past 48%. More staff gathered and tried to find a chair and a larger oxygen concentrator for the resident because they did not have one available. He was taken back to his room. A nurse called a physician and got a verbal order to increase the rate of oxygen from two liters to five liters, per minute, until the resident could get to the saturation rate reading in the high 80s or low 90s. During an interview on 7/7/22 at 11:32 a.m., with staff members N and A, staff member N stated the nursing staff had a clipboard where oxygen levels were documented. Staff member A stated whenever resident #8's condition required more numerous checks of oxygen levels they would do it. During the incident earlier that day they got an order and still had him on a higher flow rate of oxygen. Staff member A stated, resident #8 had continuous canisters switched out every two hours by CNAs. Staff member A stated the oxygen tubing was switched out once a month and noted on a form each time, instead of marking on the actual tubing. Review of resident #8's Daily Temperature Board form, for oxygen levels, showed, multiple oxygen readings documented in the low-80s and mid-70s and several blank for night shift. No documentation showed what interventions were done to increase oxygen levels for resident #8, increase in monitoring, or what could have contributed to the lower oxygen rates. Record review of resident #8's Care Plan, showed, an intervention for oxygen was to keep levels above 88% via cannula and to monitor for distress. A therapy care plan from 5/6/21 showed shortness of breath with activity, oxygen levels down to 79% when ambulating with a goal of 90%.

Based on interview and record review, the facility failed to provide completed beneficiary notices for 3 (#s 37, 41, and 48) of 3 sampled residents. This deficiency had the potential to affect any resident with discontinued Medicare part A services. Findings include: A. Review of resident #48's, SNF Beneficiary Protection Notification Review form, was filled in showing the last covered day was 4/22/22 as a facility-initiated discharge from Medicare part A services. This required an ABN form and NOMNC form to be filled out and given prior to the discharge. Resident #48's, ABN form, showed, as of 4/23/22, the care being discontinued as, Nursing Care, and the reason for stopping Medicare Part A was, Skilled Care not required at this time. No estimated cost for continued services was filled out. The three options for accepting, appealing, or paying out of pocket were not selected; no additional information was provided, and no representative signature, date, or documentation of notification was completed. Resident #48's NOMNC showed, staff member M made a note on 4/22/22 that she called the representative on 4/19/22 for resident #48 being taken off of Medicare Part A services. No signature from the representative or date indicating they received the notice was on the form. B. Review of resident #37's, SNF Beneficiary Protection Notification Review form, was filled in showing the last covered day was 1/10/22 as a facility-initiated discharge from Medicare part A services. This required an ABN form and a NOMNC form to be filled out and given prior to the discharge. Resident #37's, ABN form, showed, as of 1/11/22, the care being discontinued as, Nursing Care, and the reason for stopping Medicare Part A was, Skilled Care not required at this time. No estimated cost for continued services was filled out. The three options for accepting, appealing, or paying out of pocket were not selected; no additional information was provided, and no representative signature, date, or documentation of notification was completed. Review of resident #37's, NOMNC form, showed, a note written by staff member M for calling a representative on 1/6/22 stating resident #37 would be taken off skilled care. No signature or date by the representative indicating they received the notice was on the form. C. Review of resident #41's, SNF Beneficiary Protection Notification Review form, was filled in showing the last covered day was 5/26/22 as a facility-initiated discharge from Medicare part A services. This required an ABN form and a NOMNC form to be filled out and given prior to the discharge. Resident #41's ABN form, showed, the care being discontinued as, Nursing Care, and the reason for stopping Medicare Part A was, Skilled Care not required at this time. No estimated cost for continued services was filled out. The three options for accepting, appealing, or paying out of pocket for services were not selected; no additional information was provided, and no representative signature, date or documentation of notification was completed. Resident #41's NOMNC form, showed, staff member M called the representative on 5/24/22 and stated resident #41 would be taken off of skilled services. The form was not signed or dated by the representative indicating they received the notice was on the form. None of the resident's forms were filled out entirely, or had signatures of the responsible party for notification, selection of service option, or understanding of their rights. All three had the same reason filled out, no specific costs, and no specific services that were provided for each individual that were being dicontinued. During an interview on 7/7/22 at 11:28 a.m., staff member A stated, staff member M did the beneficiary notices by calling the power of attorney. Staff member A stated she was not aware of any training staff member M received but she had been doing the notices by calling the power of attorney instead of signatures for years.

Based on observation, interview, and record review, the facility failed to implement a comprehensive process for the appropriate use of resident position change alarms including: conducting an assessment, obtaining consent of risks and benefits, obtaining physicians orders, having clinical supporting documentation, and monitoring and care planning to ensure the position change alarms were not restraints for 2 (#s 13 and 48) of 2 sampled residents. Findings include: 1. During an observation on 6/9/21 at 3:38 p.m., resident #48 was in her wheelchair near the nurses' station. Resident #48 attempted to wheel herself, and the pressure alarm on the chair sounded, and the resident did not move any further. Minutes later a staff member went to assist resident #48. The staff member was struggling with getting the alarm to stop sounding, and then three staff members came to assist also. One staff member stated the resident alarm pad just needed to be replaced to stop the alarm from sounding, and then grabbed one from an office down the hall. Then the staff were attempting to switch out the alarm pads at the nurses' station, then decided it was better to wait till resident #48 transferred to bed. Resident #48 was left near the nurses' station, with the alarm no longer sounding, but the resident did not attempt to move again. During an interview on 6/10/21 at 8:51 a.m., staff member I stated there was no assessment to ensure the addition of a position change alarm was not used as a restraint for the resident. Staff member I stated the nurse could add any alert alarm and only needed to notify the representative, but the nurse did not get consent or physicians order. During an interview on 6/10/21 at 9:21 a.m., staff member B stated resident #48 had trouble settling in and had an increase in evening sundowning behavior. Staff member B stated resident #48 had a fall and sustained a wrist fracture, resulting in the chair and bed alarms being added. Staff member B stated the facility did not get consent for adding position change alarms for residents. Staff member B stated the facility knew the position change alarms were not restraints, although no clinical assessments or documentation were completed to verify this determination. During an observation and interview on 6/10/21 at 10:17 a.m., staff member P stated, resident #48 had position change alarms on her chair, bed, and a wanderguard(elopement alert band alarm) due to falls and wandering. Staff member P stated she only knew there were alarms for a resident from the CNA cheat sheet, and then showed where resident #48 was listed with alarms for the bed and chair, in a red binder. Staff member P stated she checked the resident's chair alarm placement when she started her shift, but if the alarm sounded, staff member P did not know of what was required or care planned for monitoring and managing the alarms, to ensure they were not restraining the resident or causing behaviors. Staff member P stated there were different types of alarms. Some were pressure pads to plug in, and others had an on/off switch, but staff member P did not know how it was determined what alarm to use specifically. Staff member P stated the CNAs would document in the log for the activities of daily living (ADL), by using a corresponding number, and then report a resident's behaviors to the nurse to be entered as a nurse note. Review of resident #48's current physician orders, signed May 2021, showed no orders for the use of position change alarms. Review of resident #48's Care Plan showed under the area of falls: -1/1/2021 fell out of bed unplugged alarm, -2/1/2021 found on floor in bathroom - was toileting self hit head [NAME] (no apparent injuries), -3/7/2021 fell next to bed [NAME] was self transferring - being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] -handwritten, 5-28-21 at 0120 (1:20 a.m.) [Resident #48] restless .Chair alarm to w/c went off. Staff found [Resident #48] on the floor [sic] Under the fall interventions for resident #48, the care plan showed: -1/1/2021 keep bed alarm out of reach of resident -2/21/21 silent alarm to bed with [Resident #48] does not like alarm struck out -silent alarm to bed and sensor to w/c and recliner - There was no date for the intervention - 3/26/21 wandergaurd The care plan did not show when the alert alarms were added, the type of alarms to be used, or any monitoring plan/system in place for the chair, bed, and wanderguard alarms, to ensure they were not used as restraints for resident #48. Review of Nurse Progress Notes, dated 12/31/20 through 5/29/21, showed resident #48 had: frequent urinary tract infections, multiple falls, wandered out of the facility unattended, had been prescribed [MEDICATION(S)] (as needed antianxiety medication) in April 2021, for agitation. The resident was still using this medication frequently, and a new medication for constipation was due to agitation while having position change alarms to the bed and chair. 2. During an observation and interview on 6/7/21 at 4:18 p.m., resident #13 was sitting in his recliner, with an alarm cord sticking out from under him, and the alarming system sitting on the bed. When conversing, the resident only verbalized or shook his head when questioned, and the resident did not move or reposition in the recliner. Resident #13 could not state what the alert alarms were for. During an interview on 6/10/21 at 8:56 a.m., staff member Q stated resident #13 had a lot of falls until moving close to the nurses' station. Staff member Q stated the nurses had the ability to put an alarm on any resident. Staff member Q stated the nurses did not need to get consent, only to notify representatives that an alarm was added, and there was no assessment for placing or reevaluating an alert alarm, to ensure the alarm was not being used as a restraint. During an interview on 6/10/21 at 9:15 a.m., staff member B stated the facility was restraint free. Staff member B stated resident #13 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff member B stated resident #13 had sounding alarms because he was impulsive, and the alarm did not affect him because he was hard of hearing. Staff member B stated it was not a restraint because the facility watched the resident. Staff member B stated there was no assessment or consent needed to ensure the alarms used were not restraints to the resident. Review of resident #13's Care Plan, showed the resident had multiple falls and constipation due to decreased mobility. Under the area of falls, for interventions, the care plan showed: -12/28/20 bed alarm and alarm to wheelchair/recliner The care plan did not show what type of alarms, when or how the alarms were to be used, how the alarms were to be monitored, and that the alarms were not a restraint for the resident. Review of resident #13's current physician orders, signed May 2021, showed no order for the use of [MEDICAL RECORD OR PHYSICIAN ORDER] Consents and assessments completed for use of the position change alarms were requested during the survey for residents #13 and #48, and were not provided by the end of the survey. A review of the facility policy titled, Restraints, Chemical & Physical, with a revision date of 7/22/20, in entirety, showed, Policy: The [Facility] is a Restraint-Free Facility. No other policy requested for alarm use was provided by the facility prior to the end of the survey.

Based on observation, interview, and record review, the facility failed to identify the risk of elopement and provide supervision for 1 (#42) of 1 sampled resident. This resulted in the resident eloping from the facility. Findings include: A record review of a facility document titled, MVH incident/accident report, dated 9/15/20 at 3:00 p.m., showed resident #42 left the facility in his electric wheelchair to visit his girlfriend. He was seen in the community by a staff member who reported seeing him in town. He was located at his girlfriend's house and returned to the facility an hour later. Since it was during a Covid-19 outbreak, the resident was quarantined for 14 days on return. During an interview on 6/08/21 at 10:20 a.m., staff member G stated, The incident was during the Covid-19 outbreak, visiting was only outside at the time, and his (#42's) girlfriend was very sick. She could not come here because of her chemo and because she was just too ill. Staff member G stated, He [resident #42] felt like he just needed to see her. During an observation on 6/9/21 at 9:32 a.m., a resident came to the nurse's station and told a surveyor he was going outside for a walk. The resident then walked to the door and let himself out. The surveyor did not know the name of the resident and did not know if he was allowed outside alone. There were no facility staff members at the nurses' station during that time. A staff member was notified a resident went out the door. During an interview on 6/10/21 at 8:39 a.m., when asked how do you know what residents are outside at any given time, staff member I stated, They [the residents] stop at the front desk and tell us. They do not have to sign out unless they are leaving the facility. During an interview on 6/10/21 at 9:20 a.m., staff member B stated, [Resident #42] called his girlfriend, and they hatched a plan. He has lived here 5-6 years and knows our routine. [Resident #42] left right after shift change. He snuck out of door #2 by SCU. [Resident #42] went all the way out the lane. He was seen in town by a staff member. He made it to his girlfriend's house, down the street, past the middle school. We called [resident #42's] son. His son called around and found him at her [the girlfriend's] house. The facility went to get him. He came home safe. During an interview on 6/10/21 at 9:25 a.m., staff member B stated, [Resident #42] had voiced a need to see his girlfriend to everyone. If he would have gotten into a depressed mode or it had caused a change in his condition, we would have let him have a compassionate visit. Review of a facility policy titled Covid-19, dated 3/24/20 with a revision date of 3/2/21, showed, compassionate care visits will be coordinated through the Care Plan Team and Infection Control. The facility will restrict visitation of all visitors and non-essetial health care personnel, exept for certain compassionate care situations, during a COVID-19 outbreak or high community spread for the safety of the residents. During compassionate care visits, visitors will be restricted to a specific room. No compassionate care visit was offered for resident #42 and his girlfriend who was given 3-6 weeks to live. In an interview on 6/9/21 at 10:53 a.m., resident #42 stated, I went to see my girlfriend because she was diagnosed with cancer, and they gave her 3-6 weeks to live. It was coming on the six weeks, so I just decided I needed to go see her. When asked if he felt as though anyone in the facility would help him get to see her, he stated, No, I don't think they would. He explained that he had already told several people his situation and nothing changed. In an interview on 6/09/21 at 2:59 p.m., staff member O stated, Some doors have alarms and wander guards for residents with a risk of elopement. We usually notice them leaving, and we will ask them where they are going. We know where they like to go, so if they have been gone awhile, we [nursing staff] will go look for them. When asked how the facility would know if a resident was missing, staff member O stated, Through rounding is how we will know if they [a resident] are gone. When asked what she would do if she found a resident was missing, staff member O stated, I would notify a supervisor and find out when was the last time anyone saw them. I would have the supervisor locate the person so I can stay on the floor. Staff member O stated she did not know the policy, but she could find it, some policies are on the unit, some policies were given to the nurses on hire and, the supervisors' office has them. A review of the resident's medical record showed the resident had his electric wheelchair removed for his personal use for 44 days, due to the elopement. He was quarantined in his room for 14 of the 44 days and didn't require the chair during that time. Review of a facility document, titled, Referral/Screen to rehab services, dated 10/28/20, showed resident #42's use of the power wheelchair was 'taken away' and he is now using a manual wheelchair. On this document a box titled No triggers indicated to support skilled rehab intervention at this time, was marked with a check mark. During an interview on 6/10/21 at 10:15 a.m., staff member N stated, some reasons a resident might have their power wheelchair taken away is if there where safety issues with how the resident was able to operate the wheelchair or if the resident graduated out of the need for the chair. During an interview on 6/10/21 at 10:18 a.m., staff member M stated, We did the initial training (for resident #42's use of the power wheelchair) in 2018, but we did not do any formal training for the elopement incident. It wasn't an issue of him being dangerous in the chair. It was not an issue of him safely using the chair, but we did talk about the expectations of using the chair. Staff member M stated, I can't tell you why he didn't get the chair back until October, 28th. It was up to (staff member B) when he got the chair back. An assessment of the resident's use of the chair related to safety, and the risk of future elopements, was not documented in the resident's medical record.

Based on record review, and interview, the facility failed to develop an initial care plan within 48 hours of admission, following a resident's hospital admission for a [CONDITION(S)] and repair, for 1 (#41) of 1 sampled resident. Findings include: Review of resident #41's interdisciplinary progress notes, dated 6/3/21 at 2:00 a.m., showed the ambulance arrived to take resident #41 to [facility name] for evaluation after a fall. Review of resident #41's interdisciplinary progress notes, dated 6/7/21 at 2:20 p.m., showed the resident returning to the facility, after an admission to the hospital for a [CONDITION(S)] and [CONDITION(S)]. The resident was out of the facility for four days. Review of resident #41's care plan on 6/8/21, showed the care plan was reviewed by nursing staff on 4/20/21, and showed the last update as 6/2/21. During an observation on 6/08/21 at 10:16 a.m., a physical therapist was in the room speaking to resident #41. She was explaining the use of a wedge pillow that needed to be used between his legs since he had surgery and also how to safely transfer out of his bed after his hip surgery. After speaking to the resident, the physical therapist walked to the nurses' station and asked the nurse for more pain medication for the resident so she could take him to the therapy room. During an interview on 6/10/21 at 8:49 a.m., staff member I stated, I would do my care plan when I do the new admit. I think we have 24 hours though. We have a packet we use. Staff member I looked in the file cabinet and found a packet [for new admits and readmissions]. Staff member I stated, If the resident is gone for more than three days you have to do a whole new packet, there is a care plan in the packet. Review of resident #41's care plan on 6/10/21, showed the care plan was reviewed by nursing staff on 4/20/21, and showed the last update as 6/2/21. There were no changes made to the care plan or new care plan in the chart since resident #41's readmission on 6/7/21. There were no new additions for transferring the resident, or the use of a wedge pillow for positioning on the care plan.

Based on observation and interview, the facility failed to maintain an effective pest control program to ensure the facility remained free of flies in the food preparation, service, and storage areas. This had the potential to affect all residents that ate food prepared in the facility kitchen. Findings include: During an observation on 8/5/19 at 1:54 p.m., four flies were observed flying in the air in the dishwashing room, outside the kitchen area. During an interview on 8/7/19 at 11:11 a.m., staff member K stated the facility has a contract with a pest control service company to spray for bugs, monitor for rodents, and also for any other special needs. During an observation and interview on 8/8/19 at 8:19 a.m., residents and staff were heard complaining about a fly bothering them in the 500 dining room. Staff member N stated she had only seen flies in the dining room that day, and staff were not allowed to smash the flies. During an observation on 8/8/19 at 9:56 a.m., a fly was observed flying in the area around the 500 hall nurses' station. During an observation and interview on 8/8/19 at 11:11 a.m., three flies were observed flying in the air in the dishwashing area. Clean glasses were noted to be stored upside down, stacked in racks in the area. During an observation on 8/8/19 at 11:13 a.m., one fly was observed flying in the air above the kitchen prep counter where 2 large pans of jello were being made. During an observation and interview on 8/8/19 at 11:14 a.m., staff member B stated the facility had placed a screen on the heat escape vent above the ovens in the kitchen, as a means to attempt to eliminate the flies coming into the kitchen. Staff member K stated the County Health Department had recommended that the facility address the fly situation with fly tape or bug zappers. One fly tape was observed hanging above the hand washing sink and toaster/bread stand area in the kitchen. Staff member K stated the VA won't allow a bug zapper in the facility, due to the possibility of a fly being partially zapped in the bug zapper and then flying out and dying, and landing on some food.